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Admission Date: [**2184-11-16**] Discharge Date: [**2184-11-19**]
Date of Birth: [**2108-10-18**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old
woman with a history of hypertension, who was recently
changed from atenolol and hydrochlorothiazide to lisinopril.
Three days prior to admission, she began to experience facial
swelling which started on the left side of her face and
gradually spread bilaterally through her lips. The patient
was given some Benadryl two days prior to admission without
any resolution of symptoms.
One to two days prior to arrival, the patient had some
pruritus in the mouth and noticed that her lip was swelling.
She was given additional Benadryl and Atarax, however, the
swelling continued to worsen to the point where her tongue
additionally swelled and she could not talk. Note that her
ACE inhibitor was stopped two days prior to admission.
In the Emergency Department, the patient was given two doses
of Epinephrine, Pepcid, Benadryl, and Solu-Medrol.
Anesthesia was consulted, and the patient was taken to the
operating room for possible endotracheal intubation versus
tracheostomy. However, the swelling began to improve, and
the patient's airway was not compromised. The patient did
note some difficulty with her tongue swelling in terms of her
breathing, and she also noted some hives when she arrived in
the Emergency Department.
REVIEW OF SYSTEMS: The patient denied fever or chills,
diaphoresis, sick contacts, cough, or shortness of breath, or
chest pain. She also denied nausea, vomiting, urinary
symptoms, or any change in bowel movements. She denied
having any snake or spider bites. She denied having any new
pets, foods, perfumes, or soaps. She did note recent travel
to Barbados about 10 days prior to admission.
PAST MEDICAL HISTORY:
1. Hypothyroidism.
2. Hypertension.
3. Right knee surgery for a total right knee replacement.
4. Hypercholesterolemia.
5. Postoperative delirium.
6. Left cataract surgery.
7. Osteoarthritis.
8. Left femoral cutaneous nerve syndrome.
ALLERGIES: Haldol and ACE inhibitors.
MEDICATIONS ON ADMISSION:
1. Synthroid 125 mg a day.
2. Lipitor 10 mg a day.
3. Lisinopril 40 mg a day.
4. Benadryl 40 mg twice a day.
5. She had previously been on Neurontin and amitriptyline as
well.
SOCIAL HISTORY: The patient smoked one pack a day for 30
years. She denies ethanol or drug abuse. The patient's
granddaughter is a RN who had helped her at home.
FAMILY HISTORY: The patient lives with her granddaughter.
There is no family history of reaction to ACE inhibitors or
other substances. The patient's daughter died of ovarian
cancer and her son died of brain cancer.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit for monitoring and IV steroids. On the 2nd
hospital day, the patient was transferred to the floor at
which time a physical examination was performed by our
medical team.
The patient's temperature was 99.0 F, blood pressure was
146/70, heart rate of 88, respiratory rate of 20, and a pulse
oximetry of 98% on room air. She was alert and oriented in
no apparent distress and quite pleasant. HEENT: Pupils are
equal, round, and reactive to light and accommodation with
some left pupil asymmetry. Extraocular motions intact.
Bilateral arcus senilis. The patient's throat and oropharynx
examination was notable for tongue swelling and a barely
visible uvula. There was no stridor over her airway. Chest
examination was clear to auscultation bilaterally, although
breath sounds were distant. There were no wheezes or
rhonchi. Cardiac examination: Regular, rate, and rhythm,
S1, S2, no murmurs, rubs, or gallops. Abdominal examination:
positive bowel sounds, obese, soft, nontender, and
nondistended, and no guarding and no rebound. Extremities:
No edema in the lower extremities. She had some limited left
knee flexion. Distal pulses were intact upper and lower
extremities. Distal and proximal strength was [**4-18**]. Cranial
nerves II through XII are intact and sensation was grossly
intact.
LABORATORIES: Laboratories on transfer from Intensive Care
Unit to floor: Her Chem-7 was normal. Her hematocrit was
35.7, which had decreased from 41.8 on admission. Her coags
were normal. TSH was 0.89 and a C1 esterase laboratory
inhibitor was pending. The C1 esterase test later came back
in the normal range at 21, reference range for that is [**6-8**].
A functional C1 inhibitor level came back greater than 100%,
and again the reference range for normal is greater than 68%.
HOSPITAL COURSE: The [**Hospital 228**] hospital course on the floor
was essentially unremarkable. She did complain of a
subjective sensation of some throat swelling on her stay on
the medical floor, and there was some question of stridor
over her airway, although minimal. She was continued for
another day on intravenous Solu-Medrol, and then changed to
po prednisone. The patient's blood pressure was treated with
hydrochlorothiazide, triamterene, and maintained within
normal range.
The patient was discharged home in good condition with a
diagnosis of presumptive angioedema secondary to ACE
inhibitor.
FOLLOWUP: She was to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within a
week of discharge.
DISCHARGE MEDICATIONS:
1. Synthroid 125 mg once a day.
2. Lipitor 10 mg once a day.
3. Triamterene/hydrochlorothiazide 37.5/25 mg tablets.
4. Atarax 25 mg a day.
5. Zantac 150 mg twice a day.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 15868**]
Dictated By:[**Last Name (NamePattern1) 2215**]
MEDQUIST36
D: [**2184-11-29**] 08:57
T: [**2184-12-2**] 08:15
JOB#: [**Job Number 29687**]
|
[
"2449",
"4019",
"2720",
"2859"
] |
Admission Date: [**2139-5-21**] Discharge Date: [**2139-5-27**]
Date of Birth: [**2060-10-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
respiratory failure, acute stroke syndrome
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Dr. [**Known lastname **] is a 78 yo male with a h/o atrial fibrillation,
dementia, and idiopathic thrombocytopenia who is transferred
from [**Hospital6 5016**] after acute onset of facial droop and
dysarthria on the morning of [**5-21**]. Per information gathered from
medical record and from family, patient awoke with slurring of
speech and right facial droop. He was immediately transferred
from the rehab facility to [**Hospital6 5016**] out of concern
for CVA. Per EMS record, patient had equal grip and strength and
denied any headache or chest pain at time of transfer.
.
On arrival to [**Hospital6 5016**] BP 121/81, HR 103-112 (afib),
T 95.3, BG 160, respirations were unlabored on 2L. He was
documented to be alert but with difficulty word finding, with
right facial droop, and slurred speech. He was able to swallow a
dose of Coreg 6.25 mg PO which was administered for rapid afib.
He subsequently received 5 mg IV lopressor for HR in the 130's.
Per family's report, he became increasingly agitated and
confused and attempted to climb out of bed. He is next
documented to have developed a 20 second period of apnea with
[**Last Name (un) **]-[**Doctor Last Name 6056**] breathing and inability to speak. He was reported
to be cyanotic in his lips and extremities at this time and was
intubated with Versed 4 mg, Ativan 2 mg IV, and Succ 200 mg. He
was transported via [**Location (un) 7622**] to [**Hospital1 18**].
.
On arrival to the [**Hospital1 18**] ED, T 97.9, BP 72/42, RR 14, SpO2 99%.
Levophed drip was started. Bedside FAST exam was performed and
LIJ sepsis catheter was placed. CT head was negative for acute
intracranial process. CT torso was negative for evidence of
occult infection. He received 4 liters NS, ceftiraxone 2 gram,
vancomycin 1 gram, Protonix 40 mg IV, Thaimine 100 mg IV, and
Decadron 10 mg IV. Neurology was consulted.
Past Medical History:
Atrial fibrillation, s/p failed cardioversions x 2 at [**Hospital1 112**]
Thrombocytopenia
h/o nasal polyp
Dementia of the Alzheimer's variant
Cardiomyopathy with globally dilated heart, EF 40% (Adenosine
sestaMIBI stress from [**4-30**]
Mild early senial demential of the Alzheimer's type
Anemia
Gout
CAD
s/p bilateral hip and knee replacements
NSVT
Social History:
Patient's family reports he smoked a pipe; he has no history of
cigarette smoking. He drank 2+ alcoholic beverages everynight.
He is married and has 8 children. He is a retired Internist. He
has temporarily been living at [**Hospital3 7665**] in [**Hospital1 3597**], NH
prior to this admission, recovering from recent medical illness.
Family History:
Father with lung cancer (smoker), MI, CVA. Mother with emphysema
(smoker). His eight children are all healthy. There is no other
significant family history of CVA, MI, or malignancy.
Physical Exam:
VS: T 97.9, HR 120, BP 127/91, RR 20, SpO2 100%
Gen: intubated, minimally responsive without sedation
CV: irregularly, irregular
Resp: lungs CTA
Abdomen: obese, soft, nt/nd
Extrem: cool to touch in all four extremities; 2+ lower
extremity pitting edema to shins; well-healed midline scars over
both knees
Skin: non-blanching purpura over lower extremities; no rashes
Neuro: no obvious facial droop; pinpoint pupils with sluggish
reaction to light; opens eyes to stimuli; moves left upper
extremity, left lower extremity & right lower extremity; flacid
tone in RUE without any purposeful or nonpurposeful movements;
areflexive in patellar tendons; upgoing toes bilaterally; no
clonus.
Pertinent Results:
[**2139-5-21**] 05:15PM WBC-11.6* RBC-3.03* HGB-9.5* HCT-31.3*
MCV-103* MCH-31.3 MCHC-30.3* RDW-16.2*
[**2139-5-21**] 05:15PM NEUTS-90.6* BANDS-0 LYMPHS-5.5* MONOS-3.4
EOS-0.3 BASOS-0.1
[**2139-5-21**] 05:15PM PLT SMR-VERY LOW PLT COUNT-41*
[**2139-5-21**] 05:15PM PT-21.0* PTT-39.1* INR(PT)-2.0*
[**2139-5-21**] 05:15PM GLUCOSE-131* UREA N-38* CREAT-1.2 SODIUM-140
POTASSIUM-4.5 CHLORIDE-111* TOTAL CO2-20* ANION GAP-14
[**2139-5-21**] 05:15PM ALT(SGPT)-197* AST(SGOT)-95* LD(LDH)-315*
CK(CPK)-45 ALK PHOS-69 TOT BILI-2.9*
[**2139-5-21**] 05:15PM LIPASE-44
[**2139-5-21**] 05:15PM cTropnT-0.69*
[**2139-5-21**] 05:15PM CK-MB-NotDone
[**2139-5-21**] 05:15PM ALBUMIN-2.9* CALCIUM-6.9* PHOSPHATE-4.2
MAGNESIUM-2.4
[**2139-5-21**] 05:15PM HAPTOGLOB-117
[**2139-5-21**] 05:15PM TSH-2.0
[**2139-5-21**] 05:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
STUDIES:
* Torso CT [**5-21**]:
1. Bilateral pleural effusions, right greater than left.
2. Mesenteric fat stranding, pericholecystic fluid, periportal
edema and small amount of ascites which may be due to low
albumin state or third spacing.
3. Bilateral hypodense lesions, some of which are too small to
characterize, others which are simple cysts.
4. Infrarenal abdominal aortic aneurysm measuring up to 4.8 x
6.2 cm in widest dimension.
5. Calcifications within the head of pancreas.
.
* Head CTA [**5-21**]:
1. No evidence of acute intracranial process on CT head.
2. CT perfusion shows no evidence of abnormal perfusion in the
visualized portions of the brain.
3. CTA head shows persistent trigeminal artery between the
basilar artery and the right cavernous carotid artery. Related
narrowing of the basilar artery as well as the vertebral
arteries, which feeds the PICA. No region of focal stenosis or
occlusion is seen.
4. A region of apparent narrowing of the left ICA distal to its
origin is likely artifactual due to a large amount of streak
artifacts from dental filling at this level.
.
* Brain MRI [**5-22**]:
1. Findings consistent with acute infarct in the deep white
matter of the left centrum semiovale. Findings suggest watershed
infarct which may be related to hypotensive episode.
2. MRA again shows persistent trigeminal artery with decreased
size of the basilar artery as well as the vertebral arteries
which feed the PICA. No region of focal stenosis or occlusion is
seen.
3. Tissue loss is again demonstrated in the left inferior
frontal lobe. Old ischemic changes also seen in the pons.
.
* Abd U/S [**5-22**]:
1. Gallbladder remains nondistended without evidence of stone.
Note is made of wall thickening and pericholecystic fluid which
is non-specific and may be seen in the setting of liver
dysfunction, congestive heart failure or hypoalbuminemia. Please
correlate clinically.
2. Trace perihepatic ascites.
3. Pleural effusion.
.
* EEG [**5-22**]:
This is an abnormal portable EEG due to the disorganized, low
voltage and slow background admixed with bursts of generalized
mixed frequency slowing. This constellation of findings is
consistent with a mild to moderate encephalopathy and suggests
dysfunction of bilateral subcortical or deep midline structures.
Medications, metabolic disturbances, infection, and hyoxia are
among the common causes of encephalopathy, but there are others.
There were no areas of prominent focal slowing, although
encephalopathic patterns can sometimes obscure focal findings.
There were no clearly epileptiform features. The beta activity
likely reflects medication effect. Note is made of the abnormal
cardiac tracing.
.
* Echo [**5-22**]: Dilated left ventricle with severe regional and
global systolic dysfunction. Dilated right ventricle with
moderate systolic dysfunction. Mild aortic regurgitation.
Moderate mitral regurgitation. Moderate pulmonary hypertension.
Dilated thoracic aorta.
.
* Head MRI [**5-26**]:
1. New large vascular territory infarct involving left MCA
territory and superimposed on previously seen left watershed
infarct. This could be embolic or thrombolic in etiology. No
hemorrhage or shift of normally midline structures is seen.
Although this is not an adequate evaluation of intracranial
vessels, the normal vascular flow voids are demonstrated.
Brief Hospital Course:
78-year-old man with a history of atrial fibrillation,
idiopathic thrombocytopenia, and dementia who presented with
left-sided watershed infarct and depressed EF, with hospital
course complicated by a PEA arrest requiring 7-minute CPR, epi x
1, re-intubation, and death.
.
# CVA: MRI on admission revealed a left centrum semiovale
stroke. The patient displayed right-sided neglect. He was
intermittently responsive to stimuli. His respiratory status
improved temporarily and he was briefly extubated before being
re-intubated again after a pulseless electrical activity arrest.
Repeat head MRI then showed a left MCA embolic stroke. The
patient's clinical status deteriorated with hypotension
requiring pressors. With continued clinical decline, and
following extensive discussions with family members (including
wife and HCP), all in agreement for DNR status, and the patient
quietly and comforably died in the presence of his family on
[**2139-5-27**].
.
# Coagulopathy: He had thrombocytopenia and required platelet
and cryoprecipitate infusions. There was no evidence for TTP.
Concerning for ITP, he was given steroids. The etiology was his
coagulopathy was unclear.
.
# Acute blood loss: patient had hematemesis and epistaxis,
likely precipated by his coagulopathy. He was transfused with
pRBCs.
.
# Atrial fibrillation: he received digoxin and diltiazem prn.
.
# Transaminitis: LFTs elevated throughout the hospital stay.
Unclear etiology.
Medications on Admission:
Allopurinol 150 mg daily
Carvedilol 6.25 mg [**Hospital1 **]
Colchicine 0.6 mg daily (d/c'd [**5-20**])
Colace 200 mg [**Hospital1 **]
Aricept 10 mg daily
Lisinopril 10 mg daily
Prednisone taper 25 mg PO daily x 1 week
NaCl nasal spray TID
Zocor 20 mg qAM
Lasix 40 mg qAM
Zosyn 3.375 g IV q 8h (started [**5-20**])
Arixtra 2.5 mg SC daily (d/c'd [**5-20**])
Zolpidem 10 mg qHS
Oxygen via NC
Discharge Disposition:
Expired
Discharge Diagnosis:
stroke
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"51881",
"42731",
"40390",
"5859",
"4280",
"V1582"
] |
Admission Date: [**2183-12-6**] Discharge Date: [**2183-12-10**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Subdural Hematoma s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] year-old woman with throat CA, HTN, a.fib, hyperlipidemia,
DVT, CHF, mitral regurgitation with a mechanical fall at nursing
facility secondary to attempted ambulation out support
presenting to us from an outside hospital with concern for
subdural hematoma. Onset was immediately prior to presentation.
per report, the patient was attempting to ambulate without
assistance but she is not capable of doing secondary to poor
balance; she fell, striking her left forehead as well as left
shoulder. No witnessed loss of consciousness. The patient
complained of a headache, was evaluated at an outside hospital,
and found to have a right occipital subdural hematoma.
Neurosurgery saw and evaluated and felt no need for urgent
intervention. Recommended Dilantin for 10 days and admit to
medicine. While waiting for be she was significantly altered and
became hypotensive to 70's SBP. Got 1 L NS and urinalysis was
floridly positive. WBC was 17. Received Vancomycin, Ceftriaxone
and haldol and calmed down. Was admitted to MICU for UTI with
sepsis and hypotension where she got IVF but no pressors and
urine grew out GNRs, not speciated. Also, via imaging lots of
gastric and colonic distension and GI was called. CT scan showed
lots of gas, no obstruction, no volvulus. Repeat kub, still lots
of gas but marginally improved. She has afib, on dig, added
metoprolol, not on aspirin or coumadin. Also, with h/o throat
CA, has voice box to speak. Fluid Balance: +1L, got total 3L NS
On arrival to the MICU, she was agitated and oriented x 0.
Past Medical History:
Dementia
CHF
SDH
AFIB
Hypothyroidism
Breast ca
HTN
Skin CA
Throat CA / with stoma
Social History:
From [**Location (un) 6598**] Manor. Otherwise unable to obtain
Family History:
Attempted to obtain but unable to due to altered mental status.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 98.9 84 97/44 97/TM(50%)
GA: AOx3, NAD
HEENT: PERRLA. MMM. stoma in neck.
Cards: irreg irreg S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, ND
Extremities: wwp, no edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact. 5/5 strength in BUE and BLE
extremities. Sensation intact to light touch
DISCHARGE PHYSICAL EXAM
VS: Tc 99.0, Tm 99.0, BP 110/70, P 85, R 26, O2 95 RA
I/O MN 200/inc, 24h 880/1575Wt: 47.3kg
GA: NAD, calm this AM
HEENT: Stoma in neck. MMM.
Cards: Irreg irreg S1/S2 heard. systolic murmur at LLSB.
Pulm: CTAB, transmitted upper airway sounds
Abd: Softly distended, hypoactive BS, NT
Extremities: wwp, no edema. DPs 1+. Multiple bruises on BLEs
that pt attributes to her falls.
Pertinent Results:
ADMISSION LABS
[**2183-12-6**] 08:11AM LACTATE-1.7
[**2183-12-6**] 06:42AM GLUCOSE-77 UREA N-31* CREAT-1.0 SODIUM-139
POTASSIUM-3.2* CHLORIDE-98 TOTAL CO2-30 ANION GAP-14
[**2183-12-6**] 06:42AM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.9
[**2183-12-6**] 06:42AM TSH-1.0
[**2183-12-6**] 06:42AM DIGOXIN-1.0
[**2183-12-6**] 06:42AM WBC-11.8* RBC-4.32 HGB-12.6 HCT-35.4* MCV-82
MCH-29.2 MCHC-35.6* RDW-16.1*
[**2183-12-6**] 06:42AM PLT COUNT-181
[**2183-12-6**] 06:42AM PT-16.2* PTT-26.8 INR(PT)-1.4*
[**2183-12-6**] 02:20AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.011
[**2183-12-6**] 02:20AM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG
[**2183-12-6**] 02:20AM URINE RBC-8* WBC->182* BACTERIA-FEW YEAST-NONE
EPI-0
[**2183-12-6**] 02:20AM URINE WBCCLUMP-OCC MUCOUS-RARE
[**2183-12-5**] 09:09PM GLUCOSE-98 UREA N-32* CREAT-0.9 SODIUM-135
POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-25 ANION GAP-18
[**2183-12-5**] 09:09PM estGFR-Using this
[**2183-12-5**] 09:09PM DIGOXIN-1.2
[**2183-12-5**] 09:09PM WBC-17.1* RBC-4.53 HGB-13.0 HCT-36.7 MCV-81*
MCH-28.8 MCHC-35.5* RDW-16.1*
[**2183-12-5**] 09:09PM NEUTS-81.8* LYMPHS-11.8* MONOS-5.3 EOS-0.7
BASOS-0.5
[**2183-12-5**] 09:09PM PLT COUNT-220
[**2183-12-5**] 09:09PM PT-16.1* PTT-26.3 INR(PT)-1.4*
DISCHARGE LABS
[**2183-12-7**] 02:40AM BLOOD PT-16.9* PTT-29.9 INR(PT)-1.5*
[**2183-12-6**] 06:42AM BLOOD TSH-1.0
[**2183-12-6**] 06:42AM BLOOD Digoxin-1.0
[**2183-12-5**] 09:09PM BLOOD Digoxin-1.2
[**2183-12-6**] 08:11AM BLOOD Lactate-1.7
[**2183-12-6**] 02:20AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.011
[**2183-12-6**] 02:20AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2183-12-6**] 02:20AM URINE RBC-8* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
[**2183-12-10**] 06:15AM BLOOD WBC-7.1 RBC-3.79* Hgb-11.0* Hct-31.7*
MCV-84 MCH-29.1 MCHC-34.8 RDW-16.4* Plt Ct-183
[**2183-12-10**] 06:15AM BLOOD Glucose-84 UreaN-9 Creat-0.6 Na-135 K-3.7
Cl-103 HCO3-25 AnGap-11
[**2183-12-10**] 06:15AM BLOOD Calcium-8.6 Phos-2.2* Mg-2.2
MICROBIOLOGY
[**2183-12-6**] URINE CULTURE (Final [**2183-12-9**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMIKACIN-------------- 8 S
AMPICILLIN------------ <=2 S =>32 R
AMPICILLIN/SULBACTAM-- <=2 S =>32 R
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S =>4 R
GENTAMICIN------------ <=1 S =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 32 S <=16 S
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
[**2183-12-6**] Blood Culture, Routine (Pending):
[**2183-12-6**] Blood Culture, Routine (Pending):
[**2183-12-7**] MRSA SCREEN (Final [**2183-12-7**]): POSITIVE FOR METHICILLIN
RESISTANT STAPH AUREUS.
Imaging:
CXR:IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs: Heart is severely enlarged. There is probably a
large hiatus hernia, though lateral view would be helpful to
confirm that. Pulmonary vasculature is engorged but there is no
edema, pneumonia, or any pleural effusion. Limited imaging of
the upper abdomen shows severe intestinal distention. Full
abdominal view is recommended.
CT HEAD W/O CONTRAST Study Date of [**2183-12-6**] 2:18 AM
IMPRESSION: Accounting for changes in positioning and
redistribution of blood products, no significant change in
subdural hematoma. No shift of midline structures.
ABDOMEN (SUPINE ONLY) Study Date of [**2183-12-6**] 7:26 AM IMPRESSION:
Two supine views of the abdomen reviewed in the absence of any
prior abdominal imaging. Severe intestinal distention is largely
if not exclusively colonic. All segments of the colon are
dilated, except the rectum. Diameter of the distended cecum is
10 cm, which appears to be greater than any of the other
portions of the colon. When the patient can tolerate an upright
view would be helpful in trying to define the orientation of the
sigmoid to determine whether there are findings of volvulus.
They are equivocal on this examination but that diagnosis is not
excluded. An upright view would also detect pneumoperitoneum
which would have to be substantial to appear on supine abdomen
radiograph.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2183-12-6**] 2:33 PM
IMPRESSION: Massively dilated, air-filled colon is in keeping
with [**Last Name (un) 3696**] syndrome/pseudo-obstruction. No evidence of
volvulus.
RENAL U.S. Study Date of [**2183-12-6**] 2:47 PM
Suboptimal exam due to patient's body habitus and technique. No
hydronephrosis or perinephric collection. Known renal cysts seen
on the CT exam of the same date are not well seen on the current
ultrasound study.
PORTABLE ABDOMEN Study Date of [**2183-12-7**] 11:24 AM
IMPRESSION: A single overhead view of the supine abdomen shows
persistent generalized distention of the colon, with some
improvement. The diameter of the distended cecum is no more than
9 cm today, yesterday it was 10.4 cm. On the other hand, the
sigmoid, previously 7.4 cm, is 8.4 cm today. Its orientation is
not classic for sigmoid volvulus, although the definitive
evaluation would require either sigmoidoscopy or a barium enema.
I cannot be sure whether a rectal tube is in place.
Findings and their clinical significance were discussed with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 656**] at the time of dictation.
Brief Hospital Course:
[**Age over 90 **] year old female presented after a fall with head-strike and
subsequently found to have an occipital subdural hematoma,
initially admitted to the MICU after she became hypotensive in
the setting of having UTI. She was transferred to the floor on
[**12-7**]. She stayed in the hospital until urine culture results
were available so that antibiotics could be tailored.
ACUTE PROBLEMS:
# Subdural hematoma: Pt initially admitted with history of fall
to [**Hospital3 **] and found to have a subdural hematoma on CT
and was transferred to [**Hospital1 **] for close monitoring. She was
evaluated by neurosurgery who felt that neurosurgical
intervention was not currently indicated and recommended the pt
start on dilantin for a total of 10 days. Repeat Head CT showed
no significant change in subdural hematoma and no shift of
midline structures. She is set to have repeat Head CT in 8 weeks
on [**2184-2-3**].
# UTI with sepsis: Patient had leukocytosis, AMS, and
hypotension in the setting of positive UA concerning for
evolving urosepsis vs pyelonephritis. Renal ultrasound showed no
evidence of hydronephrosis or perinephric abscess and pt met
criteria for sepsis. She was initially treated with Zosyn for
her urinary tract infection/urosepsis and once cultures came
back showing E. coli, the antibiotics were narrowed to Keflex to
be continued for a total of 10 days.
# Hypotension / history of hypertension: Pt initially had
hypotension that resolved over the course of her
hospitalization. This was likely due to hypovolemia in the
setting of insensible losses, poor PO intake and concomitant
infection. Her hypotension resolved with IV fluids and her home
lasix and metolazone were held in this setting. Blood cultures
(x2) were no growth at time of discharge, but still pending
final results at time of discharge.
# Abdominal distention: Pts abdominal distention was likely due
to [**Last Name (un) 3696**] syndrome/pseudo-obstruction. There was no evidence
of volvulus on KUB, and CT scan showed a massively dilated,
air-filled colon is in keeping with [**Last Name (un) 3696**]
syndrome/pseudo-obstruction, but there was still no evidence of
volvulus. Pt felt symptomatically better and less distended once
she was able to have a bowel movement (with the help of bowel
medications).
# Afib with RVR: She was continued on metoprolol and dose
uptitrated to 25mg TID as her heart rate was beginning to run in
the 120-130s on her home dose of 25mg [**Hospital1 **]. Pt was continued on
metoprolol with uptitration to 25mg TID as above. Pt's aspirin
was held due to her subdural hematoma. Okay to re-start aspirin
on [**12-15**] as long as her INR is below 1.5.
CHRONIC ISSUES:
# Heart failure, unknown EF: Pt had no evidence of volume
overload on exam. Her ejection fraction is unknown. In the
setting of hypotension during this hospitalization, her lasix
and metolazone were held. It is important that she gets daily
weights in order to monitor her fluid status and it is
recommended that she be restarted on her home lasix and
metolazone once her blood pressures can tolerate it. Her digoxin
level was 1.0 on [**12-6**] and she was continued on 0.0625 mg daily.
# Hypothyroidism: Pt was continued on her home levothyroxine.
TRANSITIONAL ISSUES
# Pt's Abilify and Paroxetine were held in-house and pt did
fine. These will be re-started upon discharge.
# Pt's lasix and metolazone were also held while in-house due to
pt's hypotension upon admission. These should be restarted as
soon as her blood pressures can tolerate it so as not to
exacerbate her heart failure.
# Pt's aspirin was held due to her subdural hematoma. This is
okay to re-start on [**12-15**] as long as her INR is below 1.5.
Medications on Admission:
Tylenol 650 Q4 hrs PRN
Bisacodyl
Deep sea saline mist
Mylanta
Milk of magnesia
Compazine PRN nausea
Megace 625 Daily
Metolazone 2.5mg one tablet daily on Monday and Friday prior to
lasix
Metoprolol 25mg [**Hospital1 **]
Multivitamin
NTG prn
Omeprazole 20mg PRN
Oxybutin 15mg ER QD
Paroxetine 30mg QD
Abilify 2mg QD
ASA 81mg QD
Budesonide INH [**Hospital1 **]
Digoxin 62.5mg QD
Lasix 40mg PO qd
tUSSIN 100MG qd
lEVOTHYROXINE 88MCG qd
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for abd distention.
7. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) neb
Inhalation every six (6) hours.
8. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day) for 9 days: Please continue this
through [**12-18**].
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 9 days: Please continue through [**12-18**].
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. Abilify 2 mg Tablet Sig: One (1) Tablet PO once a day.
13. paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO once a
day.
14. oxybutynin chloride 15 mg Tablet Extended Rel 24 hr Sig: One
(1) Tablet Extended Rel 24 hr PO once a day.
15. multivitamin Tablet Sig: One (1) Tablet PO once a day.
16. Tussin 100 mg/5 mL Liquid Sig: One Hundred (100) mg PO once
a day as needed for cough.
17. budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One
(1) neb Inhalation twice a day.
18. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
19. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5min up to three doses as needed for chest pain.
20. Daily Weights
Please measure daily weights. If weight increases > 3 lbs,
please alert MD. Consider restarting lasix and metolazone.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 6598**] Manor Extended Care Facility - [**Location (un) 6598**]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Subdural hematoma
- Urinary tract infection with sepsis
- Hypotension
- Atrial fibrillation with rapid ventricular response
SECONDARY DIAGNOSES:
- Chronic heart failure, unknown ejection fraction
- Hypothyroidism
- History of throat cancer, with stoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you during your hospital stay
at [**Hospital1 18**]. You were admitted because you had a fall and were
found to have a head bleed by imaging. You were evaluated by
neurosurgery and it was decided that there was no indication for
surgery. The bleed in your head was stable on serial imaging and
you were put on dilantin to help prevent seizures that may occur
due to your head bleed. It is important that you complete the
course of dilantin that is prescribed to you.
You were also found to have a urinary tract infection. We have
started you on an antibiotic called Keflex to treat this
infection. It is important you complete the course of this
antibiotic as it is prescribed to you.
With regards to your medications, please make the following
changes.
Please START:
1. Dilantin
2. Keflex
3. Combivent inhaler
Please STOP:
1. Aspirin -- You can restart this on [**12-15**] (10 days after your
fall) as long as your INR < 1.5
Followup Instructions:
Department: RADIOLOGY
When: TUESDAY [**2184-2-3**] at 1:15 PM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
It is important that you are seen by a doctor shortly after your
discharge from the hospital so that transitional issues may be
followed upon.
Completed by:[**2183-12-10**]
|
[
"5990",
"42731",
"2449"
] |
Admission Date: [**2105-4-20**] Discharge Date: [**2105-5-1**]
Date of Birth: [**2047-1-24**] Sex: M
Service: MEDICINE
Allergies:
Ivp Dye, Iodine Containing / Motrin / Aspirin
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
ED: CVL placement ([**2105-4-19**])
IR: Ultrasound-guided aspiration of right anterior hip fluid
collection ([**2105-4-20**])
Orthopedics: Washout and debridement of right hip joint, deep
bone biopsy ([**2105-4-21**])
Orthopedics: Arthrotomy, right hip with debridement and washout,
Biopsy proximal femur ([**2105-4-24**])
History of Present Illness:
The patient is a 58-yo paraplegic man with decubitus ulcers with
Vac drains, colostomy / urostomy, who presents with fever,
tachycardia, and hypotension. He has been feeling ill for the
past 4 days, with fevers, chills, cough, and shortness of
breath. His cough is productive of a white sputum, more than
usual, and he feels nasal congestion, but denies any chest pain,
palpitations, or chest congestion. He has also had associated
lightheadedness and orthostasis, thirst, nausea, and decreased
PO intake. His nurses were reportedly concerned also about
altered mental status. His temperature was measured at 101.4F,
and he was tachycardic to the 170s with a BP of 98/60, and his
SaO2 was 90-94% on RA. While being transferred by EMS his HR was
noted to be as fast as 189, so he was given 6mg and then 12mg of
Adenosine, without change in his HR.
.
On arrival to the ED, he was hypotensive to SBP 71 but mentating
appropriately, and his HR was running in the 150s. His initial
VS were: Temp 101.9F, HR 150, BP 70s/40s, R 17, SaO2 100% RA. A
left IJ CVL was placed and he was started on Neosynephrine and
IV fluids. His only complaint in the ED was a recent productive
cough, but he was also found to have a tender abdomen, which the
patient states is always tender. Labs were significant for WBC
23.1 (76% PMNs, 17% bands), Hct 25.4, Plt 726, K 2.6, Cr 1.3,
Alb 1.7, INR 1.6, and lactate 4.7. UA showed 21-50 WBCs and many
bacteria. His CXR was clear and ECG showed SVT at 150. He had
blood cultures sent x1 and received Vancomycin, Zosyn, and
Azithromycin. CT-Abdomen/Pelvis was done given his tender
abdominal exam, which revealed a right anterior rim enhancing
fluid collection anterior to the right hip. Surgery was
consulted and this fluid collection was subsequently tapped,
although only a very small amount of fluid was aspirated, the
results of which are still pending. His electrolytes were
repleted and he received a total of 4L NS, with improvement in
his heart rate. His temperature came down to 100.6F, and he was
weaned to room air. He continues on the Neo for pressor support,
and his lactate was found to be rising to 5.3. He is being
admitted to the MICU for sepsis.
Past Medical History:
1. paraplegia - T12 injury from motor vehicle accident 30 years
ago; no sensation or motor function distally
2. stage IV decubitus ulcers on the left buttock area, with some
ulcers on his bilateral toes and sides of his feet
3. s/p colostomy [**1-26**] proximity of ulcer to rectum
4. s/p urostomy, now s/p suprapubic cathether
5. GERD
6. depression
7. anemia with baseline Hct 26-31
8. Multiple PTX in the past, one in [**2098**] followed by talc
pleuridesis on the left side, and then more recently in [**5-/2104**]
9. Left upper lobe bisegmentectomy for T2N0 poorly
differentiated adenocarcinoma
Social History:
Has been living at [**Hospital **] Healthcare >1 year, for help with his
decubitus ulcers. Never married, no children. Prior tobacco,
quit a few years ago (60-pack-year hx). Denies frequent EtOH. No
IVDU.
Family History:
Non-contributory
Physical Exam:
VS - Temp 99.3F, BP 84/48, HR 97, R 19, SaO2 97% RA, CVP 5
GENERAL - ill-appearing male paraplegic in NAD, comfortable
HEENT - NC/AT, PERRL/EOMI, sclera anicteric, dry MM, OP clear
NECK - supple, no LAD or thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh
HEART - RRR, nl S1-S2, no MRG
ABDOMEN - +BS, soft/ND, obese, +TTP diffusely w/ voluntary
guarding, no rebound, no HSM, ostomy intact and functional,
suprapubic catheter intact and functional; stool reportedly
Guaiac neg
SKIN - multiple sacral decubitus ulcers (2 w/ wound-vacs in
place), others w/o erythema or exudate; also ulcers on ankles
bilaterally; no other rashes
EXTREM - trace BLE edema
NEURO - A&Ox3, paraplegic
Pertinent Results:
ADMISSION LABS:
[**2105-4-19**] 09:30PM WBC-23.1*# RBC-3.11* HGB-7.6* HCT-25.3*
MCV-82 MCH-24.5* MCHC-30.1* RDW-15.7*
[**2105-4-19**] 09:30PM NEUTS-76* BANDS-17* LYMPHS-4* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2105-4-19**] 09:30PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
[**2105-4-19**] 09:30PM PLT SMR-VERY HIGH PLT COUNT-726*#
[**2105-4-19**] 09:30PM PT-17.8* PTT-51.7* INR(PT)-1.6*
[**2105-4-19**] 09:30PM GLUCOSE-109* UREA N-16 CREAT-1.3* SODIUM-137
POTASSIUM-2.6* CHLORIDE-107 TOTAL CO2-17* ANION GAP-16
[**2105-4-19**] 09:30PM ALBUMIN-1.7* CALCIUM-7.0* PHOSPHATE-2.0*
MAGNESIUM-1.4*
[**2105-4-19**] 09:30PM ALT(SGPT)-7 AST(SGOT)-20 CK(CPK)-134 ALK
PHOS-113 TOT BILI-0.2
[**2105-4-19**] 09:30PM CK-MB-2
[**2105-4-19**] 09:30PM cTropnT-<0.01
[**2105-4-19**] 09:51PM LACTATE-4.7*
.
DISCHARGE LABS:
WBC 12.4 RBC 7.7 HCT 23.8 PLT 513
Na 138 K 4.2 BUN 12 Creat 0.9 Glucose 118 AGap=9
.
.
RADIOLOGY:
[**2105-4-19**] CXR - No acute cardiopulmonary process.
.
[**2105-4-20**] CT-Abdomen/Pelvis -
1. New fluid collection which has an enhancing rim anterior to
the right proximal femur (2, 104), with adjacent fat stranding.
This finding is concerning for abscess.
2. Decubitus ulcers in the sacrum and posterior to the left hip,
similar in appearance.
3. Mildly distended gallbladder with gallstones.
4. No significant change in appearance of bilateral kidneys as
described above.
5. Calcified nodule in the right hemiscrotum measuring 1.4 cm,
of uncertain significance.
.
[**2105-4-22**] TTE - Suboptimal image quality. Mild thickening of the
mitral leaflets with mild mitral regurgitation. No discrete
vegetation identified. Preserved global and regional
biventricular systolic function.
.
[**2105-4-26**] Brain MRI - The present contrast-enhanced scans are
degraded by patient motion. Other sequences are of excellent
technical quality due to the employment of motion compensating
sequences (propeller).
Since the prior study of [**2104-1-16**], no new mass lesion
has evolved, nor has there been change in ventricular size
appreciated. Diffusion-weighted images of the brain are normal.
There are no areas of abnormal susceptibility defined.
Both studies reveal a focal area of encephalomalacia within the
left frontal vertex portion of the cerebral cortex.
There were no overt extracranial abnormalities seen.
CONCLUSION: No overt interval change from the patient's prior
outside study from [**Hospital3 2576**] [**Hospital3 **].
.
MICROBIOLOGY:
[**2105-4-20**] Fluid collection aspirate -
GRAM STAIN (Final [**2105-4-20**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SHORT CHAINS.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2105-4-24**]):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. MODERATE
GROWTH.
SENSITIVITIES REQUESTED PER DR. [**Last Name (STitle) **] #[**Numeric Identifier 49268**]
[**2105-4-22**].
Sensitivity testing performed by Sensititre.
VANCOMYCIN SENSITIVITY PERFORMED ON REQUEST.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (MILLERI)
GROUP
|
CLINDAMYCIN----------- =>2 R
ERYTHROMYCIN---------- =>4 R
PENICILLIN G---------- 0.06 S
.
[**2105-4-21**] Wound Swab -
GRAM STAIN (Final [**2105-4-21**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2105-4-23**]):
BETA STREPTOCOCCUS NOT GROUP A OR B. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2105-4-27**]):
PREVOTELLA SPECIES. RARE GROWTH. BETA LACTAMASE
POSITIVE.
.
[**2105-4-24**] Wound Swab -
GRAM STAIN (Final [**2105-4-24**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2105-4-27**]): NO GROWTH.
.
PATHOLOGY:
[**2105-4-21**] Tissue: Femur bone.
Bone, right femur:
Bone and marrow with maturing trilineage hematopoiesis.
Fibrofatty soft tissue.
No necrosis or inflammation noted, all tissue was submitted for
histology.
.
[**2105-4-24**] Tissue: Bone - Hip, Right Hip Wound.
I. Right hip bone (A):
Necrotic fragments of bone with fibrous replacement of the
marrow and acute osteomyelitis.
II. Right hip wound (B):
Necrotic bone and fibrous connective tissue with marked acute
inflammation.
Brief Hospital Course:
[**Hospital 12145**] Hospital Course:
58-yo paraplegic man with decubitus ulcers with Vac drains,
colostomy / urostomy, who presents with fever, tachycardia, and
hypotension, c/w sepsis.
.
#. Septic shock / right anterior thigh abscess ?????? Pt initially
admitted with hypotension requiring Neosynephrine for
vasopressor support, but mentating appropriately. He was
aggressively fluid resuscitated, with improvement in his blood
pressure and weaning of his vasopressors, but was unable to come
off the Neosynephrine for several days. His fevers, WBC, and
renal failure improved. The source of his sepsis is a right
anterior hip abscess, which was aspirated and found to grow
Strep milleri. Blood cultures also grew Strep milleri, but
subsequent blood cultures cleared on empiric antiotic therapy
with Vanc and Zosyn (first day of Abx [**3-20**]). A TTE was done to
rule-out vegetation, which was a poor study, but a TEE was not
felt to be indicated. He was taken to the OR twice by [**Month/Year (2) 1957**] for
washouts and bone biopsies. ID was involved, and he did not grow
out any other bacteria, so the Vanc and Zosyn were changed to
Ceftriaxone and Flagyl on [**4-26**] for improved Strep milleri, Gram
negative, and anaerobic coverage. Given that he was difficult to
wean off the Neosynephrine, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test was done that
showed borderline response, so he was tried on stress-dose
steroids, and he was able to slowly wean, although he likely did
not get enough doses of the stress-dose steroids to have an
effect on his blood pressure. The stress-dose steroids were
stopped for this reason. Finally, an MRI was done to rule-out a
brain abscess, which was negative.
.
#. Decubitus ulcerations - These are chronic, and have been
treated with wound-Vacs that have been managed as an outpatient.
He was seen by his primary Plastic surgery team, who felt that
the decubitus ulcers were communicating with his right anterior
thigh abscess, but any infection would be adequately covered
with his antibiotic treatment. Wound care nursing consult was
placed as well, and he was started on additional vitamins to aid
with wound healing.
.
#. SVT - The patient had one episode of SVT to 150, which
responded to adenosine administration. It was captured on ECG
and was thought to be an AVNRT.
.
#. Anemia - The patient's hematocrit was stable for several
days, but did drop slightly prior to transfer. There has been no
evidence of bleeding, and anemia labs are pending. He was
transfused 2 units of packed RBCs.
.
#. Productive cough - Symptoms on admission were likely upper
respiratory in origin, and his clear exam and CXR were
consistent with this. His symptoms improved significantly. He
was continued on his home albuterol nebulizers.
.
#. Abdominal pain - This was chronic per the patient, and his
symptoms are migratory in nature. His CT showed chronic
findings, no acute changes. He was started on simethicone and
continued on his home PPI, and general surgery was following as
well.
.
#. Paraplegia - The patient was continued on his home
medications, including [**Hospital1 **] Lovenox; Oxycontin and PRN Percocet,
Tylenol, Ativan; vitamins; and bowel regimen.
.
#. GERD - He was continued on his home PPI and PRN antacid.
.
#. Hyperlipidemia - He was continued on his home TriCor.
.
#. Communication - with patient, girlfriend [**Name (NI) **] [**Name (NI) 49269**]
[**Telephone/Fax (1) 49270**]
.
#. FULL CODE
.
GENERAL [**Hospital 662**] HOSPITAL COURSE: Per active problem lists.
.
# Strep Milleri bactermia / right anterior thigh abscess:
Hemodynamically stable. IJ was pulled and PICC placed for
long-term antibiotics. Pathology from right hip returned
confirming osteomyelitis. Patient requires close ID follow-up
treatment of osteomyelitis, strep milleri bactermia. Current
antibiotic treatment Ceftriaxone 2g IV q24, Flagyl 500mg po 3XD
continue until [**2105-6-5**] for 8 week course. Day 1 [**2105-4-24**]. DO
NOT STOP ANTIBIOTICS UNTIL SEES INFECTIOUS DISEASE. Patient MUST
attend ID follow-up [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2105-6-4**] 10:30.
.
Requires weekly lab draws (Creat, bun, AST/ALT, CBC+diff,
ESR/CRP). All laboratory results should be faxed to Infectious
disease [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**] ([**Telephone/Fax (1) 6313**] ([**Telephone/Fax (1) 6313**]. All
questions regarding outpatient antibiotics should be directed to
the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**] or to on [**Name8 (MD) 138**] MD
in when clinic is closed.
.
Patient needs to schedule CT Abdomen/Pelvis [**2105-6-1**] prior to ID
Appointment [**2105-6-4**]. Call [**Telephone/Fax (1) 327**] to schedule.
.
# Possible left apical pleural tumor: Patient has history of
lung cancer and concern for recurrence. CXR demonstrates [**2105-4-28**]
possible left apical pleural tumor. CT scan no contrast was done
to further eval. Only prelim was avaliable prior to discharge.
FINAL CT SCAN NEEDS TO BE FOLLOWED UP BY ONCOLOGY AND THORACIC
SURGEON.
- Patient needs to follow-up with his thoracic surgeon
[**Doctor Last Name **],[**Last Name (un) 11482**] and Oncologist Dr [**Last Name (STitle) **]. CALL [**Doctor Last Name **]
[**Doctor Last Name 49271**] to schedule appointment ([**Telephone/Fax (1) 17398**].
.
# R hip decubitus ulcer: Debridement by orthopedics (see course
above). Path results confirm osteomyeletis.
- Right Hip Vac change every 4-5 days. Follow-up with
orthopedics. Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2105-5-14**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD
Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2105-5-14**] 9:20
- Vac changed day of discharge
- Wound care per discharge instructions
.
# Decubitus sacral ulcer: Has VAC in place prior to transfer.
Needs to be followed by plastic surgery. Provider: [**Name10 (NameIs) **]
SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2105-5-22**] 3:00
- Wound care per discharge instructions
.
#. Access - PICC placed by IR, L IG removed [**2105-4-29**]
Medications on Admission:
- Vitamin B12 500mcg PO daily
- MVI w/ minerals PO daily
- Ferrous sulfate 325mg PO daily
- Folic acid 1mg PO daily
- Lovenox 30mg SQ [**Hospital1 **]--unclear why he is on [**Hospital1 **] dose
- [**Name (NI) **] 100mg PO BID
- OxyContin 80mg PO BID
- TriCor 145mg PO QHS
- Benzocaine 7% oral gel Q3hrs PRN
- Omeprazole 20mg PO daily
- Acetaminophen 650mg PO Q4hrs PRN
- Liquid antacid 30ml PO Q4hrs PRN
- KCl 10mEq PO daily
- Bisacodyl 10mg supp daily PRN
- Milk of Magnesia 30ml PO daily PRN
- Albuterol nebs Q6hrs PRN
- Trazodone 50mg PO QHS PRN
- Senna 8.6mg PO BID PRN
- Percocet 5-325mg 2tabs PO Q4hrs PRN
- Lorazepam 0.5mg PO Q12hrs PRN
- Regular diet
- Promod liquid 30ml PO BID
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Cyanocobalamin 500 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Two (2)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
8. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
QHS (once a day (at bedtime)).
9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed.
11. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
Thirty (30) ML PO QID (4 times a day) as needed.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed.
14. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) as needed.
15. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
16. Ascorbic Acid 90 mg/mL Drops Sig: 504 mg PO DAILY (Daily).
17. Vitamin A 10,000 unit Capsule Sig: Three (3) Capsule PO
DAILY (Daily).
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
19. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for gas.
20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours): Continue until [**2105-6-5**] for 8 week course. .
21. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
22. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
23. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours): Prophalyxis. .
24. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
25. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One (1) Intravenous Q24H (every 24 hours): Continue until
[**2105-6-5**] for 8 week course. .
26. Outpatient Lab Work
Weekly labs required:
Creat
bun
AST/ALT
CBC+diff
ESR/CRP
.
All laboratory results should be faxed to Infectious disease
[**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**] ([**Telephone/Fax (1) 6313**] All questions regarding
outpatient antibiotics should be directed to the infectious
is closed.
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Septic shock
Strep Milleri bactermia
Stage 4 decubitus ulcers
Osteomyelitis
Discharge Condition:
Afebrile for over 24 hours
Discharge Instructions:
You were admitted for fever, tachycardia, and low blood
pressure. You had bacteria growing in your blood called Strep
milleri. The most likely source is your chronic wounds. Your
right hip was debrided by orthopedics who placed a wound Vac.
You had an infection in your bone called osteomyeletis. Because
of your serious infections it is important you continue your
antibiotics, follow-up with Infectious Disease and Orthopedics.
.
A chest x-ray demonstrated a possible recurrence of your lung
nodule. You had a CT scan prior to discharge to evaluate. The
final report was pending at discharge. It is very important that
you follow-up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 3274**] and Radiation
Oncology.
.
Medications: A list will be provided to your facility. Several
changes have been made.
.
Patient needs to make the following appointments:
- Patient needs to follow-up with his thoracic surgeon
[**Doctor Last Name **],[**Last Name (un) 11482**] and Oncologist Dr [**Last Name (STitle) **]. CALL [**Doctor Last Name **]
[**Doctor Last Name 49271**] to schedule appointment ([**Telephone/Fax (1) 17398**]. VERY IMPORTANT
TO SCHEDULE REGARDING FINAL CT READ - POSSIBLE RECURRENT LUNG
MASS.
.
Patient needs to schedule CT Abdomen/Pelvis [**2105-6-1**] prior to ID
Appointment [**2105-6-4**] Call to schedule [**Telephone/Fax (1) 327**].
.
Very important patient attends ALL appointments:
[**Telephone/Fax (1) **]:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2105-5-14**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2105-5-14**] 9:20
ID:
Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2105-6-4**] 10:30
PLASTIC:
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2105-5-22**] 3:00
.
Call your doctor if you experience fevers, chills, difficulty
breathing, chest pain, nausea, vomiting or other concerning
symptoms.
Followup Instructions:
Patient needs to make the following appointments:
- Patient needs to follow-up with his thoracic surgeon
[**Doctor Last Name **],[**Last Name (un) 11482**] and Oncologist Dr [**Last Name (STitle) **]. CALL [**Doctor Last Name **]
[**Doctor Last Name 49271**] to schedule appointment ([**Telephone/Fax (1) 17398**]. VERY IMPORTANT
TO SCHEDULE REGARDING FINAL CT READ - POSSIBLE RECURRENT LUNG
MASS.
.
Patient needs to schedule CT Abdomen/Pelvis [**2105-6-1**] prior to ID
Appointment [**2105-6-4**] Call to schedule [**Telephone/Fax (1) 327**].
.
Very important patient attends ALL appointments:
[**Telephone/Fax (1) **]:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2105-5-14**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2105-5-14**] 9:20
ID:
Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2105-6-4**] 10:30
PLASTIC:
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2105-5-22**] 3:00
Completed by:[**2105-5-5**]
|
[
"78552",
"99592",
"311",
"53081",
"2859",
"42789"
] |
Admission Date: [**2122-9-27**] Discharge Date: [**2122-10-5**]
Date of Birth: [**2080-4-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
V fib arrest
Major Surgical or Invasive Procedure:
IABP placement
Cardiac Catheterization
Central venous catheter
arterial cannulation
History of Present Illness:
The patient is a 42 yo M with a reported hx of alcoholism who
was reportedly feeling poorly yesterday afternoon. He went to
his friend's house where he had a witnessed arrest with
associated seizure like activity. CPR was started on the scene
by nurse bystander. AED was on scene and gave pt two shocks.
Pt subsequently went into sinus tach with ROSC. Pt was also
given narcan and became combative.
.
Was brought to OSH and started on amio, heparin [**Last Name (LF) 1868**], [**First Name3 (LF) **],
intubated and received 2L cool saline but not started on artic
sun. EKG showed inferior STE. Labs were notable for
hyperkalemia of 6.5, troponin of 0.06. On way to [**Hospital1 18**] pt went
into vtach requiring another shock.
.
In ED EKG showed STE in inferior leads, U/S showed paradoxical
septal wall motion and overall hypokinesis, worsened by
dopamine. Amio drip started. Dopamine gtt was started while
waiting for cath lab due to pressures 50s/30s.
.
In the cath lab, found to have circ lesion, stent placed,
concern for wide open MR. Oddly, MVO2 was 85%, and shunt run
was negative. IABP was placed.
Past Medical History:
restless leg syndrome
alcoholism
Social History:
Per mother, patient only has hx of alcoholism (30 pack of beer
every day) and was feeling tired today. Otherwise in USOH prior
to incident. As far as mother knows, does not abuse drugs.
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
VS: T=afebrile BP=96/64 HR=78 RR=24 O2 sat=100%
GENERAL: Intubated, sedated, on arrival moving all extremities
HEENT: NCAT. Sclera anicteric. PERRL, OP with poor dentition and
numerous loose teeth
NECK: Supple, JVP not elevated
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RRR, heart sounds distant, difficult to hear any MRG
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Lungs with course
sounds throughout but no crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE EXAM
Vitals - Tm/Tc: 100.0/98.8 HR: 81 (81-98) RR: 18
BP: 104/66 (104-126/63-81) 02 sat: 91% RA (91-98%RA)
Weight: 91.8 kg
GENERAL: Well developed, well nourished male in no acute
distress
CHEST: CTAB, no wheezes, no rales, no rhonchi
CV: S1 S2, Normal in quality and intensity, RRR, no murmurs rubs
or gallops
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding, neg HSM.
EXT: wwp, no edema. DPs, PTs 2+.
PSYCH: Alert and oriented x 3
Pertinent Results:
ADMISSION LABS
[**2122-9-26**] 10:55PM BLOOD WBC-20.2* RBC-4.72 Hgb-15.7 Hct-45.9
MCV-97 MCH-33.3* MCHC-34.2 RDW-12.6 Plt Ct-409
[**2122-9-27**] 02:23AM BLOOD WBC-17.1* RBC-5.08 Hgb-16.4 Hct-48.3
MCV-95 MCH-32.3* MCHC-34.0 RDW-12.6 Plt Ct-400
[**2122-9-27**] 02:23AM BLOOD Neuts-84.2* Lymphs-10.0* Monos-5.2
Eos-0.4 Baso-0.1
[**2122-9-26**] 10:55PM BLOOD PT-13.7* PTT-72.0* INR(PT)-1.2*
[**2122-9-26**] 10:55PM BLOOD Fibrino-361
[**2122-9-30**] 04:28AM BLOOD Fibrino-858*#
[**2122-9-27**] 02:23AM BLOOD Glucose-159* UreaN-19 Creat-1.0 Na-137
K-4.7 Cl-107 HCO3-19* AnGap-16
[**2122-9-27**] 02:23AM BLOOD ALT-58* AST-234* LD(LDH)-437* AlkPhos-87
TotBili-0.5
[**2122-9-27**] 05:25AM BLOOD CK(CPK)-7100*
[**2122-9-26**] 10:55PM BLOOD Lipase-23
[**2122-9-27**] 05:25AM BLOOD CK-MB-GREATER TH cTropnT-2.99*
[**2122-9-27**] 08:30PM BLOOD CK-MB-450* cTropnT-5.64*
[**2122-9-28**] 04:08AM BLOOD CK-MB-218* MB Indx-2.2
[**2122-9-30**] 04:28AM BLOOD CK-MB-10 MB Indx-0.6
[**2122-9-27**] 02:23AM BLOOD Calcium-8.5 Phos-4.6* Mg-2.3
[**2122-9-29**] 03:56AM BLOOD Albumin-3.0* Calcium-7.8* Phos-1.6*
Mg-2.0
[**2122-9-29**] 03:56AM BLOOD Hapto-178
[**2122-9-29**] 10:53AM BLOOD D-Dimer-338
[**2122-10-3**] 02:31PM BLOOD %HbA1c-5.5 eAG-111
[**2122-10-3**] 06:07AM BLOOD Triglyc-170* HDL-18 CHOL/HD-5.4
LDLcalc-45
[**2122-9-26**] 10:55PM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2122-9-26**] 11:04PM BLOOD Glucose-130* Lactate-3.7* Na-141 K-4.1
Cl-109* calHCO3-21
[**2122-9-26**] 10:55PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
DISCHARGE LABS
[**2122-10-5**] 06:20AM BLOOD WBC-13.0* RBC-3.67* Hgb-12.4* Hct-34.2*
MCV-93 MCH-33.8* MCHC-36.2* RDW-13.1 Plt Ct-565*
[**2122-10-2**] 05:16AM BLOOD PT-13.8* PTT-26.3 INR(PT)-1.2*
[**2122-10-4**] 06:09AM BLOOD Glucose-91 UreaN-11 Creat-0.8 Na-142
K-3.6 Cl-103 HCO3-25 AnGap-18
[**2122-9-30**] 04:28AM BLOOD ALT-142* AST-133* LD(LDH)-635*
CK(CPK)-1650* AlkPhos-57 TotBili-0.5
[**2122-10-4**] 06:09AM BLOOD Calcium-8.4 Phos-3.6 Mg-1.8
.
MICROBIOLOGY
[**2122-9-27**], [**2122-9-28**] Urine culture (final): NO GROWTH
[**2122-9-27**], [**2122-9-28**] Blood culture (final): NO GROWTH
[**2122-10-1**] Catheter Tip Culture (final): Due to mixed bacterial
types, no further workup performed
[**2122-9-29**] Sputum Culture (final): Coag + Staph Aureus, sparse
growth
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
IMAGING
[**2122-9-27**] Cardiac cath
1. Selective coronary angiography of this left dominant system
demonstrated two vessel coronary artery disease. The LMCA was
patent.
The LAD had minor diffuse disease. The LCX had a tubular
proximal lesion
of abotu 80% with possible thrombosis. The RCA had a chronic
occlusion
mid-vessel with collaterals filling from the left coronary
system.
2. Limited resting hemodyanmics revealed elevated right and
left-sided
filling pressures with PASP of 54mmHG and mean PCWP of 35mmHg.
3. Left ventriculography revealed global hypokinesis with an
estimated
LV ejection fraction of less than 30%. There was also [**3-6**]+
Mitral
regurgitation. Cardiac index was preserved at 4.5 L/min/m2 using
a
pulmonary arterial saturation of 85% in the Fick equation. No
shunts
were observed.
4. An intra-aortic balloon pump was placed sheathed in the right
femoral
artery.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Severe mitral regurgitation.
3. Severe systolic ventricular dysfunction.
4. Acute inferior myocardial infarction, managed by acute ptca.
PTCA of vessel.
5. Intra-aortic balloon pump placement.
.
[**2122-9-29**] ECHO: The left atrium is elongated. There is moderate
regional left ventricular systolic dysfunction with
inferior/inferolateral akinesis and anteroseptal
hypokinesis/akinesis (LVEF approximately 35 percent). Right
ventricular chamber size is normal. with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Physiologic mitral regurgitation is seen
(within normal limits). There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared to [**2122-9-27**], left ventricular function appears less
depressed but views are suboptimal for comparison.
.
[**2122-9-30**] CXR: Mild interstitial pulmonary edema predominantly in
the right upper lung is new. The large right lower lobe
consolidation most likely aspiration pneumonia is stable, now
accompanied by at least a small if not larger right pleural
effusion. Intra-aortic balloon pump has been removed. Ascending
Swan-Ganz rotation catheter ends in the right descending
pulmonary artery. ET tube in standard placement. Nasogastric
tube loops in the upper stomach. No left pleural effusion. No
pneumothorax.
.
[**2122-10-1**] CT C-SPINE W/O CONTRAST: There is no evidence of acute
fracture or malalignment. No prevertebral soft tissue edema or
hematoma is seen. The visualized portion of the aerodigestive
tract is grossly unremarkable. Multiple small bilateral cervical
lymph nodes do not meet CT size criteria. There is at least a
moderate right pleural effusion. Secondary interlobular septal
thickening seen in the lung apices are consistent with mild
pulmonary edema. The thyroid gland is grossly unremarkable.
Scattered air-fluid levels are seen within left mastoid air
cells. The visualized portions of the right mastoid air cells
are well aerated. A mucus retention cyst is seen within the left
maxillary sinus.
.
[**2122-9-28**] ANKLE (AP, MORTISE & LAT) LEFT PORT: Three views of the
left ankle were obtained. The patient is status post ORIF of a
an old distal left fibular fracture, with lateral plate and
interlocking screws. Hardware is intact, in proper position and
without signs of complication. An old fracture is also noted of
the distal tibia, with narrowing and large osteophytosis of the
tibiotalar joint. An ankle joint effusion and soft tissue
swelling are seen. No new fracture or dislocation is identified.
Brief Hospital Course:
42 yo M with a reported hx of alcoholism but no know cardiac
history admitted from osh with vfib arrest and STEMI, already
intubated for airway protection.
.
# V-fib arrest: It is unclear how long pt was down prior to CPR
initiation and shock, but on arrival to [**Hospital1 18**], pt was moving all
extremities and responsive, thus cooling protocol was not
initiated. Etiology of arrest is most likely secondary to
ischemia, given pt also presented with STEMI and cath lab
revealed large circ lesion, as described below. Pt was loaded
on amiodorone and on HD1 he had several runs of NSVT, one of
which was with rate in 200's and lasted for approximately 10
sec. Afterwards, he was started on lidocaine drip and telemetry
remained normal. He was eventually weaned off pressors and
amiodarone was discontinued as pt did not have an indication for
continuation of therapy.
.
#Cardiogenic shock: Pt has no known history of CHF, but cath lab
shows evidence of severe MR [**First Name (Titles) **] [**Last Name (Titles) **] of 30% with global
hypokinesis. Also elevated CO (consistent with MR) and elevated
left sided filling pressures. There is no evidence of right
sided strain and no evidence of tamponade. Only unexplained
factor is elevated mixed venous sats, which would raise concern
for sepsis and a RLL opacity was shown on CXR, concerning for
pneumonia (HAP v. aspiration). He was initially put on
vancomycin, cefepime, and flagyl but as his sputum culture grew
MSSA, he was only continued on cefepime and then PO cefpodoxime
for a total 8 day course of antibiotics. Pt initially required
IABP and pressor support to maintain adequate perfusion MAPs but
as his pneumonia was being treated, he slowly recovered his
vascular resistance and was weaned off the balloon pump and
pressor support.
.
#CAD: Prior to hospitalization, pt did not have known CAD. Cath
revealed two vessel disease, stenosed LCx and there was
successful PCI of the proximal LCx with a 2.75 x 12 mm Integrity
BMS. He was started on prasugril 60mg load and then
transitioned to 10mg daily but this was not continued upon
discharge. He was also started on aspirin 325mg, metoprolol XL
12.5mg daily, lisinopril 5mg daily, atorvastatin 80mg daily, and
clopidogrel 75mg daily, and was discharged on [**Last Name (Titles) **] 325mg daily,
lisinopril 5mg daily, metoprolol succinate 25mg daily,
simavastatin 40mg daily.
.
#RLL pneumonia: Pt had a WBC up to 20.2 with a left shift and
RLL pneumonia became apparent on chest x-ray from [**9-28**] and pt
was started on vancomycin, cefepime, and flagyl but as his
sputum culture grew MSSA, he was only continued on cefepime and
then PO cefpodoxime for a total 8 day course of antibiotics. WBC
normalized throughout the hospital course, and was 13.0 the day
of discharge.
.
# EtOH history: Pt's family reports that he drinks 30 beers
every day. Labs from OSH showed negative serum tox for alcohol.
Urine tox screen was negative for other substances. Pt does
not have know history of cirrhosis or alc hep. He had a mild
alcoholic transaminitis on admission (but this also could be
explained by acute ischemia), but his liver's synthetic function
was normal. Initially he was requiring very high [**Month/Year (2) 4319**] of
fentanyl and versed to achieve adequate sedation. Pt was
started on thiamine, folate and multivitamin. CIWA protocol was
not intitiated because during the period of expected withdrawal,
pt was receiving benzodiazepines while he was intubated and
sedated. Pt reports an understanding that he will need to change
his behavior and activity regarding his alcohol intake and
abuse.
.
Transitional:
# Recommend support system for EtOH abuse
Medications on Admission:
None.
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(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. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
0.5 Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular Fibrillation arrest
ST Elevation myocardial infarction
Cardiogenic shock
Aspiration pneumonia wtih methacillian sensitive staph aureus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack and a fatal heart rhythm called
ventricular fibrillation that required a shock. You were brought
to [**Hospital1 18**] and a stent was placed in your heart artery to open it.
It is extremely important that you take aspirin and plavix every
day to prevent the stent from clotting off. Do not stop taking
aspirin and plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **] tells
you it is OK. You will need to stop smoking and drinking all
alcohol in order to let your heart heal from the heart attack.
You will need to take new medicines to help your heart recover
and prevent another heart attack in the future. Physical therapy
reviewed your recommended activity for the next month at home.
Your heart is weaker after the heart attack and you will need to
monitor yourself for fluid buildup at home. Weigh yourself every
morning before breakfast, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days. You need to
avoid salt in your diet, a teaching packet was given to you
about a low salt diet.
Your memory is only slightly impaired during the evaluation by
occupational therapy. You can call Dr. [**Last Name (STitle) **] [**Name (STitle) **] at
[**Telephone/Fax (1) 91658**] if you notice that you are having any trouble with
your memory or thinking.
.
WE have started you on the following medicines:
1. START taking aspirin and plavix every day to prevent the
stent from clotting off and causing another heart attack.
2. START taking metoprolol to prevent another heart attack
3. START taking lisinopril to help your heart pump better
4. START taking simvastatin to lower your cholesterol and
prevent another heart attack.
5. START taking thiamine and folic acid to help your nutrition
6. START taking famotidine to protect your stomach from the
plavix and aspirin.
Followup Instructions:
Name: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Cardiology
[**Location (un) 33730**], [**Location (un) 9101**], Ma
Phone:[**Telephone/Fax (1) 33732**]
When: Friday, Octber 7th at 2:15pm
Completed by:[**2122-10-6**]
|
[
"51881",
"78552",
"2762",
"2875",
"5070",
"99592",
"2767",
"41401",
"4240",
"25000",
"4019",
"3051",
"2724"
] |
Admission Date: [**2177-12-19**] Discharge Date: [**2177-12-20**]
Date of Birth: [**2128-10-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
ascending thoracic aortic dissection
Major Surgical or Invasive Procedure:
[**2177-12-19**] - open repair of asending aortic dissection,
exploratory laparotomy, partial collectomy, packing of abdomen
History of Present Illness:
Patient is a 49 year old male who is transferred to [**Hospital1 18**]
with abdominal pain concern is for aortic dissection. The pain
began at 9 am this morning. Patient underwent the CT scan of the
abdomen which showed a dissection of abdominal aorta. Patient
was
subsequently transferred here. The blood pressure on admission
was in 200s systolic. Patient was hemodynamically stable. At the
time of presentation to the [**Hospital1 18**] patient continued to be
hemodynamically stable with sbp in 110 - 150s and hr in the 90s
-
100s, saturating well on room air. Patient denies any pain. He
underwent an emergent CTA of the aorta with run offs which
showed
Type A aortic dissection.
Past Medical History:
HTN (untreated)
Social History:
smoked 1.5 pack a day for at least 20 years, quit [**3-/2176**]
Family History:
non-contributory
Physical Exam:
PE: on admission
VS: 98 87 135/76 18 99% RA
gen: alert and oriented, appropriate, seemed comfortable
CV: RRR
pulm: CTA b/l
abd: mildly softly distended, minimally diffusely tender, + BS
extemities: pulses all palpable
Patient passed away. At the last examination his heart was
motionless (the chest was open), there were no pulses, the
pupils were fixed and dilated bilaterally, there were no breath
sounds.
Pertinent Results:
imaging:
[**2177-12-19**] CTA aorta with run-offs
1. Long type A aortic dissection with a small hemopericardium.
RCA, LAD, and LCx remain opacified. Dissection extends through
the common iliac arteries and into the proximal left and right
internal iliac arteries and mid right external iliac artery.
2. Complete infarction of the right kidney and spleen. Small
amount of clot in the proximal left renal artery although the
left kidney remains normally perfused.
3. Liver remains perfused but the blood supply in the celiac
trunk appears
tenuous. Blood supply in the proximal superior mesenteric artery
is also
tenuous although good flow is seen distally. Inferior mesenteric
artery
remains normally opacified.
[**2177-12-19**] 03:25PM BLOOD WBC-10.7 RBC-4.43* Hgb-13.4* Hct-40.2
MCV-91 MCH-30.3 MCHC-33.4 RDW-12.3 Plt Ct-259
[**2177-12-19**] 10:42PM BLOOD WBC-10.7 RBC-2.26* Hgb-6.8* Hct-20.8*
MCV-92 MCH-29.9 MCHC-32.5 RDW-12.3 Plt Ct-126*
[**2177-12-20**] 01:27AM BLOOD WBC-8.2 RBC-2.63* Hgb-8.1* Hct-25.2*
MCV-96 MCH-30.6 MCHC-32.0 RDW-13.1 Plt Ct-23*#
[**2177-12-19**] 03:25PM BLOOD PT-15.0* PTT-38.2* INR(PT)-1.3*
[**2177-12-19**] 09:03PM BLOOD PT-24.9* PTT-102.8* INR(PT)-2.4*
[**2177-12-20**] 01:27AM BLOOD PT-27.3* PTT-150* INR(PT)-2.6*
[**2177-12-20**] 01:27AM BLOOD Plt Smr-VERY LOW Plt Ct-23*#
[**2177-12-19**] 03:25PM BLOOD Glucose-105* UreaN-14 Creat-1.4* Na-133
K-7.3* Cl-100 HCO3-23 AnGap-17
[**2177-12-20**] 01:27AM BLOOD Glucose-206* UreaN-15 Creat-1.5* Na-148*
K-5.1 Cl-117* HCO3-10* AnGap-26*
[**2177-12-19**] 09:03PM BLOOD ALT-7370* AST-7095* AlkPhos-91
TotBili-0.7
[**2177-12-20**] 01:27AM BLOOD ALT-4328* AST-7523* LD(LDH)-8920*
AlkPhos-56 Amylase-123* TotBili-0.6
[**2177-12-19**] 03:25PM BLOOD Calcium-8.3* Phos-4.5 Mg-2.4
[**2177-12-20**] 01:27AM BLOOD Albumin-1.7* Calcium-12.7* Phos-10.2*#
Mg-2.1
[**2177-12-19**] 04:17PM BLOOD Type-ART pO2-383* pCO2-52* pH-7.21*
calTCO2-22 Base XS--7 Intubat-INTUBATED Vent-CONTROLLED
[**2177-12-19**] 11:48PM BLOOD Type-ART pO2-280* pCO2-36 pH-7.24*
calTCO2-16* Base XS--11
[**2177-12-20**] 01:36AM BLOOD Type-ART pO2-83* pCO2-50* pH-6.91*
calTCO2-VERIFIED Base XS--24
Brief Hospital Course:
Patient was brought to the [**Hospital1 18**] from [**Hospital 8641**] Hospital. He was
taken from the med-flight to the CT scanner where he was found
to have an extensive ascending Type A aortic dissection,
extending from the ascending arch to the iliac vessels. The
patient was hemodynamically stable. He was taken to the
operating room emergently for an open repair of the dissection.
In the OR patient underwent the open thoracotomy and an open
repair of the ascending aortic dissection. He was found to have
hyperkalemia and hemodialysis was initiated while patient was on
cardiac-pulmonary bypass. There was concern that patient had
ischemia of the bowel and underwent exploratory laparotomy and
bowel resection. He was left in discontinuity and his abdomen
was packed. The details may be seen in the operative notes. He
tolerated the operation and was taken from the operating room to
the CVICU intubated on multiple vasopressors.
In the CVICU the resuscitation continued. Patient was receiving
blood products and crystalloids, also protamine. He suddenly
became hypotensive and went into ventricular fibrillation. The
chest was re-opened, the packs were removed. The resuscitation
continued and the heart was shocked directly three times.
Patient was in PEA arrest. Direct open heart massage was
performed. The ventricular leads were repositioned and patient
was ventricularily paced for a while. The heart continued to be
massaged. Unfortunately, the right ventricle was progressively
less functioning. Despite all efforts at resuscitation, the
patient did not recover and passed away. The family was present
and the body was sent for an autopsy.
Medications on Admission:
none
Discharge Medications:
patient passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
Type A Aortic Dissection
Discharge Condition:
patient passed away from cardiac tamponade and likely right
heart failure
Discharge Instructions:
not-applicable
Followup Instructions:
not-applicable
Completed by:[**2177-12-21**]
|
[
"2762",
"9971",
"2767",
"4019"
] |
Admission Date: [**2115-3-5**] Discharge Date: [**2115-3-5**]
Date of Birth: Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
gentleman who fell down 20 stairs. He was sent to an outside
hospital. Reportedly not moving his lower extremities and
unresponsive at the scene.
PAST MEDICAL HISTORY: Ethanol abuse.
PHYSICAL EXAMINATION ON PRESENTATION: The patient was
intubated, previously sedated and paralyzed. Localizing at
both upper extremities. Withdraws lower extremities. His
pupils were 1.5 cm and nonreactive. Vital signs revealed
blood pressure was 110/66. His pulse was 74. The patient
was on a ventilator with oxygen saturations of 100%.
Temperature was 98.8. The patient had blood in his left ear.
PERTINENT RADIOLOGY/IMAGING: A head computed tomography
showed acute left epidural hematoma and right subarachnoid
hemorrhage.
BRIEF SUMMARY OF HOSPITAL COURSE: The patient was to the
operating room for an emergent evacuation of the epidural
hematoma. Postoperatively, the patient was sedated. Blood
pressure was 123/64 on Neo-Synephrine, heart rate was 70, and
respiratory rate was 19. Saturations of 100%.
Neurologically, pupils were 3.5 down to 2.5. Grimaced to
pain with slight elevation of the upper and lower extremities
to deep painful stimulation. The toes were downgoing.
Slight withdrawal to pain.
The patient was to the operating room on [**2114-10-14**].
He underwent a craniotomy and evacuation of the epidural
hematoma, repair of dural tear, elevation of depressed skull
fracture. There was a cerebrospinal fluid leak at the time
of surgery. ENT was consulted for a question of
facial nerve injury due to temporal bone fracture from the
fall. Preliminary findings from a computed tomography of the
temporal bone showed no fracture involving the seventh
cranial nerve, positive fracture of the left EAC and left
comminuted fracture of the lateral left temporal bone with no
involvement of the carotid or jugular bulb.
Postoperatively the patient was awake, confused, combative,
responding to questions, moving all extremities to command
involving contusions on head computed tomography frontal/
temporal area. The patient was extubated on postoperative
day one. Moving all extremities. Following verbal commands.
Localizing in the bilateral upper extremities. Pupils were
2.5 and reactive.
The patient was transferred to the regular floor on [**2114-10-17**]. Continued in a hard collar until cervical spine
could be cleared clinically. Continued to be awake, alert,
and confused. Following commands. Extraocular movements
were full. Pupils were equal, round, and reactive to light.
Followed by Physical Therapy and Occupational Therapy.
The patient had a swallow evaluation and video swallow which
he passed and was able tolerate thin liquid and soft solid
diet.
Postoperatively, had left facial weakness, left lip weakness,
and left tongue weakness. Also with difficulty keeping his
left eye closed. Followup as an outpatient with
Ophthalmology and Ear/Nose/Throat.
CONDITION AT DISCHARGE: The patient was discharged on
[**2114-10-24**] in stable condition.
DISCHARGE INSTRUCTIONS/FOLLOWUP: Followup in one month with
Dr. [**Last Name (STitle) 739**] with a repeat head computed tomography.
DISCHARGE DISPOSITION: The patient was discharged home on
[**2114-10-24**] with 24-hour supervision provided by his
mother with followup with Ophthalmology and Ear/Nose/Throat
as an outpatient.
[**Name6 (MD) 742**] [**Name8 (MD) **], M.D.
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2115-3-5**] 11:28
T: [**2115-3-5**] 12:09
JOB#: [**Job Number 51421**]
|
[
"2449"
] |
Admission Date: [**2180-10-23**] Discharge Date: [**2180-10-27**]
Date of Birth: [**2106-12-15**] Sex: M
Service: [**Location (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
male with moderate severe aortic stenosis and severe chronic
obstructive pulmonary disease admitted three times in the
past six months for chronic obstructive pulmonary disease
exacerbation, most recently last week. The patient had
arranged a visiting nurse. The patient met compliance to
assure he is on his proper medications at home. Per the
daughter, the patient is unable to keep his medications
straight and he sometimes misses doses. The patient is here
with similar symptoms to prior admissions and states he feels
better off his medications. The patient was administered
intravenous steroids and oxygen by face mask in the Emergency
Department, and he was transferred to the floor where he
became more short of breath. He has had some fevers at home
reportedly and intermittent atypical chest pain episode on
the day prior to the day of admission, left-sided pleuritic
pain and general discomfort with dyspnea.
REVIEW OF SYSTEMS: Review of systems was negative for
headache, vision changes, change in appetite and positive for
chest pain with shortness of breath, negative for orthopnea,
paroxysmal nocturnal dyspnea, edema, diaphoresis. Occasional
constipation, no bright red blood per rectum.
ALLERGIES: The patient has no known drug allergies.
HOME MEDICATIONS: Albuterol 2 puffs q.i.d., Afrin 81 q.d.,
Atrovent 4 puffs b.i.d., calcium carbonate 500 t.i.d.,
Flovent 2 puffs b.i.d., Lac-Hydrin prn, Levofloxacin finished
this course on [**9-23**], Prednisone taper ended on [**10-24**], Protonix 40, Serevent discus, Vitamin D.
PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease
with an FEV1 of 0.98, aortic stenosis, critical valve area of
0.8 cm on an echocardiogram in [**2180-3-14**]. Osteoarthritis.
Dyspepsia status post treatment for Helicobacter pylori in
[**2174**]. Hyperlipidemia. Peripheral vascular disease.
Ichthyosis. History of herpes zoster. Degenerative joint
disease and cervical spondylitis.
SOCIAL HISTORY: The patient is Somalian, a retired engineer,
lives with his wife and three children. He quit tobacco six
years ago, no alcohol, no other medications or illegal drugs.
PHYSICAL EXAMINATION: Temperature 95.2 axillary, heartrate
107, blood pressure 148/76, respiratory rate 29, 100% on
facemask. The patient is an elderly Somalian male lying in
bed in moderate severe respiratory distress. Head, eyes,
ears, nose and throat: Nasal flaring, pupils equally round,
and reactive to light, extraocular movements intact, dentures
are in place. Neck supple, notable for accessory muscle use.
Cardiovascular, tachycardiac, distant S1 and S2. Pulmonary,
poor air movement, tachypnea, diffuse wheezes. Abdominal
examination: Normal bowel sounds, soft, mild left lower
quadrant tenderness. Extremities: No edema. Neurological:
alert and oriented. Per family moves all extremities grossly
intact.
LABORATORY DATA: Laboratory data on admission notable for
lactate of 4.4 and blood gases which initially were 7.34, 47,
228 and progressed to 7.21, 60, 159. White count 11.4,
hematocrit 34.2, creatinine 1.1.
HOSPITAL COURSE: This 73 year old male with chronic
obstructive pulmonary disease exacerbation with multiple
recent admissions, readmitted for shortness of breath,
stabilized in the Emergency [**Hospital 13064**] transferred to the
floor and developed worsening respiratory failure.
Respiratory failure - The patient was transferred to the
Intensive Care Unit where he was placed on BiPAP in light of
his respiratory fatigue and increased secretions with
worsening hypoxia. He was started on Azithromycin 500 mg
times one and then 250 mg times four days. The patient was
weaned off of biPAP and had improving respiratory status.
Chest x-ray showed heart and mediastinal contours stable.
Aorta, slightly avulsed, lungs clear without effusion,
consolidations or pneumothorax. Shortness of breath improved
and the patient was transferred back to the floor on [**2180-10-25**] and was continued on steroids and was changed to
p.o. Prednisone 60 to begin a long taper. Continued on
nebulizers, chest physical therapy, Azithromycin, incentive
spirometry. The patient improved on this course. At the
time of discharge it was thought the patient would be a good
candidate for outpatient pulmonary rehabilitation.
Congestive heart failure/volume overload - In the Emergency
Department the patient had good diuresis with Lasix 20 mg
intravenously. Continued diuresis while in the Emergency
Room noted creatinine up to 1.3. In the Medicine Intensive
Care Unit the patient continued his diuresis, BUN and
creatinine were heavily followed. The patient had an
echocardiogram to assess cardiac function which revealed an
ejection fraction of 50% with mild symmetric left ventricular
hypertrophy, 1+ aortic regurgitation, aortic valves are
severely thickened and deformed. Mitral valve with 1 to 2+
mitral regurgitation, moderate 2+ tricuspid regurgitation
when compared with prior studies. In [**2180-3-14**], the left
ventricle was less hyperdynamic and the aortic valve orifice
area is now further reduced to 0.7 cm squared. The patient's
cardiologist, Dr. [**Last Name (STitle) **] was consulted who felt that this
could be managed as an outpatient and cardiac function was
not the cause of his admission or repeated admissions which
are likely due to chronic obstructive pulmonary disease. He
recommended further outpatient treatment for his cardiac
problems.
Chest/epigastric pain - Per primary care notes, this is a
chronic non-cardiac pain. The patient had ruled out and did
have a small increase in troponins, maximum of 0.02 probably
due to demand in the setting of tachycardia and tachypnea.
The patient's pain appeared worse postprandially while the
patient is on Protonix. He has had a history of gastritis in
the past. Gastrointestinal was consulted as he has had
Helicobacter pylori in the past, they recommend an outpatient
workup of the questionable gastritis. They recommend a ten
day period off Protonix prior to a Helicobacter pylori breast
test. This will be followed up with his outpatient provider.
Acute renal failure - The patient's increase in BUN and
creatinine in the setting of diuresis returned to baseline
prior to his discharge.
Elevated blood glucose levels - Most likely secondary to
steroid use. The patient was covered with an insulin drip in
the Intensive Care Unit and then transitioned to an insulin
sliding scale and q.i.d. fingersticks. Hemoglobin A1c was
measured and found to be 6.9. The patient's lowest blood
glucose even on the sliding scale were in the 150 range.
[**Last Name (un) **] Diabetes was consulted and recommended starting
Glucotrol XL 5 p.o. q.d. as well as increasing the patient's
Humalog sliding scale. They recommend a trial of Metformin
500 mg q.d. as the patient's creatinine returned to a
baseline of 1.0 and we were no longer concerned about
congestive heart failure as this medication may precipitate
congestive heart failure. The patient had a nutrition
evaluation and teaching on diabetic diet and follow up was
arranged at [**Hospital **] Clinic. The patient was assessed by
physical therapy and occupational therapy.
FINAL DIAGNOSIS:
1. Chronic obstructive pulmonary disease exacerbation
2. Moderate to severe aortic stenosis
3. Congestive heart failure
4. Diastolic dysfunction
5. Osteoarthritis
6. Chest pain, noncardiac
7. Dyspepsia, status post Helicobacter pylori treatment in
[**2174**]
8. Hyperlipidemia
9. Peripheral vascular disease
10. Ichthyosis
11. History of herpes zoster
12. Degenerative joint disease
13. Cervical spondylosis
FOLLOW UP: The patient has follow up scheduled for
rehabilitation services on [**11-2**]. Pulmonary function
tests on [**2180-11-13**]. Follow up with Dr.
.................. [**2180-11-13**]. Follow up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13065**], as well as [**Hospital **]
Clinic, [**Doctor Last Name 2866**] [**2180-11-30**].
DISCHARGE CONDITION: The patient is requiring nebulizers,
chest physical therapy, does not desaturate with walking
although has dyspnea with mild exertion. He is tolerating
p.o.
DISCHARGE MEDICATIONS:
1. Calcium carbonate 500 t.i.d.
2. Vitamin D 400 q.d.
3. Pantoprazole 40
4. Aspirin 81
5. Acetaminophen prn
6. Lac-Hydrin lotion
7. Prednisone 60 mg for a total of 5 doses, Prednisone 50 mg
for another total of 5 doses followed by Prednisone 40 mg for
a total of 5 doses followed by Prednisone 30 mg for another
total of 5 doses followed by Prednisone 20 mg for another
total of 5 doses followed by Prednisone 10 mg for another
total of 5 doses followed by Prednisone 5 mg for another
total of 5 doses, each as q.d. dose.
8. Azithromycin 250 mg for a total of a four day course.
9. Glipizide 5 mg tablets q.d.
10. Humalog sliding scale prn ..................
11. Senna
12. Docusate
13. Nebulizers prn as well as his home pulmonary medications
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-735
Dictated By:[**Last Name (NamePattern1) 5713**]
MEDQUIST36
D: [**2180-10-26**] 15:00
T: [**2180-10-26**] 16:37
JOB#: [**Job Number 13066**]
|
[
"51881",
"4280",
"4241",
"5849",
"2724"
] |
Admission Date: [**2163-10-19**] Discharge Date: [**2163-10-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
81 yo m w/ low grade BCL s/p multiple cycles of ritaxin. c/o
fatigue, seen in Dr.[**Initials (NamePattern4) 10560**] [**Last Name (NamePattern4) **] found to be anemic. BmBx
revealed Hodgkins
On day of admission, while receiving bleomycin developed chills,
t t0 104, w/ sao2 to 88%. Rec'd demerol and benadryl and taken
to ED where he was febrile to 105, rigoring, and rec'd ativanx3,
started on cefepime. ROS positive for cough x2wks, no sob. Also
chills/ night sweats.
Past Medical History:
prostate ca, s/p radiation
htn
gout
tia
BCL
Hodgkins
Social History:
Lives w/ wife
Family History:
NC
Physical Exam:
104.5, p 110, bp 152/59, r 20-24, sao2 96%
minimally responsive, localizes pain
PERRLA.
Moist MMM
No JVD
Regular, tachycardic, S1, S2. No m/r/g
LCA b/l
+bs. soft. nt. nd.
no le edema
Pertinent Results:
[**2163-10-19**] 05:20PM BLOOD WBC-1.0* RBC-3.87* Hgb-10.3* Hct-31.6*
MCV-82 MCH-26.6* MCHC-32.5 RDW-18.5* Plt Ct-83*
[**2163-10-19**] 05:20PM BLOOD PT-14.5* PTT-29.8 INR(PT)-1.3
[**2163-10-19**] 05:20PM BLOOD Gran Ct-790*
[**2163-10-19**] 05:20PM BLOOD Calcium-8.2* Phos-2.8 Mg-1.8
[**2163-10-19**] 05:32PM BLOOD Lactate-2.8*
CXR: No evidence of pneumonia.
Brief Hospital Course:
81yo m w/ hodgkins lymphoma, who developed f/rigors in the
setting of bleomycin infusion.
1) fever- Pt became afebrile soon after transfer to the MICU.
By the morning after admission he felt well and had no
complaints. At this point his standing tylenol was discontinued
and he did not spike. Onc agreed with our assessment that his
syndrome was due to bleomycin toxicity. Pt felt stable for
discharge.
2) [**Name (NI) 12329**] Pt continued on dilt. BP was stable.
3) Prostatitis - pt continued on his cipro.
3) Px: pneumoboots, GI until taking p.o.
4) Glucose: stable on QID finger sticks.
5) T/L/D- PIV
6) Full code
Medications on Admission:
Cipro
Allopurinol
Dilt
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Diltiazem HCl 60 mg Capsule, Sust. Release 12HR Sig: One (1)
Capsule, Sust. Release 12HR PO once a day.
Disp:*30 Capsule, Sust. Release 12HR(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Bleomycin reaction
Discharge Condition:
stable, afebrile, and on room air
Discharge Instructions:
follow up with your oncologists as scheduled
continue all of your current medications as listed in the
discharge paperwork.
Please call Dr [**Last Name (STitle) **] or go to the Emergency room if you have
fever, chills, lightheadedness, or trouble breathing.
Followup Instructions:
Provider: [**Name10 (NameIs) **] FELT, RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-10-21**] 10:30
Provider: [**Name10 (NameIs) 17515**] CHAIR 2D Date/Time:[**2163-10-21**] 10:30
Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2163-10-26**] 1:30
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"4019"
] |
Admission Date: [**2193-8-16**] Discharge Date: [**2193-8-20**]
Date of Birth: [**2127-12-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Abnormal stress test, shortness of breath
Major Surgical or Invasive Procedure:
[**2193-8-16**] Aortic valve replacement with a [**Street Address(2) 17009**]. [**Hospital 923**] Medical
Biocor Epic tissue valve.
History of Present Illness:
65 year old male with a possible history of Rhuematic Fever as a
child. He has known aortic stenosis and was recently cathed and
had LAD stent placed in [**12/2192**] in preparation for shoulder
surgery but surgery was deferred again. He was sent for a
surveillance stress test where he reports he developed upper
back pain associated with shortness of breath. This stress echo
was abnormal. He was referred for repeat right and left heart
catheterization. He was found to have critical aortic stenosis
and is now being referred to cardiac surgery for an aortic valve
replacement.
Past Medical History:
Aortic stenosis
Coronary artery disease s/p LAD BMS x 1 and RCA stent BMS x 2,
ISR LAD [**12-17**] treated with 2 Promus stents
Dysplipidemia
Heart Murmur since age 9
Syncope [**2181**]
Hypertension
Hypothyroidism
MVA in [**2161**] with multiple fractures in chest
Full thickness tear in right rotator cuff
Kidney Stones
Severe Anxiety/Depression
Social History:
Race:Caucasian
Last Dental Exam:upper plate with lower native teeth, has no
seen a dentist in [**2-8**] years, will make an appointment to see
Dentist and have clearance faxed to office
Lives with:Wife
Contact:[**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 89156**]
Occupation:works for state police as clerk - but has not
returned
to work waiting shoulder surgery
Cigarettes: Smoked no [] yes [x] Hx:quit [**2157**], smoked [**1-7**] ppd
for 5-6 years
Other Tobacco use:denies
ETOH: prior heavy alcohol use in his earlier years, Occasionally
has glass of scotch or glass of wine
Illicit drug use:denies
Family History:
Premature coronary artery disease- Mother with CABG in her 50's
and redo CABG at 64, Father with severe hypertension and died in
his 80's, brother just had CABG at age 66. [**Name (NI) **] brother has
had stents placed.
Physical Exam:
Pulse: 75 Resp: 16 O2 sat: 98/RA
B/P Right: 141/87 Left: 149/86
Height: 6'3" Weight: 233 lbs
General: No acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade [**3-12**] holosystolic
Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds +
[x]
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right and Left: Transmitted murmur
Brief Hospital Course:
Mr. [**Known lastname 89157**] was a same day admit and on [**8-16**] he was brought to
the operating room where he underwent an aortic valve
replacement. Please see operative note for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Later this day 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. Post-op day two
his chest tubes were removed and he was transferred to the
step-down unit for further care. Epicardial pacing wires were
removed on post-op day three.The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD 4 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged home in good
condition with appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Quinapril 20 mg PO BID
3. Fish Oil (Omega 3) 1000 mg PO BID
4. ALPRAZolam 0.5 mg PO TID:PRN anxiety
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Sodium Chloride Nasal [**1-7**] SPRY NU DAILY:PRN dry
7. Atorvastatin 20 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.4 mg SL PRN chest pain
10. Clopidogrel 75 mg PO DAILY
plavix is changed during the post-op period you will be changed
back to prasugrel by your surgeon in the next couple of months.
11. Omeprazole 20 mg PO DAILY
12. Aspirin 325 mg PO DAILY
13. Loratadine *NF* 10 mg Oral daily
14. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. ALPRAZolam 0.25-0.5 mg PO TID:PRN anxiety
3. Aspirin EC 81 mg PO DAILY
if extubated
4. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Clopidogrel 75 mg PO DAILY
plavix is changed during the post-op period you will be changed
back to prasugrel by your surgeon at your post-op visit.
RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain
RX *Dilaudid 2 mg 1 tablet(s) by mouth every four (3) hours Disp
#*50 Tablet Refills:*0
10. Metoprolol Tartrate 25 mg PO BID
hold for SBP<90, HR<55
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*1
11. Potassium Chloride 20 mEq PO BID Duration: 7 Days
RX *Klor-Con M10 10 mEq 10 mEq(s) by mouth twice a day Disp #*7
Tablet Refills:*0
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*50 Tablet Refills:*0
13. Fish Oil (Omega 3) 1000 mg PO BID
14. Loratadine *NF* 10 mg Oral daily
15. Multivitamins 1 TAB PO DAILY
16. Sodium Chloride Nasal [**1-7**] SPRY NU DAILY:PRN dry
17. Furosemide 40 mg PO BID Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
18. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic stenosis s/p Aortic valve replacement
Past medical history:
Coronary artery disease s/p LAD BMS x 1 and RCA stent BMS x 2,
ISR LAD [**12-17**] treated with 2 Promus stents
Dysplipidemia
Heart Murmur since age 9
Syncope [**2181**]
Hypertension
Hypothyroidism
MVA in [**2161**] with multiple fractures in chest
Full thickness tear in right rotator cuff
Kidney Stones
Severe Anxiety/Depression
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with dilaudid.
Incisions:
Sternal - healing well, no erythema or drainage
Trace lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Wound check: [**2193-8-27**] at 10:45AM in [**Hospital Ward Name **] buidling, [**Hospital Unit Name **]
Surgeon: Dr. [**Last Name (STitle) **] on [**2193-10-2**] at 1PM
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2193-9-18**] 11:30AM
Please call to schedule appointments with your
Primary Care Dr. [**Known firstname **] [**Last Name (NamePattern1) **] in [**4-11**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2193-8-20**]
|
[
"4241",
"41401",
"311",
"V4582",
"2724",
"4019",
"2449",
"2859"
] |
Admission Date: [**2187-7-19**] Discharge Date: [**2187-7-20**]
Date of Birth: [**2106-11-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
transfer for ? ischemia right hand
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 80yo M admitted on [**7-6**] to [**Hospital3 26615**] with
perforated diverticulitis and SBO s/p sigmoid colectomy
/Hartmann??????s procedure c/b intraperitoneal abscess, septic shock,
Afib w/ RVR, acute renal failure (crt 3.3 on admission), central
line bacteremia, bilateral aspiration pneumonia, PICC
line-associateed R radial artery, R subclavian and axillary vein
thrombosis, and respiratory failure (on ventilator since [**7-6**])
requiring tracheostomy ([**7-19**]) transferred for an evaluation of
right hand ischemia.
Patient had a PICC in place for about a week. On [**7-19**] he had
tracheostomy performed in the OR after which it was noted a
cyanotic and pulseless right hand. US revealed a thrombus in the
axillary and subclavian vein. Patient was started on a heparin
drip. He was transferred to [**Hospital1 18**] for vascular evaluation and
treatment. On admission, he had palpable right brachial, radial
and ulnar pulse. The hand had no signs of ischemia.
He is admitted to the TICU for management s/p sigmoid colectomy
and Hartmann's for perforated diverticulitis (now POD 13). The
patient has rising WBC count, he had repeat CT abdomen/pelvis
which did not show any anastomotic leak. Patient was initially
treated with Zosyn. At the time of transfer he was on
vancomycin, meropenem and diflucan.
Past Medical History:
- CAD s/p stent
- Atrial fibrilation w/RVR
- Bacteremia
- UE DVT
- Legally blind
- Diverticulitis
- Acute Renal failure
- BPH
- LAD stent [**2186-6-23**] (ASA/Plavix)
- 60% RCA stenosis
- LBBB
- HTN
- renal failure
- traumatic SAH after fall
- post-SAH seizure disorder
- glaucoma
- anemia
- unastable angina
- SAH
- acute R radial artery, R SCV and axillary vein thrombosis [**3-7**]
PICC line
PSH:
- appendectomy
- [**2187-7-6**] sigmoid colectomy and Hartmann's for perforated
diverticulitis (OSH)
- [**2187-7-19**] - open tracheostomy
Social History:
Married
Family History:
NC
Physical Exam:
PHYSICAL EXAM
Vital Signs: Temp: 98.6 Pulse: 107 BP: 172/70 O2 Sat: 100%
Vent: CMV 50%/500x16/8
Neuro/Psych: Abnormal: Trach, sedated, raises eyebrows to voice,
does not follow commands, moves only LEs.
Heart: Abnormal: Tachycardic.
Lungs: Abnormal: Tracheostomy.
Gastrointestinal: Non distended, abnormal: Lower midline
incision
C/D/I w/ steri strips intact, ostomy w/ stool.
Rectal: Not Examined.
Extremities: No varicosities.
R hand: warm, well-perfused, no cyanosis, no lesions
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RUE Radial: D. Ulnar: D. Brachial: P.
LUE Radial: Arterial Line. Ulnar: D. Brachial: P.
LUE:
RLE: DP: P PT: D
LLE: DP: D PT: P
Pertinent Results:
[**2187-7-19**] 11:00PM TYPE-ART PO2-95 PCO2-59* PH-7.27* TOTAL
CO2-28 BASE XS-0
[**2187-7-19**] 09:58PM GLUCOSE-107* UREA N-33* CREAT-1.0 SODIUM-138
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-26 ANION GAP-14
[**2187-7-19**] 09:58PM estGFR-Using this
[**2187-7-19**] 09:58PM ALT(SGPT)-24 AST(SGOT)-22 LD(LDH)-253* ALK
PHOS-164* AMYLASE-62 TOT BILI-0.6
[**2187-7-19**] 09:58PM ALBUMIN-2.1* CALCIUM-7.9* MAGNESIUM-2.0
[**2187-7-19**] 09:58PM WBC-17.0* RBC-2.94* HGB-9.2* HCT-28.4* MCV-96
MCH-31.2 MCHC-32.3 RDW-15.0
[**2187-7-19**] 09:58PM PLT COUNT-852*
[**2187-7-19**] 09:58PM PT-15.1* PTT-50.3* INR(PT)-1.3*
[**2187-7-19**] 09:51PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.013
[**2187-7-19**] 09:51PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2187-7-19**] 09:51PM URINE RBC-59* WBC-8* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2187-7-19**] 09:51PM URINE MUCOUS-RARE
.
MICRO:
OSH from discharge summary, no date provided
- wound clx: Bacterioides, Citrobater freundii, E. coli,
Klebsiella oxytoca and Group D nonenterocossus species.
.
IMAGING:
[**2187-7-16**] RUE US
- R SCV and axillary vein thrombosis
[**2187-7-19**] RUE US
- R SCV and axillary vein thrombosis - unchanged
[**2187-7-12**] CT a/p
- no free air, decreased distention of small bowel
- consolidation in both lungs
- LL spiculated opacity, re: CT chest to exclude a mass
Brief Hospital Course:
Mr [**Known lastname 62516**] was transfered to [**Hospital1 18**] from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital
for Vascular Surgery evaluation for concern of radial artery
thrombus. He was started on hep gtt and has well-perfused
extremities. Vascular surgery attending recommended no acute
vascular surgical intervention and he was therefore transfered
to the ACS service. As the pt has no acute general surgical
issues both Vascular and ACS attendings felt that he was
appropriate for transfer back to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to continue his
post-operative course.
Medications on Admission:
[**Last Name (un) 1724**]:
- asa 81 mg qd
- amlodipine 10 mg daily
- metoprolol 25 mg daily
- HCTZ 12.5 mg
- Keppra
- dilantin
- Flomax
- calcium
- vitamin D
- mirtazapine
Medications on Transfer:
- Lumigan 0.03% 1 gtt qhs
- Alphagan 0.015% 1 gtt each eye [**Hospital1 **]
- Cosopt 1 gtt each eye
- dilantin sus 400 mg qd via NG tube
- pilocarpine 1gtt each eye qd
- heparin gtt
- Keppra 500 mg IV q12h
- meropenem 1 gm IV q8h
- Diflucan 400 mg IV q24h
- vancomycin 1mg IV q24h
- ASA PR
- insulin ss Humalog
- Ativan 1mg IV q2h PRN vent management
- metoprolol 50mg PO bid via NGT
- morphine 1-2 mg
- zofran
- Protonix 40 mg iv bid
Discharge Medications:
1. fentanyl citrate (PF) 50 mcg/mL Solution Sig: 25-50 mcg
Injection Q4H (every 4 hours) as needed for pain.
2. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous Q6H (every 6 hours).
3. Vancomycin 1000 mg IV Q 24H
4. phenytoin 125 mg/5 mL Suspension Sig: Four Hundred (400) mg
PO Q24H (every 24 hours).
5. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Four
(4) Puff Inhalation Q6H (every 6 hours).
6. Lumigan 0.03 % Drops Sig: One (1) drop Ophthalmic qHS ().
7. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
8. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
9. pilocarpine HCl 2 % Drops Sig: One (1) Drop Ophthalmic Q12H
(every 12 hours).
10. aspirin 300 mg Suppository Sig: Three Hundred (300) mg
Rectal DAILY (Daily).
11. lorazepam 2 mg/mL Syringe Sig: 0.5-2 mg Injection Q4H (every
4 hours) as needed for Sedation: Give doses every 5 min until
sedated. Maintenance target: [**Last Name (un) 45802**] 3 and overbreathing
ventilator.
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. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain .
14. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1650 (1650) U/HR Intravenous ASDIR (AS DIRECTED):
for goal PTT 60-80.
15. LeVETiracetam 500 mg IV Q12H
16. Pantoprazole 40 mg IV Q24H
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
18. Insulin Sliding [**Name8 (MD) **]
MD to order on arrival to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Discharge Disposition:
Extended Care
Discharge Diagnosis:
perforated diverticulitis and SBO s/p sigmoid
colectomy/Hartmann's procedure [**2187-7-6**] c/b septic shock, renal
and respiratory failure s/p tracheostomy, admitted for Vascular
Surgery consult (complete)
Discharge Condition:
Vent dependent, bedrest
Discharge Instructions:
Pt is being transferred back to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital now that
Vascular Surgery evaluation is complete.
Followup Instructions:
No follow up necessary with [**Hospital1 18**] physicians
Completed by:[**2187-7-20**]
|
[
"5070",
"51881",
"0389",
"99592",
"78552",
"42731",
"4019"
] |
Admission Date: [**2160-3-18**] Discharge Date: [**2160-4-2**]
Date of Birth: [**2099-6-24**] Sex: F
Service: MEDICINE
Allergies:
Coumadin / Codeine / Demerol
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 60 year old woman with a hx of
paraimmunoblastic CLL, s/p MUD allo transplant 90 days post, hx
of DVTs and PE (heterozygous for the prothrombin gene mutation),
recently admitted to [**Hospital1 **] for SOB. Today she presents from
[**Hospital **] Rehab having had an acute onset of seizures involving
the left face, arm, and leg, accompanied by loss of
consciussness. This episode was witnessed by her niece and it
lasted about a minute. There was some urinary incontinence and
the patient became very confused after the episode and
essentially nonverbal, answering only yes or no. The patient had
never had a seizure before. In the ED, a CT scan w/o contrast
and an MRI/MRA showed possible posterior reversible
encephalopathy or old subacute infarcts, possibly embolic.
Neurology evaluated the patient and recommended seizure
precautions and meningitis dose of abx. She comes to the MICU
for further monitoring and management of her seizures. Her
doctor is Dr [**First Name (STitle) 1557**].
Past Medical History:
- Paraimmunoblastic CLL with chromosome 17P deletion, as above
- Hiatal hernia
- Lymph edema, LLL since [**2141**] (unknown etiology)
- Cholecystectomy, [**2158-7-3**]
- h/o DVT and PEs diagnosed in [**12-8**] (treated with Lovenox x 6
months, patient reports allergic reaction to Coumadin)
- s/p IVC filter placement [**2159-12-28**]
- h/o Obstructive Sleep Apnea
- Chronic sinusitis
- Clivus mass treated with 7 weeks fungal abx and 3-4 weeks
meropenem without change, will need surgical bx at some point
- Labile blood pressure (history of both HTN and hypotension)
- h/o Depression
- Heterozygous for antithrombin gene
Social History:
She quit smoking 30 yrs ago but has a 20-pack-year history. She
is administrative assistant, lives in [**Location 2498**]. She is married
and has one daughter. She lives with her husband, daughter,
son-in-law and four grandchildren. No ETOH.
Family History:
Her mom died of blood clots at 76 (unknown etiology). Her
father has HTN.
Physical Exam:
Vitals T 99, BP 110/50, HR 69, RR 22, O2 sat 95% on 4L
Gnl: NAD, does not answer questions except yes or no
HEENT: PERRLA, Anicteric.
CV: RRR, Normal S1 + S2, No murmurs, rubs or gallops
Resp: Crackles at bases bilaterally.
Abd: Soft, Nontender, NABS.
Extremities: no edema RLE and 1+ LLE, nonpitting
Neuro: Moves all 4 extremities spontaneously. Detailed exam
performed by Neurology consult showing normal and symmetrical
strength and sensation.
Pertinent Results:
[**2160-3-18**] 06:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2160-3-18**] 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
[**2160-3-18**] 02:41PM TYPE-[**Last Name (un) **] PH-7.31*
[**2160-3-18**] 02:41PM GLUCOSE-146* LACTATE-1.2 NA+-141 K+-3.8
CL--103 TCO2-32*
[**2160-3-18**] 02:41PM freeCa-1.40*
[**2160-3-18**] 02:00PM GLUCOSE-154* UREA N-18 CREAT-1.0 SODIUM-141
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12
[**2160-3-18**] 02:00PM ALT(SGPT)-16 AST(SGOT)-24 ALK PHOS-99
AMYLASE-13 TOT BILI-0.7
[**2160-3-18**] 02:00PM LIPASE-17
[**2160-3-18**] 02:00PM TOT PROT-5.8* CALCIUM-11.0*
[**2160-3-18**] 02:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2160-3-18**] 02:00PM WBC-6.2 RBC-3.84* HGB-11.4* HCT-33.4* MCV-87
MCH-29.6 MCHC-34.1 RDW-16.8*
[**2160-3-18**] 02:00PM NEUTS-78* BANDS-7* LYMPHS-5* MONOS-4 EOS-5*
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2160-3-18**] 02:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2160-3-18**] 02:00PM PLT SMR-NORMAL PLT COUNT-160
[**2160-3-18**] 02:00PM PT-13.0 PTT-31.5 INR(PT)-1.1
[**2160-3-18**] 01:09PM CYCLSPRN-168
CT HEAD [**3-18**]
IMPRESSION:
1. Biparietal low intensity white matter foci. Differential
diagnosis
includes posterior reversible encephalopathy and venous
infarctions from
sagittal sinus thrombosis with tumor or infectious process.
Neurological
consultation and follow up MR study is recommended.
2. Large lytic mass in the clivus.
.
MRI [**3-18**]
IMPRESSION
New increased t2 and flair signal noted within posterior
pariteal lobes
superior to ventricles and within deep left frontal [**Male First Name (un) 4746**] as noted
on CT, with slight increased signal on DWI, likely due to t2
shine through. Overall exam limited by motion, but clival mass
and sinus thickening is without sign. changes. No sinus
thrombosis noted.
Diff dx includes Posterior reversible encephalopathy (is there
htn history), or old subacute infarcts, possibly embolic given
lesion location.
CXR [**3-19**]
AP CHEST RADIOGRAPH: Compared to prior radiograph from [**2160-2-19**], there is no significant change. Again seen are low lung
volumes without
consolidation. Heart, mediastinum, hila, pulmonary vascularity
are within
normal limits. A right PICC line is present with tip overlying
the expected region of the mid SVC. No pneumothorax is
identified. There is minimal bibasilar atelectasis.
IMPRESSION: Persistent low lung volumes without evidence of
pneumonia
EEG [**3-19**]
IMPRESSION: This is an abnormal EEG due the occasional right and
left
central sharp waves, frequent large amplitude slow waves and the
slow
and disorganized background rhythm. The first abnormality
suggests a
right and left central focus of cortical hypersynchrony. The
second two
abnormalites suggest a moderate encephalopathy, which may be
seen with
toxic metabolic abnormalities, medication effect or infections
.
[**3-20**] CXR: Low lung volumes without consolidation or effusion.
Brief Hospital Course:
This is a 60 year old woman with a hx of paraimmunoblastic CLL,
s/p MUD allo transplant ~ 90 days post, hx of DVTs and PE on
lovenox, who presented from [**Hospital **] Rehab having had an acute
onset of seizures. The following issues were addressed during
her hospitalization:
1. Seizure: Per the history, the patient had a partial complex
seizure with generalization, witnessed by her niece. No had
hypoglycemia or lyte abnormalities upon presentation to [**Hospital1 18**].
No bleed or mass was found on imaging.
An EEG showed encephalopathy, but no seizure activity. An LP was
done and shoed 14-28 WBC (90% lymphs) w/ nl glucose and protein.
CSF was negative on gram stain and also for crypto ag. MR
imaging of the brain was consistent with reversible posterior
leukocencephelopathy of the brain which can be associated with
seizures. Neurology was consulted and believed that the seizure
was a result of RPLE. PPLE is often induece by HTN. In Ms.
[**Known lastname 66500**] case, her HTN was likely secondary to cyclosporine
induce hypertension. The patient's BP was controlled with
metoprolol and nifedipine. She remained seizure free during her
hospitalization.
.
# Infectious/low grade temp: The patient presented with bandemia
and a low grade temperature. Urine grew yeast, for which the
patient was treated with one dose of fluconazole. CSF cultures
were negative to the time of discharge. Clinically there were no
signs of meningitis, however patient was treated with meningitis
doses of ceftriaxone, vancomycin and acyclovir. The antibiotics
were d/c after 48 hours. CXR was clear.
.
# dropping ANC and wbc ct: Prior to discharge it was noticed
that the patient's ANC was slowly dropping. DDx included med
effect vs graft rejection. Acyclovir, bactrim, and protonix were
discontinued due to their possible marrow related effects. Her
ANC stabilized and .....
.
# Tachycardia: The patient has a baseline heart rate in the 90s
in the last few months. She was volume depleted on admission and
tachycardia resolved with a 1Liter bolus of normal saline. EKG
was normal. Anemia also thought to be contributing to elevated
HR, and the patient received two units PRBCs in the MICU. The
issue then resolved.
.
# Hypoxia: The patient has a history of PEs. O2 sats were
consistently 92-94% on 2-4L O2. Upon transfer to the BMT
service, the patient was satting 97% RA.
.
# Hypercalcemia: this was thought to be mainly due to
dehydration. SPEP and UPEP were also abnormal, as was uric acid
(elevated). The patient did not have bone pain. The
hypercalcemia resolved with fluids.
.
# Anemia: The goal was Hct>30. The patient received two units
PRBCs while in the ICU. The Hct remained stable.
.
# AMS: The altered mental status was thought to be a combination
of her postictal state coupled with reversible posterior
encephalopathy and cyclosporin toxicity. The mental status
improved sometime after 48 hours in the ICU, with a decreased
level of cyclosporin. However, the patient remained somewhat
confused at the time of her transfer to the floor.
.
# CLL s/p allo transplant 90 days: the cyclosporin levels were
monitored on a daily basis and the patient was also maintained
on her outpatient dose of prednisone. The cyclosporin dose was
lowered from 225 mg [**Hospital1 **] to 175 mg [**Hospital1 **] to 75 mg [**Hospital1 **].
.
# Hypercoagulable state. Lovenox was briefly held for 12 hours
prior to the patient having a lumbar puncture. It was then
restarted at the therapeutic doses the patient usually takes
given her history of DVTs and PEs and heterozygosity for the
antithrombin gene.
.
# FEN. The patient had a speech and swallow evaluation and a
nutrition consult. She was placed on a ground solid/thin liquid
diet. Her lytes were repleted as needed, particularly magnesium,
which can be low with neoral.
.
#ACCESS - as she was afebrile and doing well, permanent vascular
access was secured via surgery with the placement of a
double-lumen port-a-cath. She was discharged to rehab following
this procedure.
Medications on Admission:
Acyclovir 400 mg [**Hospital1 **]
Albuterol prn
Aquaphor to post head
Citalopram 20 mg PO daily
Cyclosporin microemulsion 225 mg PO bid
Lovenox 60 mg sq q 12 hours
Erythromycin eye ointment qHS
Lopressor 75 mg PO BID
Remeron 22.5 mg PO qHS
Procardia XL 120 mg PO daily
Zofran 8 mg TID
Protonix 40 mg PO daily
Prednisone 10 mg daily
Bactrim DS Mo, W, Fr
Ursodiol 300 mg [**Hospital1 **]
Tylenol, atrovent, prn
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous Q12H (every 12 hours).
4. Cyclosporine 25 mg Capsule Sig: Two (2) Capsule PO twice a
day.
5. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
Q 8HR ().
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed.
10. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
LifeCare Center of [**Location (un) 5165**]
Discharge Diagnosis:
primary:
generalized seizure
Recurrent Polyleukoencephelopathy
steroid myopathy
.
secondary:
Paraimmunoblastic CLL
Clivus mass
h/o DVT and PEs
Discharge Condition:
Good.
Discharge Instructions:
Please return to the hospital if you experience any
lightheadedness, seizure activity, or any other symptoms that
concern you.
.
It is very important that your blood pressure remains well
controlled. Please take all medications as prescribed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2160-4-4**] 2:30
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2160-4-23**] 9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"4019",
"32723"
] |
Admission Date: [**2181-10-13**] Discharge Date: [**2181-10-24**]
Date of Birth: [**2100-8-20**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Bactrim
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Transfer for management of painless jaundice
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Central line access
Arterial line access
History of Present Illness:
Ms. [**Known lastname 16590**] is an 81 yo female with a history of atrial
fibrillation diastolic heart failure, s/p cholecystectomy, and
hospitalization for ESBL Klebsiella UTI ([**2181-9-26**]) who was
transferred from [**Hospital3 **] for work-up of LFT
abnormalities. Per OSH records patient was noted to be jaundiced
while in rehab on [**2181-10-2**]. Her AP at that time was 568, AST 198,
ALT 300 and TBili 5.58. She underwent abdominal u/s on [**10-7**]
normal liver and bilateral pleural effusions. On [**10-11**] she had CT
Abd at [**Hospital3 417**] Hosp as an outpt that showed normal liver,
spleen, pancreas and bilateral pleural effusions. Following this
study, she was transferred from rehab to [**Hospital3 **] on
[**2181-10-11**] for further work-up. On admission to [**Hospital1 **] her AP was
1206 and bili 15.9. Patient transferred to [**Hospital1 18**] for further
work-up of her LFT abnormalities
.
Patient was transferred directly to the medical floor. On
arrival to the floor her SBPs were in the 70's. After about
500cc NS SBPs increased to the 80's. Her temperature was 95.2
and she was sating 95% on 2L. ABG was pH7.27 pCO233 pO277
HCO316. She was transferred to the MICU given her hemodynamic
instability.
Past Medical History:
(per OSH records):
Atrial Fibrillation
Diastolic Heart Failure
s/p pacemaker [**8-2**]
HTN
OA
h/o pleural effusions, s/p thoracentesis x 3 all transudative
h/o multi-lobular PNA [**5-3**]
Depression
UTI, ESBL Klebs, proteus and E.Coli
h/o DVT on left [**9-2**]
Social History:
Has been in and out of rehab and [**Hospital **] Hosp since [**5-3**]. Denies
any ETOH, smoking or illicit drug use.
Family History:
noncontributory
Physical Exam:
At Admission:
Vitals: T: BP: P: R: 18 O2:
General: alert, oriented, lethargic
HEENT: + scleral icterus, MMM, oropharynx clear
Skin: + jaundice
Neck: supple, JVP not elevated, no LAD
Lungs: Reduced breath sounds at base, L>R. No wheezes or
crackles
CV: Irregularly irregular, 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, 3+ LE edema from ankles to
knees
Pertinent Results:
LABS ON ADMISSION:
[**2181-10-13**] 04:44PM BLOOD WBC-12.4* RBC-3.37* Hgb-10.3* Hct-32.7*
MCV-97 MCH-30.6 MCHC-31.5 RDW-18.6* Plt Ct-409
[**2181-10-13**] 04:44PM BLOOD Neuts-75* Bands-5 Lymphs-15* Monos-1*
Eos-1 Baso-0 Atyps-3* Metas-0 Myelos-0 NRBC-2*
[**2181-10-13**] 04:44PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-1+ Target-1+ Burr-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**] [**Name (STitle) 16591**]1+
[**2181-10-13**] 04:44PM BLOOD PT-27.2* PTT-57.3* INR(PT)-2.7*
[**2181-10-13**] 04:44PM BLOOD Fibrino-563*
[**2181-10-13**] 04:44PM BLOOD Glucose-42* UreaN-39* Creat-1.2* Na-141
K-3.4 Cl-116* HCO3-13* AnGap-15
[**2181-10-13**] 04:44PM BLOOD Albumin-2.0* Calcium-6.7* Phos-4.1 Mg-1.6
[**2181-10-13**] 04:44PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE
[**2181-10-15**] 08:27AM BLOOD AMA-NEGATIVE
[**2181-10-13**] 10:36PM BLOOD Smooth-NEGATIVE
[**2181-10-13**] 10:36PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2181-10-13**] 04:44PM BLOOD IgG-909
[**2181-10-13**] 04:44PM BLOOD HCV Ab-NEGATIVE
LFT TREND:
[**2181-10-13**] 04:44PM BLOOD ALT-199* AST-233* LD(LDH)-256*
CK(CPK)-16* AlkPhos-1136* Amylase-36 TotBili-13.5*
[**2181-10-14**] 03:30AM BLOOD ALT-609* AST-1215* LD(LDH)-1277*
CK(CPK)-51 AlkPhos-1090* TotBili-16.3*
[**2181-10-14**] 10:20PM BLOOD ALT-2497* AST-6244* LD(LDH)-4500*
AlkPhos-1053* TotBili-18.5*
[**2181-10-15**] 03:59AM BLOOD Amylase-243*
[**2181-10-15**] 08:43AM BLOOD CK(CPK)-150*
[**2181-10-15**] 03:16PM BLOOD ALT-2204* AST-3672* LD(LDH)-1314*
CK(CPK)-113 AlkPhos-1040* TotBili-17.7*
[**2181-10-16**] 02:45AM BLOOD ALT-1862* AST-2292* LD(LDH)-849*
CK(CPK)-100 AlkPhos-1043* TotBili-18.0*
[**2181-10-17**] 03:56AM BLOOD ALT-912* AST-880* LD(LDH)-486*
AlkPhos-693* TotBili-20.2*
TROPONIN TREND:
[**2181-10-13**] 04:44PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2181-10-14**] 03:30AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2181-10-15**] 08:43AM BLOOD CK-MB-6 cTropnT-0.11*
[**2181-10-15**] 03:16PM BLOOD CK-MB-6 cTropnT-0.11*
[**2181-10-16**] 02:45AM BLOOD CK-MB-5 cTropnT-0.11*
Brief Hospital Course:
Patient is an 81 yo female with progressive painless jaundice
over the past two weeks now presenting with hypotension and
hypothermia likely representing sepsis.
Patient initially presented with hypotension, tachycardia and
leukocytosis of 12,000 with bandemia. Pressures initially
improved with NS boluses though MAPs remained in the mid-50's.
Initial infectious sources that were considered included
urosepsis especially given urine cx positive for ESBL E.Coli and
Cholangitis given cholestatic picture. Chest x-ray also
demonstrated patchy opacities in the left mid-lung which
concerning for possible pnuemonia. Patient was initially started
on Meropenem, Flagyl and Vancomycin. Central venous and arterial
access was also obtained and patient was intubated. She was also
started on pressors to maintain MAPS > 65.
CT abdomen and US were performed to evaluate for CBD dilitation
which were negative. Sputum cultures were obtained which were
possitive for MRSA and urine cultures were obtained which were
possitive for E.Coli and Enterococcus. Initial labs showed a
large transaminitis with elevated AP and TB. ERCP was consulted
who recommended ERCP vs. MRCP to evaluate for obstruction. Liver
was also consulted who felt the most likely etiology given
normal imaging was drug induced intrahepatic cholestasis with
components of shock liver vs. obstruction. They also recommended
MRCP vs. transjugular biopsy; however, patient had a pacer and
was not well enough to tolerate the biopsy. Hepatitis serologies
were checked and were negative. Transaminases trended down
throughout her stay while AP and TB remained elevated.
Patient began to experience atrial fibrillation with RVR to the
150's which was somewhat controlled after loading with digoxin.
Patient also began to experience anuric renal failure with
diffuse anasarca. Renal was consulted regarding possibility of
CVVH vs. HD; however, after discussion with family, this was not
consistent with her long term goals of care and thus deferred. A
TTE was performed which showed an LVEF of 30-35%. Wound care was
consulted and recommended continuing adequate skin moisturizer
to prevent tissue breakdown.
Attempts were made to wean pressors but the patient remained
pressor dependent throughout her stay. Family meetings were
routinely held discussing goals of care. On [**10-23**] the family
agreed to no escalation of care and on [**10-24**] the family asked for
patient to be made CMO. She was extubated and all medications
were stopped. Patient subsequently expired in the evening on
9/31.
Medications on Admission:
Protonix 40mg daily
Metoprolol XL 100 PO BID
ASA 81 mg daily
Remeron 30mg qHS
Lactobacillus 1 tab PO BID
Iron 325mg PO daily
Flonase 110 mcg IH daily
Combivent 1 puff [**Hospital1 **]
Coumadin 1.5 mg daily
Colace 100mg Po BID
Lasix 40mg PO daily
Tylenol PRN
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"51881",
"78552",
"5849",
"5990",
"5119",
"99592",
"4280",
"4240",
"42731",
"4019",
"311"
] |
Admission Date: [**2129-6-10**] Discharge Date: [**2129-6-25**]
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: This 88-year-old female with
coronary artery disease and left bundle branch block
presented with acute onset of dyspnea for 18 hours prior.
She was in her usual state of health, fairly sedentary and
able to ambulate about one block before developing chest
tightness and claudication, until the night before admission
when she developed progressive dyspnea at rest and was unable
to sleep. She had a cough, plus-minus fevers, and had to sit
upright to breath. She has a baseline four-pillow orthopnea.
She also reported chest tightness on the day of admission
similar to anginal pain in the past. The chest pain peaked
at noon on the day of admission. She called the emergency
medical technicians and presented to the Emergency
Department. There she was tachypneic with 30-40 respiratory
rate, oxygen saturation 100% on 4 liters face mask, and
tachycardiac to 120. Electrocardiogram showed left bundle
branch block. She was treated with aspirin, Lasix, Heparin,
and intravenous Nitroglycerin with mild improvement in her
symptoms. At 10:30 p.m. on the day of admission, she
developed acute decompensation with a respiratory rate of
40-50 and poor air movement. Her saturations remained at
100%. She was placed on BIPAP 10/5 with eventual respiratory
rate decrease to 30 after 10 minutes. She was then given
Albuterol nebulizers and oxygen via face mask with continued
improvement and was then admitted to the CCU for further
management.
PAST MEDICAL HISTORY: The past medical history revealed
coronary artery disease status post coronary artery bypass
graft in [**2121**]. Persantine Thallium study in [**10/2128**] was
normal. The patient has had left bundle branch block since
[**2124**]. There is a history of hypertension, chronic
obstructive pulmonary disease, positive PPD, pleural plaques
on chest x-ray in [**2125**], status post cholecystectomy, history
of pulmonary embolism, peripheral vascular disease with
claudication, chronic renal insufficiency with baseline of
[**12-13**].3, diabetes mellitus, and supraventricular tachycardia.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Flovent, aspirin, Baycol,
Prilosec, Coumadin 3.5 mg q. day, Verapamil 80 mg t.i.d.,
Digoxin 0.125 mg q.o.d., iron, Atrovent, Lisinopril 40 mg q.
day, Imdur 30 mg q. day.
SOCIAL HISTORY: The patient is [**Location 11543**] and speaks
Portuguese.
PHYSICAL EXAMINATION: Blood pressure was 100/80, pulse 125
and regular, respiratory rate 30-40, O2 saturation 100% on 6
liters face mask. In general, the patient was an elderly,
ill-appearing female, tachypneic. HEENT examination revealed
normocephalic, atraumatic. Sclerae were anicteric. The
oropharynx was clear. The neck was full, JVP at 12 cm. The
chest revealed shallow breaths and wheezes, inspiratory much
greater than expiratory anteriorly. Cardiovascular
examination revealed tachycardia. No murmurs, gallops, or
rubs were appreciated. The abdomen was soft and nontender.
Bowel sounds were present. The extremities revealed 1+ edema
bilaterally halfway up to the knees. Neurologically, the
patient was alert and oriented but lethargic.
LABORATORY DATA: White blood cell count was 8.7, hematocrit
42, platelets 264,000. Differential revealed 61 polys, 29
lymphocytes, 4 monocytes, 3 eosinophils. Sodium was 142,
potassium 4.6, chloride 100, bicarbonate 27, BUN 16,
creatinine 1.3, glucose 195. Digoxin level was 0.4. PT was
18.8, PTT 27.9, INR 2.3, CK 51, troponin less than 0.05,
amylase 143, lipase 100. Electrocardiogram revealed sinus
tachycardia at 125 beats per minute, left bundle branch
block, no significant changes from prior of [**2126-6-18**]. Chest
x-ray revealed cardiomegaly, slight upper zone
redistribution, and pleural thickening in the left mid lung
field.
ASSESSMENT: This elderly female with coronary artery disease
and chronic obstructive pulmonary disease presented with
acute dyspnea at rest.
HOSPITAL COURSE
Cardiovascular: The patient was initially treated with
aspirin, Heparin, Nitroglycerin, and Digoxin, and her CKs
were cycled. No beta blocker was given at that time because
of her underlying chronic obstructive pulmonary disease.
Arterial blood gases were drawn to assess the pulmonary
status from the right femoral artery and she developed
hematoma at this site; however abdominal CT showed no
retroperitoneal bleed. During her hospital stay, there was
concern for mesenteric ischemia and her Digoxin was stopped.
In addition, her hospital course was complicated by multiple
episodes of chest pain of sudden onset with elevations in her
blood pressure to around 200 systolic with her heart rate in
the 140s. Her pain was relieved with sublingual
Nitroglycerin and on one occasion required morphine for
relief after sublinguals. Throughout all her episodes of
chest pain, she had no EKG changes and her CKs remained flat.
During one of her episodes of chest pain, a pain MIBI was
performed and showed no signs of ischemic change. Thus
cardiology concluded that her chest pain was not of cardiac
ischemic origin. Early in her hospital course, she remained
persistently tachycardiac in the 130s and 140s. She was
switched to Verapamil 120 mg q.i.d. and Isordil 80 mg t.i.d.
and eventually her baseline heart rate came down to the 70s
and 80s. However she still had occasional chest pain with
the elevated blood pressure and heart rate. There was a
question of whether her chest pain episodes were related to
meals; however no confirmation was obtained.
Pulmonary: Her initial presentation was consistent with
chronic obstructive pulmonary disease flare and she was
started on Albuterol, Solu-Medrol, and oxygen as well as
Levaquin. Her oxygen requirement was eventually weaned down
to her home baseline of 0.5 liters of oxygen per nasal
cannula and Prednisone was weaned during her hospital stay.
There was a question of whether her sinus tachycardia was
related to pulmonary embolism and D-dimer sent was negative.
However no VQ scan was performed because of her baseline
chest x-ray abnormalities. A pulmonary angiogram was not
done secondary to her baseline chronic renal insufficiency.
In addition, she was already on Heparin therapy and thus we
would not have changed our management.
Renal: The patient has a baseline chronic renal
insufficiency with a creatinine of 1.3 and thus all her
medications were renally dosed. She was hydrated before and
after angiography. There were no bumps in her creatinine
secondary to any dye loads.
Gastrointestinal: According to her primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 8499**], she has had multiple admissions in the past
for sudden onset chest pain and epigastric pain with
shortness of breath. She has also had intermittent
elevations in her amylase during these episodes which
eventually resolved in 12 to 48 hours. During this
admission, she had no episode of nausea, vomiting, or
diarrhea. She denied any postprandial pain, sitophobia, or
any weight loss. However her primary care physician wanted
to pursue a GI evaluation for her previous pain. An MRA that
was done at an outside hospital showed questionable
mesenteric stenosis and thus we proceeded to perform a
mesenteric angiogram while the patient was in-house. This
showed no significant stenoses. In addition, an MRCP was
also performed to evaluate for any pancreatic ductal
pathology and this showed ectatic pancreatic ducts with no
signs of obstruction. She remained guaiac negative with no
elevations of amylase or lipase during this admission. It
was recommended that she continue followup evaluation of her
symptoms as an outpatient.
Hematology: The patient was on Coumadin as an outpatient
which was stopped as she was supratherapeutic. She was
started on Heparin, however, will be discharged on Coumadin
and Lovenox subcutaneously until she is therapeutic. Iron
studies showed a microcytic anemia with a low absolute
reticulocyte count and thus she was started on iron therapy.
Endocrine: The patient was kept on NPH and regular insulin
sliding scale for her glucose intolerance.
Disposition: The patient will be discharged home with home
physical therapy services as well as VNA for her Lovenox
administration b.i.d. until her INR is therapeutic.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES: Chronic obstructive pulmonary disease
flare, chest pain, and abdominal pain of unknown etiology.
CODE STATUS: Full code.
DISCHARGE MEDICATIONS: NPH 10 units q.a.m. and 4 units
before dinner, Zestril 40 mg q. day, enteric coated aspirin
325 mg q. day, Combivent 120/21 mcg MDI 2 puffs b.i.d., iron
325 mg q. day, Lipitor 10 mg q. day, Prednisone 15 mg q. day
x 3 days starting [**2129-6-26**] and then 5 mg x 3 days starting
[**2129-6-29**], Verapamil 120 mg p.o. q.i.d., Isordil 10 mg p.o.
t.i.d., sublingual Nitroglycerin 0.3 mg sublingually p.r.n.
pain up to three doses, Coumadin 5 mg p.o. q. day, Lovenox 70
mg subq. b.i.d. until INR greater than or equal to 2.
DISCHARGE FOLLOWUP: The patient will follow up with her
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8499**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10134**], M.D. [**MD Number(1) 11525**]
Dictated By:[**Last Name (NamePattern1) 11544**]
MEDQUIST36
D: [**2129-6-25**] 10:50
T: [**2129-6-26**] 11:05
JOB#: [**Job Number **]
|
[
"42789",
"25000",
"41401",
"V4581",
"V1582"
] |
Admission Date: [**2142-8-5**] Discharge Date: [**2142-8-13**]
Date of Birth: [**2095-3-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest pain radiating to the back
Major Surgical or Invasive Procedure:
[**2142-8-7**] Four Vessel Coronary Artery Bypass Grafting(left internal
mammary artery to left anterior descending, vein grafts to
diagonal, obtuse marginal, and PDA)
History of Present Illness:
Mr. [**Known lastname 74177**] is a 47 yo male with history of MI x 2 most recently
in [**6-/2142**] with cath showing severe 3 vessel disease with bare
metal stents x2 to LCX and plan for CABG in 1-2months, who woke
up this am at 5:30 and went to use restroom, noticed substernal
chest pain, radiating to his back [**8-10**] in severity. The pain
persisted and he went to OSH around 11am. BP 156/89, HR 59 He
was given NTG x 3 with no effect, Maalox with some relief,
followed by 1mg of morphine with complete resolution of chest
pain. Was transferred to [**Hospital1 18**] for further care.
Past Medical History:
Coronary Artery Disease
History of MI [**2137**] and NSTEMI/IMI in [**2142-6-1**]
Prior PCI and bare metal stents to circumflex artery
Hypertension
Hypercholesterolemia
Insulin Dependent Diabetes Mellitus
Obesity
Osteoarthritis - chronic low back, hip and knee pain
History of Retroperitoneal Bleed(s/p cardiac cath)
Pilonoidal Cyst Surgery
Ankle Surgery
Social History:
Denies any hx tobacco, etoh use. Works as truck driver. Lives
at home with wife and 11 year old twins. Does not exercise
regularly
Family History:
Father history CAD, HTN CABG at 74 yo
Mother with hx HTN, died from cerebral hemorrhage at 54 yo.
Physical Exam:
VS: T97.6 , BP 138/79R 137/69L , HR 52=7 , RR 12, O2 98% RA
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple, no JVD
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits. BS+
Ext: No c/c/e.
Skin: No ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 2+ DP, no femoral bruit
Left: Carotid 2+ without bruit; 2+ DP, no femoral bruit
Pertinent Results:
[**8-7**] Echo: Prebypass: 1.No atrial septal defect is seen by 2D or
color Doppler. 2. There is mild to moderate regional left
ventricular systolic dysfunction of the apex, apical portions of
the anterior, septal and inferior walls . The mid septal and
inferior walls are also hypokinetic. 3. Right ventricular
chamber size and free wall motion are normal. 4. There are
simple atheroma in the descending thoracic aorta. 5. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. 6. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Post Bypass:
1. Biventricular systolic function remains unchanged. 2. Mild 1+
mitral regurgitation is unchanged. 4. Ascending aorta is intact
post-decannulation. 5. At one point there was severe hypotension
associated with Supraventricular tachycardia when LV function
was severely depressed. Post cardioversion the cardiac function
recovered to baseline.
[**8-13**] CXR: The cardiomediastinal contour is widened compared to
preoperative films but appears stable on the postoperative
period. Median sternotomy wires are again. The left-sided
pleural effusion appears worse compared to the prior study.
Right lower lobe atelectasis posteriorly is also worse compared
to the prior film.
[**2142-8-5**] 02:40PM BLOOD WBC-7.0 RBC-4.34* Hgb-13.3* Hct-38.5*
MCV-89 MCH-30.7 MCHC-34.6 RDW-15.8* Plt Ct-164
[**2142-8-8**] 09:37AM BLOOD WBC-8.6 RBC-3.57* Hgb-11.0* Hct-31.7*
MCV-89 MCH-30.9 MCHC-34.8 RDW-15.8* Plt Ct-177#
[**2142-8-13**] 09:05AM BLOOD WBC-4.7 RBC-3.03* Hgb-9.3* Hct-27.3*
MCV-90 MCH-30.8 MCHC-34.2 RDW-15.5 Plt Ct-227#
[**2142-8-5**] 02:40PM BLOOD PT-12.3 PTT-26.9 INR(PT)-1.1
[**2142-8-7**] 09:05PM BLOOD PT-15.3* PTT-68.2* INR(PT)-1.4*
[**2142-8-5**] 02:40PM BLOOD Glucose-135* UreaN-22* Creat-1.1 Na-138
K-4.3 Cl-104 HCO3-26 AnGap-12
[**2142-8-13**] 09:05AM BLOOD Glucose-99 UreaN-22* Creat-1.3* Na-136
K-4.1 Cl-100 HCO3-29 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 74177**] was admitted to the cardiology service and remained
pain free on medical therapy which included intravenous Heparin.
There was no evidence of active ischemia. He was well known to
the cardiac surgical service and surgical revascularization was
planned for the near future. Given his angina, and his known
coronary artery disease, he was taken to the operating room on
[**8-7**] and underwent coronary artery bypass grafting surgery
by Dr. [**First Name (STitle) **]. Operative course was notable for supraventricular
tachycardia. Amiodarone was initiated, and cardioversion was
successfully performed. For additional surgical details, please
see separate dictated operative note. Following the operation,
he was brought to the CSRU for invasive monitoring. Within 24
hours, he awoke neurologically intact and was extubated without
incident. He remained on Amiodarone without further occurrence
of atrial or ventricular arrhythmias. He gradually weaned from
inotropic support and tolerated resumption of beta blockade. His
CSRU course was otherwise uneventful and he transferred to the
SDU on postoperative day two. Epicardial pacing wires were
removed on post-op day three. He remained stable over the next
several days while receiving physical therapy for strength and
mobility. On post-op day 6 he was doing well and ready for
discharge home with VNA services and the appropriate follow-up
appointments.
Medications on Admission:
Aspirin 325 qd
Metoprolol 100 am/50 pm
Lipitor 80 qd
Lisinopril 5 qd
Plavix 75 qd
Heparin gtt
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Insulin Glargine 100 unit/mL Solution Sig: Thirty Eight (38)
UNITS Subcutaneous once a day: SubCutaneously at bedtime.
Disp:*qs qs* Refills:*2*
4. Insulin Lispro 100 unit/mL Solution Sig: 2-20 UNITS
Subcutaneous four times a day: Use As Directed by sliding scale.
Disp:*qs qs* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Please take 400mg once a day for 7 days then decrease to 200mg
daily and follow up with Dr [**Last Name (STitle) **] .
Disp:*60 Tablet(s)* Refills:*0*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
9. 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*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
11. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO once a day for 2 weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Bayada Nurses Inc
Discharge Diagnosis:
Coronary Artery Disease - s/p Coronary Artery Bypass Graft x 4
Intraoperative Supraventricular Tachycardia
PMH: History of MI [**2137**] and IMI [**6-/2142**], Prior PCI and bare metal
stents to LCX, Hypertension, Hypercholesterolemia, Insulin
Dependent Diabetes Mellitus, Obesity, Osteoarthritis
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**]
Blood glucose please continue to follow sliding scale and lantus
as prior to admission, please call [**Last Name (un) 387**] if bg > 200 x2
Followup Instructions:
Please call to schedule appointments
Dr. [**First Name (STitle) **] in [**4-5**] weeks, [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] in [**2-3**] weeks [**Telephone/Fax (1) 74178**]
Dr. [**Last Name (STitle) **] in [**2-3**] weeks [**0-0-**]
Wound check appointment please schedule with RN [**Telephone/Fax (1) 3633**]
Dr. [**Last Name (STitle) **] on [**2142-8-23**] @ 01:40pm - please call to confirm appt
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2142-10-9**] 9:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2142-10-9**]
10:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2142-8-13**]
|
[
"41401",
"9971",
"42789",
"412",
"4019",
"2720",
"25000",
"V5867"
] |
Admission Date: [**2125-11-27**] Discharge Date: [**2125-12-2**]
Date of Birth: [**2063-12-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Levaquin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional chest pain
Major Surgical or Invasive Procedure:
[**2125-11-28**] Urgent Coronary Artery Bypass Grafting x 3 (left
internal mammary artery to left anterior descending, vein grafts
to diagonal and obtuse marginal)
History of Present Illness:
This is a 61 year old male with history of hyperlipidemia who
has had progressive exertional chest pain over the past year.
Pain is releived with rest and is associated with mild dyspnea.
Cardiac catheterization on [**2125-11-27**] at [**Hospital 5279**] Hospital revealed
60% distal left main lesion and normal left ventricular
function. Given critical coronary anatomy, he was transferred to
the [**Hospital1 18**] for surgical revascularization.
Past Medical History:
Coronary Artery Disease
Hypertension
Dyslipidemia
Prostate Cancer
Erectile Dysfunction
Hernia repair
Prostatectomy
Tonsillectomy
Cataract removal
Social History:
Race: Caucaisian
Last Dental Exam: one year ago
Occupation: Works for homeland security
Tobacco: Denies
ETOH: 5-6 beers/day
Family History:
Denies premature coronary disease
Physical Exam:
Admission:
Temp 97.5 Pulse:75 B/P:118/80 Resp: 18 O2 sat: 95%-RA
Height: 5'8" Weight:69.9K/153 lbs
General:
Skin: Dry x[] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None
[x]
Neuro: Grossly intact
Pulses:
Femoral Right: cath site Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit none Right: +2 Left:+2
Pertinent Results:
[**2125-11-27**] WBC-8.9 RBC-4.51* Hgb-13.5* Hct-39.9* Plt Ct-208
[**2125-11-27**] PT-12.9 INR(PT)-1.1
[**2125-11-27**] UreaN-15 Creat-1.0 Na-141 K-3.9 Cl-104 HCO3-28 AnGap-13
[**2125-11-27**] ALT-31 AST-22 LD(LDH)-154 CK(CPK)-59 AlkPhos-75
Amylase-27 TotBili-0.5
[**2125-11-27**] %HbA1c-5.8
[**2125-11-27**] Carotid Ultrasound: No significant internal carotid
artery stenosis identified bilaterally.
[**2125-11-30**] 05:30AM BLOOD WBC-9.8 RBC-3.43* Hgb-10.4* Hct-30.5*
MCV-89 MCH-30.4 MCHC-34.2 RDW-13.5 Plt Ct-197
[**2125-11-30**] 05:30AM BLOOD Glucose-93 UreaN-11 Creat-1.0 Na-137
K-4.7 Cl-101 HCO3-30 AnGap-11
[**2125-11-27**] 03:40PM BLOOD %HbA1c-5.8
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the cardiac surgical service and
underwent routine preoperative evaluation. He remained pain free
on medical therapy. Workup was unremarkable and he was cleared
for surgery. On [**11-28**], Dr. [**Last Name (STitle) 914**] performed urgent
coronary artery bypass grafting surgery. For surgical details,
please see operative note. Following surgery, he was brought to
the CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident.
He was transferred to the floor on POD 1 and beta blockade and
diuretics were begun. Physical Therapy worked with him for
mobility and strength. Chest tubes and temporary pacing wires
were removed according to protocol. Hospital course was
uneventful. By the time of discharge, on POD 4, the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. He was discharged home in good condition
on POD 4.
Medications on Admission:
Vytorin 40/10 QD, Metoprolol XL 25 [**Last Name (LF) 244**], [**First Name3 (LF) **] 81 QD, Levitra prn
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a
day.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 6011**] Care
Discharge Diagnosis:
Coronary Artery Disease
s/p coronary artery bypass grafts
Dyslipidemia
Hypertension
History of Prostate Cancer
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with tylenol prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Surgeon Dr [**Last Name (STitle) 914**] in 2 weeks ([**12-18**] @ 1:30
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10861**] in [**12-15**] weeks([**Telephone/Fax (1) 10862**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39975**] in 4 weeks
please call for these
Completed by:[**2125-12-2**]
|
[
"41401",
"5119",
"2859",
"25000",
"2724",
"4019"
] |
Admission Date: [**2177-7-26**] Discharge Date: [**2177-8-1**]
Date of Birth: [**2124-4-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Neurontin / Prozac
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**7-26**] Cardiac Catheterization
[**7-28**] Off-Pump Coronary Artery Bypass Graft x 3 (LIMa to LAD, SVG
to Ramus, SVG to OM)
History of Present Illness:
53yo gentleman with h/o CAD (2 vessel disease of LCx and
co-dominant RCA), mild systolic CHF (EF 45%), and DM2
transferred from [**Hospital3 417**] with NSTEMI.
Patient reports stuttering exertional and non-exertional chest
pain for anywhere from days to months, depending on the
interviewer. He had dismissed the pain as being due to acid
reflux. Of note, he had stopped taking many of his cardiac
medications (including plavix, metoprolol, lisinopril, and
imdur) without discussing the matter with his PCP. [**Name10 (NameIs) **] finally
came into the hospital at [**Hospital3 **] because his pain did not go
away after a few days despite taking antacids. He also admits to
doing 4 lines of cocaine 2 days prior to presentation. During
his initial work-up at [**Hospital1 **], he was found to have ST
depressions in V5 and V6 with troponin of 3.1, at which point he
was transferred to [**Hospital1 18**]. He received ASA, plavix 300mg, and
lovenox and was on a nitro gtt prior to transfer. He was also on
an amiodarone gtt for reported frequent ectopy.
In the ED, his initial VS were: 97.2 146/85 25 95% 4L. He was
having mild chest pain and frequent runs of NSVT. Cardiology was
consulted for positive biomarkers. He was put on an integrillin
gtt and given morphine and zofran for symptom management. He
also received lasix 40mg IV x 1 because of evidence of heart
failure on exam.
Past Medical History:
CAD s/p MI ([**2175**]) and multiple overlapping DES to LCx ([**2176-8-5**])
HTN
Hyperlipidemia--no LDL, HDL available at [**Hospital1 18**]
GERD
DM2--no A1C available
Nocturia
Hepatitis C--no viral load available
Chronic back pain s/p laminectomies, rod placement d/t
injury--on chronic methadone
COPD--no PFTs available
Arthritis
Bipolar
Social History:
Social history is significant for the presence of current
tobacco use: he has smoked [**1-15**] PPD x "all my life". There is a
history of alcohol abuse in the past; he has been sober x 8
years. He admits to using 4 lines of cocaine 2 days ago.
Family History:
There is a family history of premature coronary artery disease
in his grandmother and aunt.
Physical Exam:
VS: T 97.4, BP 90/48, HR 71, RR 16, O2 94% on 5L
Gen: Overweight gentleman in significant distress from pain and
anxiety. Oriented x3. Anxious. Somewhat circuitous with answers.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 8-10cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Somewhat distant heart sounds, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. ? crackles at bases
b/l, though patient has difficulty staying still for exam
secondary to pain. No wheeze.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits. Femoral sheath in place with IABP.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+; Femoral sheath in place; DP dopplerable
Left: Carotid 2+; Femoral 1+ without bruit; 2+ DP
Pertinent Results:
EKG (06:39) demonstrated NSR with normal axis and good R wave
progression. T wave flattening in aVL and III that is old as
compared with prior dated [**2176-8-16**].
EKG (08:28) as above with frequent PVCs.
EKG (16:19) NSR with normal axis and T wave flattening in aVL,
III, ? ST depressions in V4 and V5.
QTc in all EKGs is prolonged, ranging up to 477ms.
[**7-26**] Cardiac Cath: 1. Selective coronary angiography of this
co-dominant system revealed three vessel coronary artery
disease. The LMCA had mild disease. The LAD had a 60-70%
proximal tubular lesion. The LCX was subtotally occluded with
diffuse in stent restenosis and thrombosis. The RCA was
distally occluded and filled by collaterals. 2. Limited resting
hemodynamics revealed significantly elevated left sided filling
pressures with LVEDP of 45 mm Hg. There was no gradient upon
pullback of the catheter from LV to the aorta. There was mild
systemic arterial hypotension of 94/65 mm Hg. 3. Left
ventriculography was deferred. 4. Successful insertion of IABP.
[**7-28**] Echo: PREGrafting: No atrial septal defect is seen by 2D or
color Doppler. The left ventricular cavity is moderately
dilated. There is moderate to severe regional left ventricular
systolic dysfunction with dyskinesis of the inferolateral wall,
hypokinesis of the distal anterior and anterolateral walls..
LVEF ~25-30%. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are moderately
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The MR
increased to (2+) moderate during manipulation of the heart
during off pump CABG. A well positioned balloon pump catheter is
seen in the descending thoracic aorta. Post Grafting: 1+ mitral
regurgitation seen post-grafting. Aortic balloon pump catheter
remains in descending thoracic aorta just distal to the
subclavian artery. LV function and wall motion appears mildly
improved. (EF 30-35%.) The distal anterior wall appears to be
improved. Previous wall motion abnormalities persist. Remaining
exam is unchanged from pre-grafting.
[**2177-7-26**] 06:50AM BLOOD WBC-11.7*# RBC-4.04*# Hgb-12.5* Hct-36.4*
MCV-90# MCH-30.9# MCHC-34.2 RDW-13.8 Plt Ct-248
[**2177-7-31**] 05:11AM BLOOD WBC-9.6 RBC-2.98* Hgb-9.3* Hct-27.9*
MCV-94 MCH-31.2 MCHC-33.3 RDW-14.3 Plt Ct-176
[**2177-7-26**] 06:50AM BLOOD PT-12.7 PTT-34.1 INR(PT)-1.1
[**2177-7-30**] 02:10AM BLOOD PT-13.4 PTT-30.4 INR(PT)-1.1
[**2177-7-26**] 06:50AM BLOOD Glucose-266* UreaN-29* Creat-0.9 Na-134
K-6.2* Cl-98 HCO3-28 AnGap-14
[**2177-7-31**] 05:11AM BLOOD Glucose-179* UreaN-40* Creat-1.1 Na-130*
K-5.1 Cl-96 HCO3-33* AnGap-6*
[**2177-8-1**] 05:00PM BLOOD WBC-8.3 RBC-3.24* Hgb-10.0* Hct-29.9*
MCV-92 MCH-30.9 MCHC-33.5 RDW-14.3 Plt Ct-268#
[**Known lastname **],[**Known firstname 7167**] [**Medical Record Number 15111**] M 53 [**2124-4-21**]
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2177-7-30**] 4:45 PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2177-7-30**] SCHED
CHEST PORT. LINE PLACEMENT Clip # [**Clip Number (Radiology) 15112**]
Reason: assess for line position, pneumothorax
[**Hospital 93**] MEDICAL CONDITION:
53 year old man s/p RIJ central line exchange over wire
REASON FOR THIS EXAMINATION:
assess for line position, pneumothorax
Wet Read: KYg WED [**2177-7-30**] 5:46 PM
RIJ SWAN GANZ EXCHANGED FOR CVL. NO PTX. SCATTERED ATELECTASIS
SLIGHTLY
IMPROVED IN THE LEFT BASE. MILDLY IMPROVED. PULMONARY VASCULAR
CONGESTION.
CARDIOMEGALY UNCHNANGED. [**Doctor Last Name 7410**]
Final Report
HISTORY: Right IJ central line exchange over wire, to assess for
position.
FINDINGS: In comparison with the study of [**7-29**], the right IJ
Swan-Ganz
catheter tip lies in the lower portion of the SVC. Continued
enlargement of
the cardiac silhouette with improving atelectatic changes at the
left base.
Some evidence of pulmonary vascular congestion and continued
cardiomegaly.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: [**Doctor First Name **] [**2177-7-31**] 1:44 PM
Brief Hospital Course:
53yo gentleman with h/o CAD s/p DES in [**7-/2176**], DM, and recent
cocaine abuse admitted with NSTEMI and acute on chronic systolic
heart failure, also noted to have frequent bursts of NSVT. When
his cardiac enzymes trended up (CD 1452->1463 with positive MB
fraction), it was decided to take him to the cath lab. In the
cath lab, he was found to have a subtotally occluded LCx with
diffuse in-stent restenosis. The RCA was occluded distally but
filled by collaterals. His LAD had 60-70% proximal disease. It
was felt that treating the LCx lesions in the cath lab might
compromise his collateral circulation and he was referred to CT
surgery for evaluation. Hemodynamics revealed LV EDP of 45 and
an IABP was placed. On [**7-28**] he was brought to the operating room
where he underwent a off-pump coronary artery bypass graft x 3.
Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. Later on op day he was weaned from
sedation, awoke neurologically intact and extubated. On post-op
day one his IABP was removed. Beta-blockers and diuretics were
initiated on this day and he was gently diuresed towards his
pre-op weight. On post-op day two he was transferred to the
telemetry floor for further care.Pain services,substance
abuse,psychiatry and social work were all consulted for
reccommendations. Dilaudid PCA dc'd and converted to oral
agents.On POD#4 Mr.[**Known lastname 4020**] was ready for discharge.
Follow up as outpatient for institution of ACE-I, unable to
start prior to discharge due to BP.
Medications on Admission:
CURRENT MEDICATIONS: (x = confirmed with pharmacy: [**Telephone/Fax (1) 15113**])
ASA 325mg daily
xPlavix 75mg daily
xNTG SL 0.3mg Q5min PRN
Insulin Glargine 50-60units [**Hospital1 **]/Lispro 20 units Q supper
xOxycodone 15mg QID
xMethadone 50mg TID
xValium 5mg TID
Omeprazole 20mg daily
Calcium Carbonate 1500mg [**Hospital1 **]
xAlbuterol 2 puffs QID
xAmbien 5mg QHS PRN
xDocusate 100mg [**Hospital1 **]
xMiralax powder 1 capsule daily
Psyllium [**Hospital1 **]
Of note, patient was on metoprolol 12.5 [**Hospital1 **], lisinopril 5, imdur
30, lasix 10, tamsulosin 0.4, rosiglitazone 4, and cymbalta 60,
all of which he stopped b/c of concern for side effects but did
not tell his PCP he had done so.
Discharge Medications:
1. Methadone 10 mg Tablet Sig: Four (4) Tablet PO TID (3 times a
day): please continue as prior to admission and follow up with
PCP .
2. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain: please continue as prior to admission
and follow up with your PCP .
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
Disp:*qs qs* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*0*
10. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Insulin Glargine 100 unit/mL Solution Sig: 50 units
Subcutaneous twice a day.
Disp:*qs qs* Refills:*2*
13. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
14. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: please resume home dosing .
15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
16. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
17. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Off-Pump Coronary Artery Bypass
Graft x 3
Myocardial Infarction
Acute on chronic systolic heart failure
PMH: s/p Multiple DES to LCX, Hypertension, Hyperlipidemia,
Hepatitis C, Diabetes Mellitus, Gastroesophageal Reflux Disease,
Anxiety, Bipolar Disease, Chronic Pain (on Methadone)
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.
Do not use lotions, powders, or creams on wounds.
Call our office for temp.>101.5, sternal drainage.
Shower daily, let water flow over wounds, pat dry with a towel.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.
Please avoid all use of cocaine or illicit drugs as they will
interfer with your recovery and medications.
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks
Dr. [**First Name (STitle) **] in [**1-15**] weeks
Follow up with outpt.substance abuse counsellor
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2177-8-1**]
|
[
"41071",
"41401",
"4280",
"25000",
"4019",
"53081"
] |
Admission Date: [**2163-6-20**] Discharge Date: [**2163-7-1**]
Date of Birth: [**2131-10-19**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
motorcycle crash
Major Surgical or Invasive Procedure:
Percutaneous tracheostomy [**2163-6-20**]
percutaneous endoscopic gastrostomy [**2163-6-23**]
History of Present Illness:
31M un-helmeted motorcycle crash, +EtOH. Found unresponsive
approximately 30 feet from motorcycle and intubated at scene.
Seen at OSH with report of decerebrate posturing and asymmetric
pupils. Transferred to [**Hospital1 18**] for trauma evaluation
Past Medical History:
none
Pertinent Results:
Discharge labs:
142 102 22
-------------< 125
4.9 31 0.9
Ca: 9.8 Mg: 2.6 P: 5.4
12.6 > 35.5 < 791
Brief Hospital Course:
In the ED, he had a CT Head, C-Spine, Torso, b/l tib/fib, knee,
femur films, and was admitted to TSICU intubated and sedated.
Work-up revealed the following injuries:
Right lat, med, inf orbital wall fx's
Right zygoma fx
Right lateral pterygoid plate FX
Left ant, post, med maxill sinus wall fx
Bilat mandib fx's
Nasal fx/s
Dense debris beneath right eyelid.
Left SAH
Bilateral lower extremity abrasions
Left palm burn
In addition to Acute Care Surgery, Neurology and Plastic Surgery
were also involved with his care.
In brief, regarding his facial fractures, plastic surgery
recommended follow-up with as an outpatient. His SAH was noted
to be stable and neurosurgery signed off after two head CT scans
on [**6-19**] and [**6-20**]. He did have a discordant exam (decorticate
posturing) from imaging results (NCHCT revealed only minor
traumatic intracranial changes) so neurology was consulted on HD
2 and recommended MRI to assess for brainstem injury -- it was
consistent with diffuse axonal injury. They did further
recommend EEG which was negative for seizure. He did receive a
tracheostomy on HD 2 which went without incident. He did
develop fevers during his hospitalization starting on HD 6 --
this was noted to be likely due to bilateral lower lobe
consolidations. It was treated initially with vanc/zosyn, this
was transitioned to unasyn while awaiting cultures and he
continued to spike through the antibiotic coverage. Following
speciation, he was switched to nafcillin/cipro and his fevers
resolved. He did have a CT abdomen and CT sinus on [**6-29**]; the CT
abdomen was negative, the CT sinus was positive for air fluid
levels. Considering he was afebrile with no signs of
obstruction, plastic surgery recommended against drainage of the
sinus and including levofloxacin in his antibiotic regimen. His
antibiotics were changed to nafcillin/levofloxacin on day of
discharge and should be continued until [**2163-7-5**]. He was also
started on afrin nasal spray and sudafed for a four day course
-- until [**2163-7-4**].
Details, by system:
Neuro: As detailed above -- diffuse axonal injury and a small
intracranial hemorrhage which has been stable with small left
subdural hematoma. As of discharge he does continue to exhibit
decorticate posturing and has had minimal improvement in his
neurologic exam (see pasted 'neurology sign off note' below for
complete documentation of his neuro status on discharge). EEGs
have been negative for seizure activity. He was receiving Q4H
neurochecks, his HOB was elevated at 30 degrees per neurosurg.
He was started on baclofen per neurology for muscle spasms, on
clonidine 0.3 TID, baclofen 10mg TID (per neuro for muscle
spasms), oxycodone and ativan.
Per the neurology sign-off note on [**6-29**]:
As on our prior examination (2-3d ago), his eyes open to sternal
rub and sometimes do so spontaneously. He does not follow
commands. He does not track or blink to threat. His left eye
moves horizontally with doll's eyes testing (appropriately
opposite the direction of head-turn). His right eye moves as
well, to a lesser extent, intermittently conjugate (of note,
this
is a new finding -- R eye no movement last week). When
dysconjugate, the L eye shows brief horizontal nystagmus. Still
weak corneal blink reflexes bilaterally. Grimace to nasal tickle
intact as before; this also elicited drooling out the right side
of the mouth. Brow, lid, and lower face still less strong at
rest
and on grimace on the right relative to the left (likely a R
[**Name (NI) **]/peripheral VII [**3-3**] traumatic facial injuries). Breathing
spontaneously and rhythmically via trach collar. He becomes
intermittently tachycardic to the 130s with SBP up to 150 and RR
in the mid or upper 20s.
He exhibits Left hand tremor (arm rigid in a flexed position,
but
moveable) and rigidity/posturing in both arms and both legs,
both
spontaneously and on minimal tactile stimulation. He withdrew
the
Right arm from noxious nailbed pressure, up and away, in a
manner
that was not similar to prior flexor or extensor posturing, but
not clearly purposeful, either. The right and left arm
flexor-posture more frequently today and at only one time did
the
Right arm extend (in response to noxious stimulation of the
left). The legs are both rigidly extended. Pathologically brisk
patellars (spastic legs) and nascent ankle contractures (despite
bilateral AFOs). Clonus on the Right (sustained, as before), not
on the left. Toes briskly up-going bilaterally.
We do not have any further recommendations for Neurologic
testing
or treatment at this time. Repeat MRI can be considered in
several months' time (to reassess the degree of axonal shear
injury from the TBI, the extent of which is not evident on
initial MRI). Agree with continuing PT, AFOs, baclofen for
spasticity, BB & low-dose clonidine for dysautonomia. Brain/stem
injury is severe, but exam shows gradual slight improvements.
Recovery will be gradual and highly limited, over the many weeks
to several months.
Cardiac: He did have intermittent tachycardia and hypertension
attributed to increased sympathetic activity. He was started on
metoprolol 25 mg PO TID and was also on clonidine 0.3 mg TID.
At time of discharge his blood pressure was consistently in the
140s systolic and HR in the 70s.
Pulmonary: He had a tracheostomy on [**2163-6-20**]. He was quickly
weaned to trach collar with intermittent CPAP vent support as
needed. He did not require ventilatory support for the last
five days of his hospitalization. He did develop a pneumonia
which was treated initially with vanc/zosyn prior to narrowing
to unasyn and then ultimately changed to
nafcillin/ciprofloxacin.
Gastrointestinal: Kept on famotidine prophylaxis and a bowel
regimen (bisacodyl, milk of magnesia, colace, senna). He had a
PEG placed on [**6-23**] and subsequent x-rays and CT abdomen did show
pneumoperitoneum (no evidence of leak from any part of the
intestine), which is expected and normal after this procedure.
He was fed with Replete with Fiber with a goal rate of 75 ml/hr.
He tolerated tube feeds well.
Renal: He had a foley cathter initially, this was transitioned
to a condom catheter and he made adequate urine during his
hospitaziation with a Cr of 0.9 on discharge.
Hematology: SQH prophylaxis and venodynes. No issues.
Endocrine: no active issues.
ID: He was treated for both a pneumonia and a sinus infection -
cultures from BAL/sputum growing H.flu, Klebsiella, Staph Aureus
(MSSA) -- antibiotics started on [**6-23**] as vanco/zosyn, narrowed
to unasyn on [**6-25**] and switched with speciation of MSSA to
nafcillin/cipro on [**6-29**]. Upon detection of sinus fluid, was
switched to nafcillin/levofloxacin on [**6-29**] for enhanced gram
positive coverage for the sinusitis. His blood and urine
cultures have remained negative. WBC was 18 on admission,
peaked to 20.7 on [**6-24**] and trended down to 12.6 on discharge.
He should continue the nafcillin/levofloxacin until [**2163-7-5**].
MSK: Regarding his facial fractures, plastic surgery
recommended against inpatient operative management and
recommended f/u in clinic 1-2 weeks post-discharge, no OR
planned as an inpatient. He was noted to have a left palm burn
on admission which was treated with silvadene cream with daily
dressing changes. His lower extremity abrasions were treated
with bacitracin ointment.
Lines / Tubes / Drains: left PICC ([**6-23**]-), trach ([**6-20**]-), PEG
([**6-23**]-), condom cath
Discharge Medications:
1. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day).
2. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000
unit injection Injection TID (3 times a day).
7. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic Q1H (every hour).
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. oxycodone 5 mg/5 mL Solution Sig: 5-15 mg PO Q3H (every 3
hours) as needed for pain.
13. clonidine 0.1 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
15. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
16. Ativan 1 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for agitation.
17. nafcillin 2 gram Recon Soln Sig: Two (2) grams Intravenous
every four (4) hours for 4 days: Continue until [**7-5**].
18. levofloxacin 25 mg/mL Solution Sig: Seven [**Age over 90 1230**]y
(750) mg Intravenous once a day for 4 days.
19. oxymetazoline 0.05 % Mist Sig: One (1) Spray Nasal [**Hospital1 **] (2
times a day) for 4 days: Until [**2163-7-4**].
20. pseudoephedrine HCl 30 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 4 days: Until [**2163-7-4**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] [**Hospital1 8**]
Discharge Diagnosis:
multiple facial fractures, SDH/SAH (small, stable), pneumonia,
sinusitis
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname **] was admitted after a motor cycle accident. He
suffered multiple facial fractures and small head bleed as well
as diffuse axonal injury. While he was here, he was also
treated for a pneumonia and sinusitis with antibiotics. He will
be discharged to an extended care facility -- instructions and
hospital course detailed in discharge summary.
Followup Instructions:
Follow up with the Acute Care Surgery service in clinic [**7-14**] at 1:30 PM on the [**Hospital1 18**] [**Hospital Ward Name 517**] in the [**Hospital Unit Name **]
[**Location (un) 470**]. Call ([**Telephone/Fax (1) 2537**] with questions or if you need to
reschedule.
[**Hospital 878**] clinic (Dr. [**First Name4 (NamePattern1) 1399**] [**Last Name (NamePattern1) 54849**]) at ([**Telephone/Fax (1) 2528**]. Followup
is scheduled for [**2163-9-29**] on the [**Hospital1 18**] [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Building [**Location (un) **] at 4:30 PM.
Plastic Surgery clinic at ([**Telephone/Fax (1) 7138**]. Followup scheduled
for Friday [**7-15**] at 9:45 AM with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the
[**Hospital Unit Name **] on the [**Hospital1 18**] [**Hospital Ward Name 517**]. Please call the office
with questions or if you need to reschedule.
Completed by:[**2163-7-1**]
|
[
"51881",
"5180",
"42789"
] |
Admission Date: [**2156-2-3**] Discharge Date: [**2156-2-6**]
Date of Birth: [**2106-2-17**] Sex: M
Service: CCU
HISTORY OF THE PRESENT ILLNESS: This is a 44-year-old male
with hypertension and hyperlipidemia who complained of chest
pain radiating to his bilateral shoulders. He also
complained of clamminess. He denied nausea, vomiting,
shortness of breath, palpitations, or syncope. His chest
pain was [**11-4**]. He was taken to [**Hospital3 4527**] where he
was noted to have [**Street Address(2) 2051**] elevations. He was transferred to
[**Hospital1 18**].
He had right-sided leads demonstrating 1 mm elevations.
Catheterization revealed proximal LAD 60%, ostial proximal
occlusion. During the pass at the RCA, initial reperfusion,
he had bradycardia and hypotension. He was treated with
thrombectomy and stent. He had an episode of ventricular
fibrillation and was cardioverted. Hemodynamics: Wedge
pressure 23, RA 16, PA 30/20. He was transferred to the CCU
for further monitoring.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Rectal polyps.
4. Occasional GERD with a questionable ulcer.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Lipitor 20 q.d.
2. Aspirin 81 mg p.o. q.d.
3. V vitamins.
No over the counter medicines.
FAMILY HISTORY: His father had a heart attack at age 66.
His mother had breast cancer. He is a 9-1-1 dispatcher.
Positive tobacco use. He has two grown children.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
98.7, pulse 86, blood pressure 121/73, respiratory rate 20,
98% on room air. He is a pleasant male in no acute distress.
His pupils are equally round and reactive to light and
accommodation. The mucous membranes were moist. He had a
regular rate and rhythm with distant heart sounds. No
murmurs, rubs, or gallops. No JVD appreciated. Lungs:
Clear to auscultation anteriorly. Extremities: He had no
clubbing, cyanosis or edema. He had positive dorsalis pedis
pulses.
LABORATORY DATA: White count 22.2, hematocrit 43.4,
platelets 375,000. Sodium 142, potassium 3.8, chloride 110,
bicarbonate 24, BUN 18, creatinine 1.0, glucose 95. Initial
CK 112, troponin 0.8, albumin 3.6, calcium 7.5, phosphate
3.0, magnesium 1.4.
HOSPITAL COURSE: He was monitored in the CCU overnight. He
initially had a lot of ectopy on telemetry including
nonsustained V tach which decreased in frequency once his
electrolytes were repleted. He was started on a beta
blocker; however, his blood pressure would not tolerate the
addition of an ACE inhibitor. His enzymes peaked with a CK
peak of 3,213, troponin greater than 50. His triglycerides
were 193, LDL 86, HDL 43.
He was started on Plavix after his stent was placed. His
hospital course was fairly unremarkable. However, one day
prior to admission it was noted that his hematocrit had
trended down slightly from his admission to a hematocrit of
39.6 to 35. He had thin and Guaiac positive stool which was
dark and tarry. He was made n.p.o. and started on IV
Protonix b.i.d. He had no further episodes of this dark
tarry stool. His following hematocrit was stable. He had
two days of stable hematocrit despite the episode of melena.
He was seen by GI who felt that a scope was needed; however,
in the peri MI period, it was determined that this would not
be appropriate and would be of high risk.
Because he had no further episodes of GI bleed and the
hematocrit remained stable, he was sent home on b.i.d.
Protonix with warning signs that if dark tarry stools or
melena were to recur or he became lightheaded he was to call
his primary care physician or go to the Emergency Room for
evaluation.
He was discharged home in good condition.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg once a day.
2. Plavix 75 mg once a day.
3. Atorvostatin 40 mg once a day.
4. Pantoprazole 40 mg b.i.d.
5. Metoprolol 25 mg b.i.d.
FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 7389**] and to
have light rest until then.
DISCHARGE INSTRUCTIONS: Low activity for one to two weeks
and also if dark tarry stools or lightheadedness occur to
call PCP or go to the Emergency Room.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) 20150**]
MEDQUIST36
D: [**2156-2-6**] 11:40
T: [**2156-2-6**] 14:06
JOB#: [**Job Number 46262**]
|
[
"41401",
"3051",
"2720"
] |
Admission Date: [**2135-8-28**] Discharge Date: [**2135-9-5**]
Service: MEDICINE
Allergies:
Penicillins / Fosamax
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardioversion
History of Present Illness:
83 yo M with history of DM2, HTN, hyperlipidemia, AAA s/p
repair, recent IMI [**7-10**], s/p DES to LCx with severely depressed
EF admitted to CCU now returns with recurrent chest pain.
Patient reports developing chest "tightness" localized to LUQ,
lower left chest, focal, non radiating, no N/V/diaphoresis, no
SOB. Anginal equivalent is sob, never has had CP before. He was
at rest, wife gave him 3 sl ntg without relief, here nitro
without relief, relieved by morphine. Of note, patient w/ SVT
atrial flutter s/p DCCV on last admission. Patient went to
[**Hospital1 **], transferred to [**Hospital1 **] for further management.
.
In the ED VS 110/72 77 18 99% 2L. Given ASA 162, sl ntg x 3,
nitro past, plavix, heparin gtt, integrilin gtt, morphine 2 mg
IV x 2, nitro gtt. Continued to have CP [**2139-4-5**] at 12:25, nitro
increased with relief of pain to 0/10, no EKG changes. Again CP
[**4-13**] at 17:20, nitro increased, came up to floor with 1/10 CP
not able to be relieved.
.
Upon arrival to the floor, VSS, denies any CP, says morphine
helping, denies any change in stool, no melena/brbpr, last BM
yesterday, normal diet cooked by wife last night, no PND, stable
2 pillow orthopnea. No N/V/diarrhea as mentioned above, no
cough, URI symptoms. Ambulates around house, does not do stairs,
limited by arthritis. Reports compliance with meds since
discharge in [**7-10**].
Past Medical History:
- CAD s/p IMI [**7-7**] stent to LCx
- CHF with EF <25% global hypokinesis
- AAA status post repair about 15 years ago
- DM2
- Hypertriglyceridemia
- Hypertension
- Basal cell carcinoma of the ear
- Squamous cell carcinoma, sublingual
- BPH
- COPD
- Gastritis s/p GI bleed EGD [**2135-7-11**] showing mild esophagitis and
gastritis with erosions, Brunner's gland hypertrophy, H.pylori
negative.
Social History:
Smokes Heavy smoker for 60 years. Currently smokes 0.5-1 pack
per day. Denies alcohol use or IVDU. Lives with his wife. [**Name (NI) **]
one daughter, 4 grandchildren, retired electric inspector.
Family History:
NC
Physical Exam:
VS: 97.5 122/63 75 20 100% 4L
Gen: elderly man, lying flat, NAD, pleasant
Heent: red face, OP clear, moist, anicteric, no pallor
Neck: supple, no JVD appreciable
Chest: very poor air entry, decreased BS at bases, ?crackles
right base
CVS: nl S1 S2, irreg, very distant heart sounds, no m/r/g
appreciated
Abd: obese, soft NT/ND in all 4 quadrants, NABS
Ext: warm, trace edema, 1+ dp pulses b/l
Pertinent Results:
[**2135-8-28**] 10:10AM BLOOD WBC-4.3# RBC-3.51* Hgb-10.0* Hct-29.6*
MCV-84 MCH-28.4 MCHC-33.7 RDW-16.5* Plt Ct-226
[**2135-9-5**] 07:35AM BLOOD WBC-4.9 RBC-3.26* Hgb-9.3* Hct-27.6*
MCV-85 MCH-28.6 MCHC-33.7 RDW-16.0* Plt Ct-235
[**2135-8-28**] 10:10AM BLOOD PT-25.7* PTT-37.8* INR(PT)-2.6*
[**2135-8-28**] 05:00PM BLOOD PT-26.1* PTT-80.1* INR(PT)-2.7*
[**2135-8-29**] 06:10AM BLOOD PT-27.0* PTT-86.9* INR(PT)-2.8*
[**2135-8-30**] 06:40AM BLOOD PT-23.1* PTT-25.0 INR(PT)-2.3*
[**2135-9-1**] 05:15AM BLOOD PT-39.6* PTT-33.9 INR(PT)-4.4*
[**2135-9-2**] 05:13AM BLOOD PT-69.7* INR(PT)-8.9*
[**2135-9-2**] 03:05PM BLOOD PT-41.2* PTT-35.8* INR(PT)-4.7*
[**2135-9-3**] 05:15AM BLOOD PT-17.3* INR(PT)-1.6*
[**2135-9-5**] 07:35AM BLOOD PT-14.2* PTT-28.3 INR(PT)-1.3*
[**2135-9-5**] 07:35AM BLOOD Glucose-148* UreaN-15 Creat-1.1 Na-138
K-3.9 Cl-97 HCO3-32 AnGap-13
[**2135-9-1**] 05:15AM BLOOD Glucose-118* UreaN-27* Creat-1.5* Na-139
K-4.0 Cl-101 HCO3-27 AnGap-15
[**2135-9-1**] 06:45PM BLOOD Glucose-102 UreaN-27* Creat-1.6* Na-137
K-4.0 Cl-99 HCO3-28 AnGap-14
[**2135-9-2**] 05:13AM BLOOD Glucose-107* UreaN-25* Creat-1.4* Na-138
K-3.7 Cl-101 HCO3-28 AnGap-13
[**2135-8-28**] 10:10AM BLOOD CK(CPK)-41
[**2135-8-28**] 05:00PM BLOOD ALT-23 AST-34 LD(LDH)-237 CK(CPK)-35*
AlkPhos-71 Amylase-79 TotBili-0.5
[**2135-8-29**] 06:10AM BLOOD CK(CPK)-32*
[**2135-8-29**] 07:16PM BLOOD CK(CPK)-59
[**2135-8-30**] 06:40AM BLOOD CK(CPK)-57
[**2135-9-3**] 05:33PM BLOOD CK(CPK)-17*
[**2135-9-4**] 05:23AM BLOOD CK(CPK)-14*
[**2135-8-28**] 05:00PM BLOOD Lipase-59
[**2135-8-28**] 10:10AM BLOOD CK-MB-NotDone
[**2135-8-28**] 10:10AM BLOOD cTropnT-0.01
[**2135-8-28**] 05:00PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2135-8-29**] 06:10AM BLOOD CK-MB-NotDone cTropnT-0.02* proBNP-1322*
[**2135-8-29**] 07:16PM BLOOD CK-MB-2 cTropnT-<0.01
[**2135-8-30**] 06:40AM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2135-9-3**] 05:33PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2135-9-4**] 05:23AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2135-8-29**] 06:10AM BLOOD TSH-0.45
[**2135-9-1**] 06:45PM BLOOD TSH-0.24*
[**2135-8-29**] 06:10AM BLOOD Free T4-1.5
[**2135-9-2**] 03:05PM BLOOD Free T4-1.1
[**2135-9-2**] 05:13AM BLOOD Cortsol-29.1*
[**2135-8-28**] 05:00PM BLOOD Digoxin-1.0
[**2135-9-1**] 05:15AM BLOOD Digoxin-1.0
CXR [**8-28**]: FINDINGS: Again noted is apical bullous disease. There
is no focal consolidation or superimposed edema-like process.
There is mild tortuosity of an atherosclerotic aorta. Cardiac
silhouette remains borderline enlarged. No pleural effusion or
pneumothorax is seen.
IMPRESSION: Emphysema with no radiographic evidence for volume
overload.
CTA CHEST WITH IV CONTRAST [**8-29**]: Pulmonary arteries enhance
normally without filling defect. There is an enlarged nodular
goiter. Moderate emphysematous changes in the lungs. Biapical
scarring. Again identified is a concerning spiculated nodule
just adjacent to the minor fissure, which is difficult to
accurately measure but is approximately 1.4 x 0.8 cm. However,
it appears more pronounced and denser than on the prior CT.
There is a second 3-mm pulmonary nodule in the right lower lobe,
which is unchanged. Small nonspecific nodular opacity in the
right lower lobe appears new. Scarring in the left lower lobe.
There is extensive calcified atherosclerotic plaque throughout
the ascending aorta with multiple areas of large penetrating
ulcers. There been no interval development of extension into
aortic dissection. Ectasia but no definite aneurysmal
dilatation. No pathologically enlarged lymph nodes are seen
throughout the axilla, mediastinum, and hilum. Heart,
pericardium, and great vessels are unremarkable with the
exception of coronary artery calcification and heart size upper
limits of normal. Limited axial imaging through the upper
abdomen demonstrates no abnormalities. No focal osseous
abnormalities.
IMPRESSION:
1) No pulmonary embolism.
2) Severely atherosclerotic thoracic aorta with multiple
prominent penetrating ulcers.
3) Multiple pulmonary nodules; the spiculated nodule along the
minor fissure appears worrisome, and perhaps slightly more dense
than the prior CT scan. PET/CT may be helpful for further
assessment.
4) Emphysema with biapical scarring.
Persantine MIBI [**8-30**]: The image quality is adequate. The arms
are suboptimally positioned. Motion correction was performed on
the stress perfusion images.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the myocardium.
Gated images reveal septal hypokinesis. The loss of photon
counts in the last frame of the gated images is consistent with
arrhythmia (atrial fibrillation). The calculated left
ventricular ejection fraction is 58%.
There is no prior myocardial perfusion imaging study available
for comparison.
IMPRESSION: Normal myocardial perfusion. Normal left ventricular
cavity size. Septal hypokinesis. Calculated LVEF 58%.
Stress [**8-30**]:
INTERPRETATION: This 83 year old type 2 IDDM man with a history
of
CAD and AF was referred to the lab for evaluation of chest pain.
The
patient was infused with 0.142 mg/kg/min of dipyridamole over 4
minutes.
Prior to the test, he noted a "severe" chest discomfort that was
localized to under his left breast. This discomfort did not
change
throughout the procedure. There were no additional ST segment
changes
during the infusion or in recovery. The rhythm was atrial
fibrillation
throughout. Appropriate hemodynamic response to the infusion.
The
dipyridamole was reversed with 125 mg of aminophylline IV.
IMPRESSION: Atypical symptoms in the absence of ST segment
changes.
Nuclear report sent separately.
TTE [**9-2**]: Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is mildly depressed.
2. The aortic root is mildly dilated.
3. The aortic valve leaflets (3) are mildly thickened.
4. The mitral valve leaflets are mildly thickened.
5. Mild pulmonary hypertension is present.
6. Compared with the prior study (images reviewed) of [**2135-7-9**],
LV function has improved.
Admission ECG: Atrial flutter with variable block. Right axis
deviation. Compared to the previous tracing of [**2135-7-12**] atrial
flutter is new.
Brief Hospital Course:
1. Chest pain: There was no clear etiology of his pain. His
symptoms were somewhat atypical, in that his chest pain was
generally relieved with burping. His ECGs did not show any
ischemic changes, and numerous sets of cardiac enzymes were
negative. A persantime-MIBI was negative for ischemic changes
in the setting of having chest pain immediately prior to the
test (please see report above). A CTA demonstrated penetrating
aortic ulcers, which per review with radiology was unchanged
from [**3-10**]. CT Surgery was consulted and saw him in-house, and
they did not feel his pain was related to these ulcers. He has
f/u with them already arranged. He was continued on his
aspirin, plavix, and statin. He was given amlodipine in case
his chest pain was from esophageal spasm, but this was
discontinued as it did not seem to help.
On [**9-2**], he became acutely hypotensive and bradycardic
(30s-40s). He had received one dose of beta-blocker that AM.
He was given glucagon and atropine without response, and was
transferred to the CCU. While there, his bp/pulse were
maintained with dopamine. He was found to be in atrial flutter
with variable block, and was cardioverted. He was transferred
back to the floor a couple of days later after being weaned off
of the dopamine and remaining hemodynamically stable. His
digoxin was discontinued (although dig level was not elevated,
at 1.0).
2. PUMP. Severely depressed EF after IMI, although calculated EF
on MIBI was 58%. He did not appear overtly volume overloaded on
exam. He was continued on his statin. An ace inhibitor was
started without complication. A beta-blocker resulted in
bradycardia and hypotension as above. He was continued on his
home dose of Lasix (20 mg daily).
3. Rhythm: He was found to be in atrial flutter with variable
block. While in the CCU, he was cardioverted. He was continued
on his amiodarone 200 mg daily. His coumadin was held for a
supratherapeutic INR (as high as 8) but was restarted upon
discharge. His INR was low on discharge (1.3) and so he was
bridged with lovenox. This was discussed with his wife and his
outpt cardiologist. Thyroid studies were normal.
4. Spiculated lung nodule: Seen on prior CTA [**3-10**] as well as CTA
done [**2135-8-29**]. Per pt's wife, he is having an extensive workup as
an outpt, including a PET which was nondiagnostic. They are
currently seeing a thoracic surgeon regarding this.
5. Fever: Had fever overnight on [**8-30**], with UTI (pan-[**Last Name (un) 36**] e
coli) and pneumonia on CXR. These were both treated with a ten
day course of levofloxacin.
6. DM: on humalog 75/25 at home as well as metformin and actos.
These were held as he was hypoglycemic in the CCU. He was
restarted on half-dose 75/25, and continued on his metformin.
His actos was held and he was given instructions to hold it
until follow-up with his PCP.
7. COPD: Not on rx at home, exam c/w COPD. He was given
atrovent as needed.
8. H/o GIB/gastritis: continued on PPI.
9. HTN: continued on home regimen, started on lisinopril as
above.
Medications on Admission:
- Coumadin 1.5-3.0 mg daily
- Ecorin 325 mg daily
- gemfibrozil 600 mg [**Hospital1 **]
- metformin 500 mg [**Hospital1 **]
- Insulin Humalog 75/25 36 U AM/25 U pm
- Nexium 40 mg daily
- Amiodarone 200 mg daily
- Actos 45 mg daily
- Lipitor 20 mg daily
- Plavix 75 mg daily
- Lasix 20 mg daily
- Digoxin 0.125 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
2. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Hospital1 **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
[**Hospital1 **]:*1 inhaler* Refills:*6*
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for pain.
[**Hospital1 **]:*200 ML(s)* Refills:*2*
6. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
[**Hospital1 **]:*60 Tablet, Chewable(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
8. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours): take until instructed to
stop by your doctor.
[**Last Name (Titles) **]:*28 syringes* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*1 Disk with Device(s)* Refills:*2*
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
[**Hospital1 **]:*90 Tablet(s)* Refills:*2*
15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
[**Hospital1 **]:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Atrial flutter with variable block
Discharge Condition:
stable, ambulating, tolerating po, chest pain-free
Discharge Instructions:
You were admitted to the hospital for chest pain. You had a
stress test that indicated you were not having a heart attack,
and your labs were negative for any evidence of damage to your
heart.
You were also seen by the Cardiac Surgeons because you have an
ulcer in your aorta. The ulcer was unchanged from your CAT scan
in [**Month (only) 547**] of this year. You have an appointment scheduled with
them later this month to further discuss this.
You have a mass in your lung, which we discussed with you. You
are currently have a workup of this done as an outpatient.
You were started on lovenox here, which you should take until
your coumadin is therapeutic.
We made several [**Month (only) 4085**] changes while you were here. Your
digoxin was discontinued. Your actos and Humalog 75/25 were
also discontinued because your sugar level was low the morning
that you were transferred to the CCU. You can restart your
Humalog 75/25 at HALF the dose you were taking before. Check
your fingersticks 4 times per day. Do not restart your Actos
until we have discussed this with your primary care doctor. You
are still taking your Metformin. We started you on a new blood
pressure [**Month (only) 4085**] called Lisinopril. We also started you on 2
inhalers to help your breathing: Atrovent and Flovent.
You had a fever while you were here, and your chest x-ray showed
a pneumonia. We started you on levofloxacin, which is an
antibiotic. You should take this to complete a 10 day course (4
more days).
Please call your doctor or come to the ER for fevers, chills,
chest pain, shortness of breath, or any other concerns.
Followup Instructions:
Follow up with your Cardiologist, Dr. [**Last Name (STitle) **], this week to
discuss your Lovenox and Coumadin, as well as discussing your
diabetes medications.
You also have an appointment with your Cardiac Surgeon:
Provider: [**Name10 (NameIs) **],[**Last Name (Prefixes) 413**] CARDIAC SURGERY LMOB 2A
Date/Time:[**2135-9-22**] 2:00
We made you an appointment with Dr. [**Last Name (STitle) **] to discuss
possible ablation of your atrial flutter, which you discussed
with him in the hospital:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2135-10-19**] 1:20
|
[
"42789",
"486",
"5990",
"4280",
"496",
"4240",
"41401",
"V4582",
"4019",
"42731",
"2724",
"V5861"
] |
Admission Date: [**2142-10-12**] Discharge Date: [**2142-10-12**]
Date of Birth: [**2093-10-21**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Colchicine / Ace Inhibitors
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
throat swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 110037**] is a 48 year-old male with PMHx of hypertension,
on atenolol & lisinopril - recently started on chlorthalidone 3
weeks ago, who presents with acute onset of stuffy nose, left
eye redness, sore throat/hoarseness. States that he had dinner
(rice, beans, baked chicken & a couple glasses of chardonnay) at
6pm; around 7:15pm developed Patient took Report that he began
to develop "swelling in the back of his throat", which prompted
him to go to the ED. Has had no difficulty swallowing
secretions.
In the ED, initial VS were 97.7 77 143/92 20 98%RA. Exam was
significant for angioedema (specifically in the posterior
pharynx). Received benadryl 50mg, Solu-Medrol 125mg IV and
famotidine 50mg IV with good effect. Patient was transferred to
the ICU for close monitoring. VS on transfer were 98.9, HR 78,
127/79, 18, 100%RA.
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:
hypertension
alcoholism c/b alcoholic hepatitis
moderate OSA
gout
obesity
diarrhea
erectile dysfunction
Social History:
Currently in AA. Still drinks occasionally.
Family History:
His brother has asthma, and his mother's side has HTN.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs upon admission:
[**2142-10-12**] 03:35AM BLOOD WBC-7.5 RBC-4.87 Hgb-13.6* Hct-37.3*
MCV-77* MCH-28.0 MCHC-36.5* RDW-14.2 Plt Ct-304
[**2142-10-12**] 03:35AM BLOOD Neuts-57.5 Lymphs-34.8 Monos-5.2 Eos-1.6
Baso-0.9
[**2142-10-12**] 07:17AM BLOOD PT-13.2 PTT-20.8* INR(PT)-1.1
[**2142-10-12**] 07:17AM BLOOD ESR-10
[**2142-10-12**] 03:35AM BLOOD Glucose-108* UreaN-29* Creat-1.4* Na-136
K-4.3 Cl-98 HCO3-25 AnGap-17
[**2142-10-12**] 07:17AM BLOOD ALT-17 AST-26 LD(LDH)-157 AlkPhos-76
TotBili-0.4
[**2142-10-12**] 07:17AM BLOOD Calcium-8.5 Phos-2.7 Mg-1.9
[**2142-10-12**] 07:17AM BLOOD CRP-7.2*
[**2142-10-12**] 07:17AM BLOOD C3-159 C4-38
[**2142-10-12**] 07:17AM BLOOD C1 INHIBITOR-PND
Labs upon discharge:
[**2142-10-12**] 07:17AM BLOOD WBC-7.5 RBC-4.86 Hgb-13.9* Hct-37.3*
MCV-77* MCH-28.5 MCHC-37.1* RDW-14.9 Plt Ct-282
[**2142-10-12**] 07:17AM BLOOD Glucose-138* UreaN-29* Creat-1.3* Na-135
K-4.3 Cl-97 HCO3-23 AnGap-19
Imaging:none
Brief Hospital Course:
48 year-old male with hypertension on atenolol, lisinopril and
recently started on chlorthalidone, who presented with
angioedema. He was given steroids, benadryl and initially was
given an H2 blocker. His throat and eye swelling decreased to
normal by the morning after discharge. Angioedema was likely
secondary to lisinopril, although chlorthalidone was recently
started and could have contributed, although chlorthalidone and
angioedema are not typically related. Both lisinopril and
chlorthalidone were stopped. The patient was discharged from
the ICU with a 5 day prednisone course and benadryl as needed.
Appointments were made with his PCP and allergy for follow up
(recommend starting [**Last Name (un) **] at next appointment) and likely RAST
testing.
Of note, he also had new acute kidney injury with creatinine
elevated at 1.3-1.4 (baseline 0.9), suspected to be pre-renal
(FeUrea 26%) in the setting of recently starting chlorthalidone.
We recommend repeating kidney function tests to ensure
resolution to baseline at follow up PCP [**Name Initial (PRE) 648**].
Allopurinol dosing was decreased in accordance with his GFR.
The patient was full code for this admission.
Medications on Admission:
ALLOPURINOL - 300 mg Tablet - 2 Tablets by mouth twice a day
ATENOLOL - 100 mg Tablet - 1 Tablet by mouth once a day
CHLORTHALIDONE - 25 mg Tablet - 1 Tablet by mouth once a day
LISINOPRIL - 40 mg Tablet - 1 Tablet by mouth once a day
LOPERAMIDE - 2 mg Capsule - 1 Capsule by mouth twice a day as
needed for diarrhea
OMEPRAZOLE - 20 mg Capsule, Delayed Release (E.C.) - 1 Capsule
by mouth once a day
SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet by mouth one hour
before sexual activity
TRAMADOL - 50 mg Tablet - 1-2 Tablets by mouth every 6 hours not
to exceed 8 a day
CALCIUM CARBONATE - 500 mg (1,250 mg) Tablet - 2 Tablets by
mouth twice a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - 400 unit Capsule - 2
Capsules by mouth once a day
FERROUS GLUCONATE - 240 mg (27 mg Iron) Tablet - 1 Tablet by
mouth twice a day
MAGNESIUM OXIDE - 250 mg Tablet - 2 Tablets by mouth twice a day
Discharge Medications:
1. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
2. atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. loperamide 2 mg Capsule Sig: One (1) Capsule PO twice a day
as needed for diarrhea.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. sildenafil 100 mg Tablet Sig: One (1) Tablet PO once a day as
needed for prior to sexual activity.
6. tramadol 50 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain: do not exceed 8 tablets per day.
7. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: Two
(2) Tablet PO BID (2 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. ferrous gluconate 240 mg (27 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
10. magnesium oxide 250 mg Tablet Sig: Two (2) Tablet PO twice a
day.
11. allopurinol 300 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for itching.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Angioedema
Secondary Diagnosis: Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 110037**],
You presented to [**Hospital1 18**] with a stuffy nose, left eye redness,
sore throat and hoarseness. This was mostly likely due to your
lisinopril, one of your blood pressure medications. It is less
likely due to chlorthalidone, but because this medication was
started recently, we recommend stopping it in case it was
related to your reaction.
Your kidney function was slightly abnormal, likely due to
medications. Please discuss this with your primary care doctor
and have it rechecked at your follow up appointment with him.
We made the following changes to your medications:
1. STOPPED lisinopril
2. STOPPED chlorthalidone
3. STARTED prednisone 40mg daily for the next 4 days
4. DECREASED allopurinol to one 300mg tablet twice a day
5. STARTED benadryl 25mg every 6 hours as needed for itching or
swelling
Please follow up with your physicians. We have made an
appointment for you with your primary care doctor as well as an
allergy specialist so that you can be tested to determine which
allergies you have. Please see below for these appointment
locations and times.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2142-10-19**] at 10:30 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2967**], RNC [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] None
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2142-12-11**] at 1:20 PM
With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You should discuss with Dr. [**Last Name (STitle) **] about seeing an Allergy
specialist.
Department: DIV OF ALLERGY AND INFLAM
When: THURSDAY [**2142-11-15**] at 9:45 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) 71988**], MD [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS Best Parking: Parking on Site
Completed by:[**2142-10-12**]
|
[
"5849",
"4019",
"32723"
] |
Admission Date: [**2140-6-26**] Discharge Date: [**2140-7-5**]
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
worsening SOB
Major Surgical or Invasive Procedure:
status post ICD interrogation and reprogramming
History of Present Illness:
Pt. is an 82 yo Russion speaking M w/ h/o CAD (3VD refusing
CABG), CHF (EF-20%),s/p ICD for sick sinus syn., HTN, DM, A.fib
who presented from [**Hospital1 **] w/ worsening SOB. Pt. was w/out
complaints two days prior, ambulating w/out SOB. Yesterday
noticed inc. SOB, now +SOB at rest. Inc. abd girth. Denies any
fevers, CP, palpitations. Pt found to be tachy (120's), hypoTN
(sbp low 80's). At [**Hospital1 **], given 1.5L fluid, sbp stayed in
80's. Transferred to [**Hospital1 **] for further eval. Started on Levophed
at 7 mcg/min. Pacer interoggated by EP, found to have V-paced
rhythm at 120's (ICD max tracking rate). V-pacing inhibition
revealed AT at 135 bpm with high degree AV block. Overdrive
atrial pacing performed--> sinus at 50 bpm--> pacer changed back
to DDD ( AV pacing at 70 bmp). Max ventricular tracking rate
decreased to 100. Pt remained rel hypoT (SBP in 80's on
levophed). admitted to CCU for BP stabilization and diuresis.
Levophed was weaned off in ED w/ SBP>90.
Past Medical History:
CAD(3VD- Prox,mid RCA 90%, distal RCA 100%, LMCA 20%, Prox. LAD
80%, Mid LAD 70%, Prox Circ 70%, OM2 99%)
CHF(EF20%)
HTN
DM II
COPD
Paroxysmal A.fib
s/p ICD for sick sinus syn.
pulm. HTN
Echo ([**2140-5-31**]): EF 20%; biatrial enlargement(6.7 cm); mod LV
dilation (6.3 cm); AK (inf; mid inf-lat; apex); mod glo; [**12-18**] +
AR; 2+ MR; 2+ TR; global RV free wall HK
hyperlipidemia
urinary retention
Social History:
retired, lives with wife
had been in [**Hospital **] rehab s/p ICD placement
no tob, occ etoh, no drug
Family History:
n/c
Physical Exam:
Temp 96.7
BP 89/40stand, 100/70 supine
Pulse 70
Resp 23
O2 sat 100 on 4.5L
Gen - chronically ill appearingAlert, no acute distress
HEENT - PERRL, extraocular motions intact, anicteric, mucous
membranes moist, poor dentition
Neck - JVD 10cm, no cervical lymphadenopathy, no mass, no bruit
Chest - diffuse wheezing, decreased breath sounds at bilateral
bases
CV - Normal S1/S2, RRR, II/VI holosystolic TR murmur. no rubs,
or gallops
Abd - Soft,tympanic , distended, with normoactive bowel sounds.
nontender, no masses.
Back - No costovertebral angle tendernes
Extr - 2+ b/l femoral pulses. 1+ DP and PT pulses bilaterally.
Bilateral tibial edema. No clubbing, cyanosis.
Neuro - Alert and oriented x 3, cranial nerves [**1-28**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Pertinent Results:
EKG:
[**2140-6-26**] V paced rhythm @120bpm
[**2140-6-26**] EKG w/ pacing inhibition: AT with high degree block (no
visible pauses, HR 65, IVCD, diffuse ST-T changes in precordial
leads)
[**2140-6-26**] after overdrive atrial pacing- AV paced at 70 bpm
CXR: persistent CHF, small R pleural effusion, cardiomegaly, no
significant change
Echo: [**2140-5-31**] EF 20%; biatrial 6.7 cm dilation; mod LV dilation
(6.3cm). akinesis: basal-inf, mid-inf, basal inf-lat, mid inf
lat, ant-apex, septal apex, inf apez, lat apex. RV cavity
dilation. mod global RV free wall hypokinesis, [**12-18**] AR, 2+MR,
2+TR
Cardiac cath10/03: RA 21/20, RV 70/20, PA 70/28/42; PCWP 26; CO
4.4, CI 2.5
proximal RCA 90% occluded
mid RCA 90% occluded
distal pDA 100% occluded
LMCA 20%occluded
prox LAD 80%occluded
mid LAD 70%occluded
prox LCx 70%occluded
OM2 99%occluded
Exercise MIBI [**9-18**] modified [**Doctor Last Name **]; exercised 8 min; achieved
74%; uninterpretable EKG. MIBI: fixed severe inferior wall
defect, partially reversible moderated lateral wall perfusion
defect.
[**2140-6-26**] 04:00PM GLUCOSE-151* UREA N-48* CREAT-1.8* SODIUM-133
POTASSIUM-5.7* CHLORIDE-99 TOTAL CO2-23 ANION GAP-17
[**2140-6-26**] 04:00PM ALT(SGPT)-26 AST(SGOT)-41* ALK PHOS-130*
AMYLASE-152* TOT BILI-0.7
[**2140-6-26**] 04:00PM LIPASE-42
[**2140-6-26**] 04:00PM CK-MB-5 cTropnT-0.17*
[**2140-6-26**] 04:00PM ALBUMIN-3.8
[**2140-6-26**] 04:00PM WBC-8.5 RBC-3.69* HGB-10.8* HCT-35.0* MCV-95
MCH-29.3 MCHC-31.0 RDW-17.0*
[**2140-6-26**] 04:00PM NEUTS-77.1* LYMPHS-11.4* MONOS-7.4 EOS-3.5
BASOS-0.6
[**2140-6-26**] 04:00PM PLT COUNT-281
[**2140-6-26**] 04:00PM PT-17.9* PTT-31.4 INR(PT)-2.1
[**2140-6-26**] 04:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2140-6-26**] 04:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-SM
[**2140-6-26**] 04:00PM URINE RBC-21-50* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-<1
Brief Hospital Course:
Hypotension: Pt was weaned off Levophed with SBP's stable in
90-110's. Cultures remained negative to date.
Cardiac:Pump-Pt. w/ CHF(EF20%) decompensated [**1-18**] atrial tachy.
Also likley has significant RV dysfunction contrinuting to
hypotension. weaned off of levophed. Held BB, nitro, ACEI
secondary to tenuous BP's. He was given one dose of Lasix with
poor effect and decreasing uring output. Family refused Swan
Ganz monitoring. In this setting, he was given a gentle bolus
of normal saline. His urine output subsequently increased
appropriately.
3 Vessel coronary artery disease w/ refusing CABG. Pt was
without signs of current/new ischemia and had stable cardiac
enzymes. ASA, statin were continued. Pt was not a candidate for
CABG during this admission.
Rhythm- AT: ICD interrogated and reprogrammed. Pt was maintained
on amiodarone and heparin gtt. His coumadin was held in case he
needed AT ablation. At the end of his admission his amiodarone
was increased to 200 tid, which was to be continued for 6 days.
Atfter this, he was to be weaned to 200 [**Hospital1 **] for another weak and
then to be stabilized on 200 qd thereafter/
Coagulopathy-The patient't INR was increased, in the range of
INR 2.4-5.7. Given, his LFT's were within normal limits, he was
given 1 dose vitamin K with good effect. At the end of his
admission, he was switched back to coumadin from heparin.
[**Name (NI) 12329**] Pt hypotensive on admission, likely [**1-18**] CHF. His BP meds
were held during this admission.
[**Name (NI) 3672**] Pt w/ audible wheezing [**1-18**] CHF and/or COPD. CXR w/ sm. rt.
pleural effusion. He was given alb/atrovent nebs prn, keeping
sats>93%. with O2 as needed.
DM- The patient was maintained on insulin sliding scale with QID
fingerstick checks.
Renal- His renal insufficiency and poor urine output was
believed likely secondary to decreased perfusion due to his CHF.
He did not initially respond well to Lasix. However, he was
given 250cc NS bolus over 1h with an appropriate increase in
output. His renal insufficiency improved with resolution of his
acute CHF and he is now at his likely new baseline.
Conjunctivitis-the patient was found to have crusty discharge
from b/l eyes during the admssion and was started on
erythromycin eye drops for 10 days total. His conjunctivitis
improved significantly with this treatment.
[**Name (NI) 3687**] Pt exhibited agitation and confusion nightly. He was
maintained on evening dose of seroquel 12.5 qhs and occasionally
required 1:1 sitter and/or restraints for safety in the
evenings.
Code-After discussion with the patient's son and wife (who
deferred further medical decisions to her son), the patient was
made DNR/DNI. The son was made aware of hospice services, if
the family feels that they are ready for this.
Medications on Admission:
Coreg 6.25 [**Hospital1 **], amiodarone 200 qd, Indur 30 qd, Lasix 20 qd,
Seroquel 12.5 qd, Lisinopril 2.5qd, ASA, Albuterol/Atrovent prn,
Lansoprazole, Lipitor 40 qd, Coumadin 3.5 qd, MVI, Colace,
Lactulose, Iron
Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO QD (once a day).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Lactulose 10 g/15 mL Syrup Sig: Fifteen (15) ML PO Q8H (every
8 hours) as needed for constipation.
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed.
7. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
9. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO QD
(once a day).
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Quetiapine Fumarate 25 mg Tablet Sig: 0.5 Tablet PO QHS
(once a day (at bedtime)).
12. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID
(4 times a day) for 7 days.
13. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
14. Regular Insulin Sliding Scale
Breakfast Lunch Dinner Bedtime
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-60 mg/dL [**12-18**] amp D50 [**12-18**] amp D50 [**12-18**] amp D50 [**12-18**] ampD50
61-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
> 400 mg/dL 12 Units 12 Units 12 Units 12 Units
15. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
16. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 4 doses.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Acute exacerbation of congestive heart failure
Acute Atrial tachycardia terminated by overdrive pacing
status post ICD interrogation and reprogramming
bilateral Conjunctivitis, on erythromycin ointment.
Chronic Decompensated Congestive heart failure
3 Vessel coronary artery disease
History of Hypertension
Diabetes Mellitus Type II
Chronic Obstructive Pulmonary disease
status post ICD placement for sick sinus syndrome
h/o atrial fibrillation
Chronic renal insufficiency, baseline Cr ~2.
Discharge Condition:
Fair
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
Pt is off of Lasix, Beta blocker and Lisinopril secondary to
tenuous but asymptomatic blood pressures throughout admission.
Consider starting Lisinopril 2.5 mg po qd tomorrow if Creatinine
is stable and if blood pressure remains stable. Likely no
benefit from starting beta blocker since pt is ventricularly
paced at lowest ventricular pacing threshold of 70 beats per
minute. Follow urinary output for chronic renal insufficiency
secondary to decompensated CHF.
If has another persistent episode of atrial tachycardia, send pt
to ED immediately.
Follow daily QTC intervals while patient is reloaded on
amiodarone. Provided QTc is stable, plan is to continue to have
amiodarone 200 TID for the next five days followed by 200 [**Hospital1 **]
for the next seven days followed by 200 qd.
Pt started on Zpack for total 5 day course for presumed
tracheobronchitis in this patient with COPD.
Pt has bilateral Conjunctivitis, on erythromycin ointment for
several days with marked improvement.
Patient has sundowning in evenings and gets very agitated,
occasionally requiring restraints but is doing well on qhs
seroquel.
Pt is DNR/DNI
Followup Instructions:
follow up daily INR, creatinine, EKGs (follow QTC since patient
is on Amiodarone).
Follow urinary output.
Follow up with your PCP in one week.
|
[
"42731",
"41401",
"25000"
] |
Admission Date: [**2167-3-26**] Discharge Date: [**2167-4-7**]
Date of Birth: [**2093-7-20**] Sex: F
Service: [**Doctor Last Name 1181**]-ME
HISTORY OF PRESENT ILLNESS: Miss [**Known lastname **] is a very pleasant 73
year old woman with a history of atrial flutter who presented
to the Emergency Department with atrial fibrillation/atrial
flutter. The patient was watching TV in bed on the evening
prior to admission when she noted a "busy-ness" in her chest
which she felt was most likely the result of palpitations.
The patient's pulse at that time was irregular, although she
did not know what the rate was. The patient denied
associated chest pain, shortness of breath, nausea, vomiting,
lightheadedness, dizziness, diaphoresis, paroxysmal nocturnal
dyspnea and orthopnea. The patient slept well on that
evening (prior to the day of presentation). On the morning
of the day of presentation, the patient saw her primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], for her regularly scheduled
appointment. At that time, the patient's chest "busy-ness"
recurred, and she was found by EKG to be in atrial flutter
with 2:1 block. The patient was referred at that time to the
[**Hospital1 69**] Emergency Department.
In the Emergency Department, the patient was in atrial
fibrillation with a rate between the 60s and 80s; she did not
have any palpitations at that time.
On further review of systems, the patient denied recent
illness, nausea, vomiting, diarrhea, headache, change in
medications. The patient is on a low calorie liquid diet, in
order to decrease weight and alleviate her GI symptoms
(related to a history of gallstones and pancreatitis); she
has iron supplementation with this diet. The patient
admitted having had dark stools since starting this diet,
which she attributed to the iron supplementation. The
patient denies hematochezia, dysuria and hematuria.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction, status post catheterization and percutaneous
transluminal coronary angioplasty with stent placement to the
left anterior descending in [**2166-10-11**];
catheterization in [**2166-10-11**], revealed a left
ventricular ejection fraction of 45 to 50%.
2. Hypertension.
3. Hyperlipidemia.
4. Hypothyroidism.
5. Raynaud's Syndrome.
6. Status post bilateral cataract repair.
7. Status post right glaucoma repair.
8. History of atrial flutter and atrial tachycardia.
9. History of mild hearing loss.
10. Gallstones.
11. History of pancreatitis.
12. Osteoarthritis.
ALLERGIES: No known drug allergies.
OUTPATIENT MEDICATIONS:
1. Levoxyl 137 micrograms q. day.
2. Zestril 40 mg q. day.
3. Toprol XL 50 mg q. day.
4. Ursodiol one p.o. twice a day.
5. Zocor 50 mg q. day.
6. Multivitamin two p.o. q. day.
7. Citrucel two p.o. q. day.
8. Tylenol Extra Strength, two q. day plus p.r.n.
9. Advil.
10. Aspirin 325 mg q. day.
SOCIAL HISTORY: The patient is a retired pediatric nurse.
She quit smoking at age 50. The patient's primary care
physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]. The patient's cardiologist
is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**].
PHYSICAL EXAMINATION: On presentation, vital signs:
Temperature 97.2 F; heart rate 126 and then subsequently in
the 80's; blood pressure 132/97; respirations 18 per minute,
saturating 98% on room air. In general, awake in bed, in no
acute distress. HEENT: Moist mucous membranes; oropharynx
clear. Head: Normocephalic, atraumatic. Sclerae were
anicteric. Pupils equally round and reactive to light and
accommodation. Extraocular muscles are intact bilaterally.
Neck: Supple, without jugular venous distention or bruits.
Cardiovascular: Irregular regular rate and rhythm with a
rate of approximately 82 beats per minute; normal S1 and S2
without audible murmurs, rubs or gallops. Chest is clear to
auscultation bilaterally with good air movement. Abdomen:
Obese, soft, nontender, nondistended. Positive normal active
bowel sounds. No palpable hepatosplenomegaly or pulsatile
masses. Extremities with no cyanosis, clubbing or edema.
Positive pedal pulses bilaterally. Rectal examination
revealed guaiac negative per report from the patient's
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**]. Neurologic examination
revealed alert and oriented times three. Speech was normal
and appropriate. There were no focal deficits.
LABORATORY: On presentation, CBC revealed a white blood cell
count of 7.7 with a differential of 67% neutrophils and 23%
lymphocytes. Hematocrit was 40.7, platelets were 278.
Coagulation studies revealed INR of 1.1, PT of 12.3, PTT of
21.9.
Chem-7 revealed a sodium of 139, potassium of 6.0 (5.2 on
retesting), chloride 103, bicarbonate 23, BUN 25, creatinine
1.0, glucose 94. Electrolytes revealed calcium 10.3,
phosphorus 4.4, magnesium 1.7. Urinalysis was negative,
although with 30 protein.
Electrocardiogram revealed atrial fibrillation at the rate of
70; there was a Q wave in lead III, as well as delayed R wave
progression. These findings were old since the prior study
of [**2167-1-2**]. There were no new changes.
BRIEF HOSPITAL COURSE: The patient was admitted to the
[**Doctor Last Name **] Medicine Service for further evaluation and treatment
of her atrial fibrillation. Subsequent TSH level was 0.41.
The patient was anti-coagulated with both heparin and
Coumadin following admission. The patient's PTTs remained
within the normal therapeutic range with the exception of one
level of 150 and one level of 145.8 on [**3-27**] and
[**3-28**] respectively. The patient's INR never rose above
2.2. On [**2167-3-30**], the patient underwent
transesophageal echocardiogram which was essentially normal.
She subsequently underwent successful DC cardioversion and
was thus in sinus rhythm thereafter.
The remainder of the [**Hospital 228**] hospital course will be
outlined by system as follows:
1. Cardiac rate and rhythm issues: As noted above, the
patient was anti-coagulated following admission and
subsequently underwent successful DC cardioversion. Thus,
following DC cardioversion, the patient remained in sinus
rhythm; however, there were rare isolated "bursts" of atrial
fibrillation noted on the patient's Telemetry. For the most
part, however, she has remained in sinus rhythm and has
remained entirely asymptomatic (regarding her above-noted
palpitations). The patient has, since cardioversion,
remained on Sotalol. Given the patient's recent
cardioversion, the Cardiology Service felt that she ought to,
if at all possible, remain anti-coagulated (please see
Hematologic issues below).
2. Hematologic Issues: On [**2167-3-28**], the patient
began having bilateral lumbosacral pain as well as bilateral
thigh pain; a CK level was checked on [**2167-3-29**] and
found to be elevated (although CK MB and troponin levels were
both normal). The patient's CK level continued to climb
thereafter over the next two days, while her pain persisted
and her hematocrit was noted to be decreasing (from 40 to 36
to 32, and then eventually to 28.7). An initial abdomen and
pelvic CT scan revealed a 3.1 by 2.6 cm hematoma at the left
psoas muscle though there was no clear explanation for the
patient's hematocrit drop at that time. The patient was
transfused initially with two units of packed red blood cells
over [**3-30**], although her hematocrit increased to only
30 (from 28) at that time.
On [**2167-3-31**], the patient was noted to be
hypotensive, with a systolic blood pressure to the 80s which
corrected quickly with intravenous fluid boluses; the patient
was also somnolent status post morphine and Ativan
administration (for her above-noted back and thigh pain).
The patient's heparin drip was discontinued on the morning of
[**2167-3-31**]. In the afternoon of [**2167-3-31**],
the patient's hematocrit was noted to be 20; she was
transfused with packed red blood cells and fresh frozen
plasma and she was also given Vitamin K. She was transferred
to the Medical Intensive Care Unit. A subsequent CT scan of
the abdomen and pelvis on [**2167-3-31**], revealed a
stable left psoas hematoma, but a new left intra-abdominal
wall hematoma and a new right iliac hematoma as well as
increased pleural effusions.
In the Medical Intensive Care Unit the patient was
transiently hypotensive (blood pressure 78/30) over the night
of [**2167-3-31**]; her blood pressure again responded to
intravenous fluid boluses. The patient received
approximately seven units of packed red blood cells and four
units of fresh frozen plasma over [**3-31**] through
[**2167-4-1**]. She remained off Coumadin and heparin.
Overall, the patient did well in the Medical Intensive Care
Unit and her hematocrit stabilized following transfusion and
correction of her anti-coagulation. Also, the patient's pain
abated almost entirely.
The exact etiology of the patient's intra-abdominal bleed is
not clear. The Hematology Service was consulted. The
patient does not appear to have any coagulopathy; it is
possible that her transient super-therapeutic heparin dose
may have been the cause of her hematomata and CK elevations.
Based on intensive discussions between the Hematology Service
and the patient's attending (Dr. [**Last Name (STitle) 73**], the following
plan was outlined: The patient would certainly benefit from
anti-coagulation from the cardiac standpoint as she is status
post DC cardioversion. On the other hand, she has
demonstrated a proclivity to hemorrhage in regularly normal
and therapeutic doses of heparin and Coumadin. Thus, the
patient was started on Lovenox late on [**2167-4-3**].
Thereafter, the patient's hematocrit has been followed twice
a day and has remained stable. The patient's Lovenox level
(checked via Factor XA level), has been fairly stable,
ranging from 0.41 to 0.89; the goal is to keep the Lovenox
level on the lower end of the therapeutic range. Thus, the
patient has been maintained on 60 mg of Lovenox twice a day.
She will require this anti-coagulation for two to three
weeks; during this time, the patient should remain off all
other anti-coagulation and anti-platelet drugs, including
aspirin. Once the patient ceases her Lovenox therapy, she
may restart aspirin at that time.
3. Congestive heart failure: The patient is on Zestril and
Sotalol.
4. Coronary artery disease: The patient, as noted above, is
on Zestril and beta blockade. At this time, aspirin is being
held as she is on Lovenox. Once the patient finishes Lovenox
she may restart her aspirin.
5. Physical Therapy and Occupational Therapy: The patient,
for the most part, is mobile, however, she still requires
some assistance with building up her endurance, and with some
activities of daily living. Thus, she would benefit from
further rehabilitation.
CONDITION AT DISCHARGE: Vital signs stable, afebrile;
stable hematocrit.
DISCHARGE DIAGNOSES:
1. Atrial fibrillation.
2. Status post DC cardioversion [**2167-3-30**].
3. Status post left lateral abdominal wall bleed.
4. Hypothyroidism.
5. Coronary artery disease.
6. Hyperlipidemia.
7. Osteoarthritis.
DISCHARGE MEDICATIONS:
1. Lovenox 60 mg subcutaneously twice a day.
2. Sotalol 120 mg twice a day.
3. Levoxyl 137 micrograms p.o. q. day.
4. Zestril 40 mg p.o. q. day.
5. Multivitamin one tablet p.o. q. day.
6. Ursodiol, one tablet p.o. twice a day.
7. Tums, two tablets p.o. twice a day.
8. Colace 100 mg p.o. twice a day, p.r.n.
9. Tylenol 650 mg p.o. q. four to six hours p.r.n.
DISCHARGE INSTRUCTIONS:
1. The patient is being discharged to a rehabilitation
facility; during her rehabilitation the patient will need
assistance with her Lovenox administration as well as the
rest of her medical regimen.
2. Also, the patient will need further assistance with
Physical and Occupational Therapy.
3. The patient should be on a cardiac diet (there is some
feeling that the patient's above-noted liquid, low-calorie
diet, may have contributed to her propensity to bleed; the
Nutrition Service has been consulted and had felt that the
patient's earlier liquid diet was insufficient to meet her
daily needs).
4. The patient should follow-up with her primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], telephone [**Telephone/Fax (1) 10492**].
5. Also, the patient will be following up with her
Cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**].
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2167-4-7**] 12:17
T: [**2167-4-7**] 12:24
JOB#: [**Job Number 14574**]
|
[
"53081",
"4019"
] |
Admission Date: [**2116-8-4**] Discharge Date: [**2116-8-21**]
Date of Birth: [**2031-8-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional dyspnea and occassional chest pain
Major Surgical or Invasive Procedure:
[**2116-8-5**]:
1. Aortic valve replacement with a 21-mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
Magna Ease aortic valve bioprosthesis. Model number 3300TFX.
Serial number [**Serial Number 101479**].
2. Coronary artery bypass grafting x1 with left internal mammary
artery to left anterior descending coronary artery.
History of Present Illness:
History of Present Illness: 84 year old active gentleman with
history of aortic stenosis which has been followed by serial
echcardiograms. More recently he has noticed increased symptoms
of exertional dyspnea and mild chest pain. He has also noticed
that he is considerably more fatigued. A recent echocardiogram
revealed critical aortic stenosis with mild left ventricular
hypertrophy with a normal left ventricular ejection fraction. He
was admitted today after catherization for AVR/CABG
Past Medical History:
[**2116-8-5**] AVR CABG x 1 LIMA->LAD
Past Medical History:
Aortic stenosis
GERD
Depression
Hypertension
Eosinophilia since [**2113**]
Pruritis
BPH
Past Surgical History:
Hemicolectomy [**2076**] c/b infection and prolonged recovery
Multiple bowel surgeries for adhesions/obstruction
Right knee arthroscopy
MOH's surgery x2 on head for Basal cell
Recent varicose vein repair after trauma
Social History:
Race: Caucasian
Last Dental Exam: Every 6 months - Last exam [**2116-7-28**] with dental
clearance obtained
Lives with: Wife in [**Name2 (NI) **]
Occupation: Retired Physics professor [**First Name (Titles) **] [**Last Name (Titles) **]
Cigarettes: Smoked no [] yes [X] last cigarette [**2076**] Hx: [**12-1**] ppd
x20 years
ETOH: < 1 drink/week [] [**1-6**] drinks/week [X] >8 drinks/week []
Illicit drug use: None
Family History:
Family History: Father died at age 56 of heart disease
Physical Exam:
Physical Exam
Pulse: 50 SB Resp: 16 O2 sat:100% RA
B/P Right:162/79 Left: 162/77
Height: 64" Weight: 145lb
General: AAO x 3 in NAD
Skin: Warm, Dry and intact. Multiple well healed abdominal
incisions. Infraumbilical incisional hernia.
HEENT: NCAT, PERRLA, EOMI, sclera anicteric, OP benign. Missing
multiple teeth - poor repair
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] IV/VI Systolic Murmur
Abdomen: Soft[X] non-distended[X] non-tender [X] + bowel
sounds[X]
Extremities: Warm [X], well-perfused [X] Trace Edema
Varicosities: Right below knee grossly varicosed laterally. No
appreciable varicosities in thigh.
Neuro: Grossly intact [X]
Pulses:
Femoral Right:cath site Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Transmitted vs. Bruit bilaterally
Pertinent Results:
[**2116-8-18**] 04:54AM BLOOD WBC-19.0* RBC-4.22* Hgb-12.3* Hct-36.0*
MCV-85 MCH-29.0 MCHC-34.0 RDW-13.4 Plt Ct-420
[**2116-8-17**] 03:09AM BLOOD WBC-17.7* RBC-4.27* Hgb-12.6* Hct-36.4*
MCV-85 MCH-29.6 MCHC-34.7 RDW-13.4 Plt Ct-420
[**2116-8-18**] 04:54AM BLOOD PT-18.9* INR(PT)-1.7*
[**2116-8-17**] 03:09AM BLOOD PT-24.1* INR(PT)-2.3*
[**2116-8-16**] 04:04AM BLOOD PT-23.5* INR(PT)-2.2*
[**2116-8-15**] 05:25AM BLOOD PT-18.8* PTT-27.6 INR(PT)-1.7*
[**2116-8-14**] 05:51AM BLOOD PT-19.2* INR(PT)-1.7*
[**2116-8-13**] 04:08AM BLOOD PT-21.3* PTT-43.8* INR(PT)-2.0*
[**2116-8-12**] 01:59AM BLOOD PT-23.0* INR(PT)-2.1*
[**2116-8-11**] 12:09AM BLOOD PT-16.5* PTT-35.0 INR(PT)-1.5*
[**2116-8-10**] 01:04AM BLOOD PT-13.4 INR(PT)-1.1
[**2116-8-9**] 01:08AM BLOOD PT-12.5 INR(PT)-1.1
[**2116-8-18**] 04:54AM BLOOD UreaN-41* Creat-1.1 Na-139 K-4.8 Cl-107
[**2116-8-17**] 03:09AM BLOOD Glucose-132* UreaN-43* Creat-1.0 Na-139
K-4.4 Cl-108 HCO3-24 AnGap-11
[**2116-8-16**] 04:04AM BLOOD UreaN-46* Creat-1.0 Na-142 K-4.4 Cl-109*
[**2116-8-20**] 05:33AM BLOOD WBC-15.2* RBC-4.35* Hgb-12.4* Hct-36.4*
MCV-84 MCH-28.5 MCHC-34.0 RDW-13.2 Plt Ct-484*
[**2116-8-19**] 01:58AM BLOOD WBC-17.3* RBC-4.00* Hgb-11.8* Hct-33.9*
MCV-85 MCH-29.4 MCHC-34.7 RDW-13.1 Plt Ct-414
[**2116-8-20**] 05:33AM BLOOD PT-16.8* INR(PT)-1.5*
[**2116-8-19**] 01:58AM BLOOD PT-20.0* INR(PT)-1.8*
[**2116-8-20**] 05:33AM BLOOD Glucose-116* UreaN-32* Creat-1.0 Na-134
K-4.9 Cl-99 HCO3-27 AnGap-13
[**2116-8-19**] 01:58AM BLOOD Glucose-123* UreaN-36* Creat-0.8 Na-137
K-4.8 Cl-104 HCO3-26 AnGap-12
Echo: [**2116-8-5**]
PREBYASS:
-No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
-No atrial septal defect is seen by 2D or color Doppler.
-There is mild symmetric left ventricular hypertrophy with
normal cavity size. Regional left ventricular wall motion is
normal.
-Doppler parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction.
-Right ventricular chamber size and free wall motion are normal.
-There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta.
-There are three aortic valve leaflets. 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 mildly thickened. Mild (1+)
mitral regurgitation is seen.
-The left ventricular inflow pattern suggests impaired
relaxation.
-The tricuspid valve leaflets are mildly thickened. There is no
pericardial effusion.
POSTBYPASS:
The patient is AV paced on low dose phenylephrine infusion.
There is a well seated prosthetic valve in the aortic position.
Peak Gradient=48mmHg. There is trace AR. Biventricular function
remains intact. The aorta remains intact.
[**2116-8-21**] 06:43AM BLOOD WBC-14.5* RBC-4.16* Hgb-12.3* Hct-35.0*
MCV-84 MCH-29.5 MCHC-35.0 RDW-13.6 Plt Ct-444*
[**2116-8-21**] 06:43AM BLOOD PT-17.7* INR(PT)-1.6*
[**2116-8-20**] 05:33AM BLOOD PT-16.8* INR(PT)-1.5*
[**2116-8-19**] 01:58AM BLOOD PT-20.0* INR(PT)-1.8*
[**2116-8-21**] 06:43AM BLOOD Glucose-102* UreaN-28* Creat-0.9 Na-131*
K-4.5 Cl-99 HCO3-29 AnGap-8
[**2116-8-20**] 05:33AM BLOOD Glucose-116* UreaN-32* Creat-1.0 Na-134
K-4.9 Cl-99 HCO3-27 AnGap-13
Brief Hospital Course:
Mr [**Known lastname **] has known aortic stenosis, he was admitted one day
prioor to suregy for cardiac catheterization. On [**8-5**] he was
brought to the operating room for aortic valve replacement and
coronary bypass grafting, please see operative report for
details. In summary he had: Aortic valve replacement with a
21-mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
Magna Ease aortic valve bioprosthesis. Model number 3300TFX.
Serial number [**Serial Number 101479**].
And coronary artery bypass grafting x1 with left internal
mammary artery to left anterior descending coronary artery. His
bypass time was 110 minutes with a crossclamp time of 89
minutes. He tolerated the operation and was brought from the
operating room to the cardiac surgery ICU on Neosynephrine and
Propofol. Post-operatively he experienced significant bleeding
and requiried multiple units of fresh frozen plasma, platelets
and packed red blood cells. He stopped without returning to the
operating room but was kept sedated on the day of surgery.
His chest xray showed moderate pulmonary conjestion requiring
aggressive diuresis prior to weaning from the ventilator. He
finally extubated on POD3, he remained somewhat lethargic after
extubation and failed a speech and swallow evaluation. A feeding
tube was placed on POD 5. His mental status improved slowly and
steadily. He was evaluated at the bedside by speech and swallow
pathology and was cleared for ground solids and thin liquids. He
continued to progress and a video swallow was done and he was
cleared for soft solids and thin liquids. His appetite remains
fair with patient consuming ~50% meals and supplements were
ordered. He pulled his dobhoff multiple times and it was decided
that it would left out with encouragement with meals. He
continued to need supervision and assistance with meals. He
remains on calorie counts.
He experienced post-operative afib which was managed with
lopressor and amiodarone. While on Lopressor 25 [**Hospital1 **] and
Amiodarone 400 [**Hospital1 **] he developed complete heart block with a
stable blood pressure. He was transferred back to the CVICU for
closer monitoring. Electrophysiology was consulted and
recommended decreasing the Amiodarone to 200 daily. Once rhythm
was stable, his Lopressor was added back and titrated up to 25
mg [**Hospital1 **]. He remained in a sinus rhythm with PAC's in the 70-80's
throughout the remainder of his hospital course. Coumadin was
initiated for Atrial fibrillation with 1-2 mg doses for INR goal
2.0-2.5. He will need coumadin follow up arranged post
discharge from rehab. He is discharged to the [**Hospital 100**] Rehab MACU
on POD 16 in stable condition. All follow up appointments were
arranged.
Medications on Admission:
Active Medication list as of [**2116-7-13**]:
Amoxicillin 2grams dental prophylaxis
LEXAPRO - 10MG Tablet - ONE TABLET EVERY DAY
LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth once a day
RANITIDINE HCL - 150 mg Tablet - 1 Tablet(s) by mouth twice a
day
TRIAMCINOLONE ACETONIDE - 0.5 % Ointment - apply to affected
area
twice a day # 30 gm
Medications - OTC
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day - No Substitution
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - Tablet - 1
Tablet(s) by mouth once a day
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR for Coumadin ?????? indication afib
Goal INR 2.0-2.5
First draw [**2116-8-22**]
Results to phone fax : plaese arrange coumadin follow up with
PCP upon discharge from rehab
2. aspirin 81 mg Tablet, Delayed Release (E.C.) [**Month/Day/Year **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever/pain.
4. magnesium hydroxide 400 mg/5 mL Suspension [**Month/Day/Year **]: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. bisacodyl 10 mg Suppository [**Month/Day/Year **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. losartan 50 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY (Daily).
7. amiodarone 200 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day.
8. escitalopram 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY
(Daily).
9. simvastatin 10 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO DAILY
(Daily).
10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. amlodipine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
12. furosemide 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily)
for 7 days.
13. potassium chloride 20 mEq Packet [**Last Name (STitle) **]: One (1) Packet PO once
a day for 7 days.
14. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
15. warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: MD
to dose daily for goal INR 2-2.5, dx: afib.
16. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Two (2) PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
[**2116-8-5**] AVR CABG x 1 LIMA->LAD
PMH:
Aortic stenosis, GERD, Depression, Hypertension, Eosinophilia
since [**2113**], Pruritis, BPH, Hemicolectomy [**2076**] c/b infection and
prolonged recovery, Multiple bowel surgeries for
adhesions/obstruction, Right knee arthroscopy, MOH's surgery x2
on head for ?Basal cell, Recent varicose vein repair after
trauma
Discharge Condition:
Alert and oriented x3 nonfocal
Transfers from bed to chair with assistance, deconditioned
Incisional pain managed with tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Edema: none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month 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:
Surgeon: Dr.[**Last Name (STitle) 914**], [**First Name3 (LF) **] #[**Telephone/Fax (1) 170**] on [**9-15**] at 1:30pm in
the [**Hospital **] medical office building [**Hospital Unit Name **]
Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2116-9-3**] on 10:00am
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD Date/Time:[**2116-9-21**] 10:10
**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 afib
Goal INR 2.0-2.5
First draw [**2116-8-22**]
Results to phone fax : please arrange coumadin follow up with
PCP upon discharge from rehab
Completed by:[**2116-8-21**]
|
[
"4241",
"2851",
"5119",
"41401",
"42731",
"2875",
"53081",
"4019",
"311"
] |
Admission Date: [**2198-7-31**] Discharge Date: [**2198-8-8**]
Date of Birth: [**2198-7-31**] Sex: M
Service: NB
ID: Baby [**Name (NI) **] ([**Name2 (NI) **]) [**Known lastname 64003**] is a 8 day old former 31 [**3-5**] wk
premature infant being transferred from [**Hospital1 18**] to [**Hospital 1474**]
Hospital.
HISTORY OF PRESENT ILLNESS: [**Hospital **] [**Known lastname 64003**] is the former 1.755
kilogram product of a 31-3/7 week gestation pregnancy born to
a 30-year-old G2, P1 now 2 woman. Prenatal screens: Blood
type A-positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis B surface antigen negative, group B
Strep positive. Pregnancy was complicated by preterm labor 6
days prior to delivery. The mother was admitted to [**Name (NI) 1474**]
Hospital and treated with IV fluids, terbutaline, and
betamethasone. She was noted to have fetal heart rate
decelerations and was transferred to the [**Hospital1 346**]. There ultrasound showed
oligohydramnios and a biophysical profile of [**8-6**]. There was
suspected placental insufficiency and oxytocin challenge test
was failed. Therefore, the mother was taken to cesarean
section.
Rupture of membranes occurred at delivery with clear fluid.
The infant born vigorous with spontaneous respirations and cry.
Apgars were 7 at 1 minute and 8 at 5 minutes. He was admitted to
the neonatal intensive care unit for treatment of prematurity.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 1.755 kilograms (60th percentile), length 42 cm
(50th percentile), head circumference 30 cm (60th
percentile). General: Nondysmorphic preterm male in moderate
respiratory distress. Head, eyes, ears, nose, and throat:
Anterior fontanel is soft and flat. Nondysmorphic facial
features, intact palate. Red reflex deferred. Chest: Moderate
retractions, fair-to-poor aeration. Breath sounds equal.
Cardiovascular: Tachycardic, no murmur, normal pulses.
Abdomen: Soft, 3-vessel cord, no hepatosplenomegaly, normal
male with descended testes, patent anus. Spine: Straight. No
sacral dimple. Hips: Stable. Skin: Mongolian spots on
buttocks. Neuro: Active, normal tone for age with good
perfusion.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: [**Date Range **] was placed on continuous positive
airway pressure upon admission to the neonatal intensive
care unit. He had continued work of breathing and was
electively intubated, and received 2 doses of surfactant.
He was extubated to CPAP on day of life 1 and then
transitioned to nasal cannula O2 on day of life 2. He
weaned to room air on day of life 4 and continues in room
air at the time of discharge.
[**Date Range **] was started on caffeine citrate for apnea and
bradycardia. He has not had any spontaneous episodes in the
48 hours prior to discharge. At the time of discharge, he is
breathing comfortably in room air with oxygen saturations
greater than 96%, respiratory rate of 50-60.
2. Cardiovascular: [**Date Range **] has remained normotensive with
normal heart rates. No murmurs have been noted. Recent
blood pressure is 67/30 with a mean of 44.
3. Fluid, electrolytes, and nutrition: [**Date Range **] was initially
NPO and treated with IV fluids. Enteral feeds were started
on day of life #2 and gradually advanced to full volume.
At the time of discharge, he is taking 150 cc per kilogram
of preemie Enfamil or breast milk fortified to 24 calories
per ounce all by gavage. Weight on the day of discharge is
1.645 kilograms. Serum electrolytes were checked at 24
hours of life and were within normal limits.
4. Infectious disease: [**Date Range **] was evaluated for sepsis upon
admission to the neonatal intensive care unit. His initial
CBC included WBC 9.9 with 10% polys and 0% bands, with Hct 52
and platelet count 231. A blood culture was obtained
prior to starting intravenous ampicillin and gentamicin,
and was no growth at 48 hours at which time the antibiotics
were discontinued.
5. Gastrointestinal: [**Date Range **] required treatment for
unconjugated hyperbilirubinemia with phototherapy. His
peak serum bilirubin occurred on day of life 4, total of
10.2/0.4 mg per deciliter. His phototherapy was
discontinued on [**2198-8-7**] and a rebound serum
bilirubin on [**8-8**] was 3.9/0.2.
6. Hematological: Hematocrit at birth was 52%. [**Month (only) **] did not
receive any transfusions of blood products. Iron
supplementation has not yet been started.
7. Neurology: Head ultrasound was performed on [**8-8**] and
was normal. [**Month (only) **] has maintained a normal neurological exam
and there are no neurological concerns at the time of
discharge.
8. Sensory: Audiology: Hearing screening has not yet been
performed. Ophthalmology: Screening eye exam for retinopathy
of prematurity is recommended at 4-5 weeks of life.
9. Psychosocial: This family's primary language is
Portuguese. They have been very involved in [**Month (only) **]'s care.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Is transferred to the [**Hospital 1474**]
Hospital for continuing level II care. The primary
pediatrician is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52551**], [**Hospital3 64004**],
[**Last Name (NamePattern1) 57378**], [**Hospital1 1474**], [**Numeric Identifier 50562**], phone number [**Telephone/Fax (1) 64005**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: Preemie Enfamil or breast milk 24 calories per
ounce, 150 cc per kilogram per day by gavage.
2. Medications: Caffeine citrate 10 mg PG once daily.
3. Car seat position screening is recommended prior to
discharge.
4. State newborn screen was sent on [**2198-8-3**] with no
notification of abnormal results to date. A 2nd screen is
recommended at 2 weeks of age.
5. No immunizations administered.
6. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: 1. Born at less than
32 weeks; 2. Born between 32 and 35 weeks with 2 of the
following: Daycare during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings; or 3. With chronic lung disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity at 31-3/7 weeks gestation.
2. Respiratory distress syndrome.
3. Suspicion for sepsis ruled out.
4. Apnea of prematurity.
5. Unconjugated hyperbilirubinemia.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2198-8-8**] 01:50:48
T: [**2198-8-8**] 04:32:38
Job#: [**Job Number 64006**]
|
[
"7742",
"V290"
] |
Admission Date: [**2119-8-28**] Discharge Date: [**2119-8-29**]
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy with Cauterization of bleeding
History of Present Illness:
86 y/o F, Iranian speaking, with PMH of diverticulosis,
hemorrhoids, MI, CAD, HTN, with recent post-polypectomy bleed,
cauterized 2 days PTA, presents with recurrent bright red blood
per rectum. 6 episodes of BRBPR since 6pm the day of admission.
No associated abdominal pain, N/V, CP/lightheadedness.
.
In ER, Hct 34.9->26.2. HD stable. Discussed w/ GI fellow. Plan
for tagged red blood cell scan to evaluate for bleeding source.
Given 2 units pRBCs. 2 large bore PIV. Admit to MICU.
Past Medical History:
CAD: MI in [**2116**] with reperfusion and stents in LAD
Osteoporosis
Hyperlipidemia
HTN
Diveticulosis
Hemorrhoids
Alzheimers disease
Social History:
born in [**Country **], married; No h/o tobacco, etoh, IVDU
Family History:
Mother died in her 60's from MI. Brothers died of MI at
age 55 and 60.
Physical Exam:
vitals- T 97.6, BP 93/67, HR 89, RR 16, 99% 4l 02 via NC
gen- awake, alert, NAD
heent- EOMI. OP clear. no scleral icterus
neck- supple. no jvd
pulm- CTA b/l. no r/r/w
cv- RRR. no m/r/g
abd- soft, NT/ND
ext- no c/c/e
neuro- moving all extremities
Pertinent Results:
[**2119-8-27**] 08:52PM BLOOD WBC-10.2# RBC-4.01* Hgb-12.2 Hct-34.9*
MCV-87 MCH-30.4 MCHC-35.0 RDW-14.7 Plt Ct-192
[**2119-8-28**] 04:46AM BLOOD WBC-8.1 RBC-2.92*# Hgb-8.8*# Hct-25.0*
MCV-86 MCH-30.1 MCHC-35.2* RDW-14.9 Plt Ct-129*
[**2119-8-29**] 03:58AM BLOOD WBC-7.7 RBC-4.00*# Hgb-11.8*# Hct-32.8*
MCV-82 MCH-29.6 MCHC-36.0* RDW-15.4 Plt Ct-113*
Brief Hospital Course:
Pt was admitted to the MICU with bleeding from her rectum and
falling hematocrit. She was seen and evaluated by GI and due to
her hx it was presumed that she had bleeding from her old
polypectomy site. Pt received colonoscopy prep and colonoscopy
at which time a foci of bleeding was found and cauterized. She
received 4 units of blood total and responded appropriately.
She was D/C on HD #2 with stable HCT. She will f/u with her PCP
for platelets, Hct, LFT [**Month/Day/Year 7941**].
Medications on Admission:
1. Donepezil 10 mg PO HS
2. Atorvastatin 80 mg PO DAILY
3. Trazodone 50 mg PO HS
4. Prilosec OTC 20 mg PO once a day.
5. Docusate Sodium 100 mg PO BID
6. Diovan 80 mg PO once a day
7. FOSAMAX 70 mg PO once a week.
8. Toprol XL 50 mg q24 PO once a day
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Post-polypectomy GI bleed
Discharge Condition:
Good
Discharge Instructions:
You have had a significant episode of bleeding that required
transfusion of blood. You should follow-up with your doctor to
monitor your platelet levels. You should be off of Aspirin for
one month after leaving the hospital. You should also follow-up
with your doctor [**First Name (Titles) **] [**Last Name (Titles) 7941**] of your liver function on
Lipitor. Please discuss this laboratory testing with Dr.
[**Last Name (STitle) **].
You were admitted to the hospital for a GI bleed. You should
call your doctor or return to the ER should you experience any
of the following:
Severe increase in drainage from rectum
Increasing blood from rectum
Fever > 101
Severe pain in abdomen
Numbness/Tingling/Paralysis
Severe Dizziness
Loss of Consciousness
Nausea/Vomiting
Severe Chest Pain/SOB
Any other symptoms that worry you.
Followup Instructions:
Please follow-up with your primary care doctor Dr. [**Last Name (STitle) **]
within one week of discharge for blood work. You should call and
schedule an appointment.
Please follow-up with your regularly scheduled appointments
below:
Provider: [**First Name11 (Name Pattern1) 18169**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], OD Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2119-10-6**] 3:00
Provider: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) 279**], [**Name12 (NameIs) 280**] Date/Time:[**2119-10-31**] 6:00
Completed by:[**2119-8-29**]
|
[
"2851",
"2875",
"V4582",
"412",
"41401",
"2724",
"4019"
] |
Admission Date: [**2142-5-24**] Discharge Date: [**2142-5-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization with stent placement
History of Present Illness:
Pt is an 83 yo male, with HTN, DM, CAD s/p CABG x 5 in [**11-3**]
(LIMA-->D2, SVG--> D1, SVG-->LAD, SVG--> PLV, SVG--> PDA), who
presents with 1 day of chest pain, found to have STEMI, and is
s/p catheterization here. In [**10-4**] ETT MIBI showed ST depressions
in V5-V6 with imaging study showing a medium-sized inferior wall
defect and mild inferior wall hypokinesis with LVEF 64%. Pt was
treated medically and underwent cardiac catheterization showing
right dominant circulation, LMCA with minimal distal narrowing,
LAD with multiple proximal, mid and distal stenosis, and diag 1
with 90% stenosis. Lcx-90% stenosis and RCA-100% acute
thrombotic occlusion. Pt was taken for acute CABG.
Since [**2138**], pt has been doing well, symptom free. On the day of
admission, pt went to VA for his regular interval PCP
[**Name Initial (PRE) 648**]. He went home afterwards, and had an "[**9-12**]"
mid-chest "dull" pressure feeling. No radiation to the jaw, arm,
back, or abdomen. No N/V or diaphoresis. Mild SOB. Pt went to
the ED, and was found to have STEMI inferiorly. Right sided
leads showed V4 STE .5 mm. He was taken to catheterization
emergently.
Cath showed: RA 8, RV 38/0, PA 40/15 (mean 24), PCW 15. LMCA no
obstructive disease, RCA 90% mid, complex TO distal, SVG patent
to OM2, LAD, PDA. CO 4.67, CI 2.53. Driver stent to RCA (acute
marginal supplied to inferior wall). Of note, three balloons
were ruptured during catheterization.
Upon arrival to CCU pt with "[**2147-3-8**]" chest pain that has
persisted since it started with above characteristics. He was
started on nitro gtt.
Past Medical History:
1. CAD s/p CABG x 5 in [**11-3**]- LIMA-->D2, SVG--> D1, SVG-->LAD,
SVG--> PLV, SVG--> PDA.
2. HTN- since [**27**]'
3. Gout-last flare 03'
4. BPH- Better control recently
5. DM-"in good control" per VA notes
6. Nephrolithiasis-treated by outside urologist. Resolved with
lithotripsy 10-12 years ago.
Social History:
Lives in [**Location 1411**]. He is married for 20 years to his second wife
(first wife died of cancer). One grown daughter from first
marriage. 2 step children in their 20s. Never smoked. EtOH: [**3-8**]
drinks per week. Does ADLs, yardwork.
Family History:
No DM, HTN in family. Mother died in mid-50s, unknown cause of
death.
Physical Exam:
VS: T: 100.0; BP: 137/59; HR: 64; RR: 12; O2: 97% RA
Gen: Laying in bed, plethoric face, speaking in full sentences
in NAD
Neck: Laying at 180 degrees, no JVD
CV: RRR S1S2. NO M/R/G
Lungs: CTA anteriorly
Abd: Soft, NT, ND.
Ext: Right groin: sheath still in place. DP 1+ b/l. Warm
extremities. trace edema b/l.
Neuro: CN II-XII grossly intact without focal deficit.
Pertinent Results:
EKG: STE II, III, AvF (III>II). PR prolongation at .24. QRS
borderline .12.
Cath showed: RA 8, RV 38/0, PA 40/15 (mean 24), PCW 15. LMCA no
obstructive disease, RCA 90% mid, complex TO distal, SVG patent
to OM2, LAD, PDA. CO 4.67, CI 2.53. Driver stent to RCA (acute
marginal supplied to inferior wall). Of note, three balloons
were ruptured during catheterization.
________________________________
Labs on admission:
[**2142-5-24**] 03:30PM WBC-18.7* RBC-5.42 HGB-17.3 HCT-50.3 MCV-93
MCH-32.0 MCHC-34.5 RDW-12.7 PLT COUNT-162
NEUTS-95.7* BANDS-0 LYMPHS-2.2* MONOS-2.0 EOS-0 BASOS-0.1
HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL [**Name (NI) 60958**] [**Name (NI) 60959**]
PT-13.4 PTT-24.5 INR(PT)-1.1
calTIBC-306 FERRITIN-211 TRF-235 IRON-128
CK-MB-4 cTropnT-0.01 CK(CPK)-122
GLUCOSE-213* UREA N-22* CREAT-1.2 SODIUM-145 POTASSIUM-3.6
CHLORIDE-104 TOTAL CO2-28
________________________________
Cardiac Labs:
[**2142-5-24**] 03:30PM BLOOD CK(CPK)-122
[**2142-5-25**] 01:29AM BLOOD CK(CPK)-267*
[**2142-5-25**] 06:05AM BLOOD CK(CPK)-375*
[**2142-5-25**] 03:15PM BLOOD CK(CPK)-413*
[**2142-5-24**] 03:30PM BLOOD CK-MB-4
[**2142-5-24**] 03:30PM BLOOD cTropnT-0.01
[**2142-5-25**] 01:29AM BLOOD CK-MB-23* MB Indx-8.6*
[**2142-5-25**] 06:05AM BLOOD CK-MB-38* MB Indx-10.1* cTropnT-0.54*
[**2142-5-25**] 03:15PM BLOOD CK-MB-41* MB Indx-9.9* cTropnT-0.61*
[**2142-5-26**] 07:15AM BLOOD CK-MB-25* MB Indx-11.1* cTropnT-0.91*
_________________________________
Other Labs:
[**2142-5-24**] 08:30PM BLOOD Ret Aut-1.1*
[**2142-5-24**] 03:30PM BLOOD calTIBC-306 Ferritn-211 TRF-235
_________________________________
Labs upon discharge:
[**2142-5-26**] 07:15AM BLOOD WBC-9.0 RBC-4.61 Hgb-14.7 Hct-42.3 MCV-92
MCH-31.9 MCHC-34.8 RDW-12.8 Plt Ct-136*
[**2142-5-26**] 07:15AM BLOOD Glucose-162* UreaN-24* Creat-1.1 Na-141
K-4.0 Cl-104 HCO3-25 AnGap-16
[**2142-5-26**] 07:15AM BLOOD Calcium-8.6 Phos-2.1* Mg-1.9
Brief Hospital Course:
1. Cardiac
a. [**Name (NI) **] Pt was s/p inferior STEMI and stent to RCA. Right sided
pressures were normal so there was not an RV infarct. Pt was
monitored in the CCU secondary to possible in-stent thrombus
given the multiple balloon ruptures and difficulty with
catheterization (see cath report). There was not a problem and
pt did well. We kept pt on ASA and started Plavix. Ace inhibitor
and beta blocker were kept at the outpt dose. He was on
atorvastatin (80 mg) while in the hospital but we had to switch
him back to Zocor as that was on the VA formulary where he got
his medication. Additionally, he was on a Nitro gtt for pain
control which was d/cd on HD #2. Mr. [**Known lastname **] was kept on a tight
regular insulin sliding scale post-MI.
b. Pump- EF 50% by MIBI at OSH last year, which was now 40%
according to echo here with inferior and posterolateral
hypokinesis to akinesis. We continued an ACE inhibitor for
afterload reduction and mortality benefit. Additionally, there
was initial concern for an RV infarct and pt received 3L IVF for
preload.
c. Rhythm- On EKG pt had mild first degree AV block. Given the
RCA involvement there was concern for nodal involvement; however
EKG remained stable. Pt was monitored on telemetry.
d. [**Name (NI) 12329**] Pt with longstanding HTN. We continue beta blocker, ace
inhibitor, and calcium channel blocker. BP was well controlled
2. Diabetes [**Name (NI) 6229**] Pt with DM2. We held his metformin
initially given the possibility of needing further intervention.
He was on a RISS for tight glucose control. Metformin was
restarted upon discharge.
3. BPH- We continued Flomax and finasteride.
4. Increased Hct- On admission, pt with a Hct of 50.3. He had no
evidence of pancreatitis and other possibilities included:
hemachromatosis (pt with bronzy skin, plethoric face),
polycythemia [**Doctor First Name **], and dehydration. Iron studies showed unlikely
hemachromatosis. After pt received hydration, Hct went down to
normal (low 40s).
5. Leukocytosis- WBC 18.7 on admission. There was no evidence of
infection on ROS and physical exam. CXR was negative for an
acute process. WBC trended down and leukocytosis was likely
secondary to stress response and demargination.
6. Gout- We continue allopurinol. Indomethacin was held given
the acute CAD process.
7. PPX- subcutaneous heparin, took POs, RISS, and pain control.
8. F/E/N- [**Doctor First Name **]/ cardiac heart healthy diet. Pt received nutrition
counseling regarding diet.
9. Access- PIVs.
10. Code Status- Full Code. This was discussed with pt.
Medications on Admission:
1. ASA 325 qday
2. Atenolol 25 qday
3. Felodipine 10 mg qday
4. Lisinopril 40 qhs
5. Allopurinol 300 qday
6. Metformin 500 SA, 2 tab po before dinner.
7. Simvastatin 40 mg qday
8. Proscar 5 mg qday
9. Flomax- 0.4 mg qday
10. Indomethacin 25 mg qday prn
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Felodipine 5 mg Tablet Sustained Release 24HR Sig: Two (2)
Tablet Sustained Release 24HR PO DAILY (Daily).
9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
ST elevation myocardial Infarction
Systolic CHF
Diabetes type II
BPH
Gout
First Degree Heart Block
Discharge Condition:
Stable
Discharge Instructions:
PLease make all appointments and take all medications as listed
in the discharge paperwork.
Seek medical attention if you have any of the following : chest
pain, shortness of breath, fevers, chills, tingling in your jaw
or arm.
Followup Instructions:
Please follow up with your primary care provider [**Last Name (NamePattern4) **] [**2-4**] weeks.
You NEED to follow up with your cardiologist at the VA in 1
week!
|
[
"41071",
"4280",
"41401",
"25000",
"2720",
"4019"
] |
Admission Date: [**2170-2-15**] Discharge Date: [**2170-5-10**]
Date of Birth: [**2170-2-15**] Sex: M
Service: NB
IDENTIFICATION: Baby [**Name (NI) **] [**Known lastname **] is an 84 day old former 26 2/7
weeks gestation infant, now post-menstrual age 38 2/7 weeks, who
is being transferred from [**Hospital1 18**] NICU to [**Hospital6 204**]
SCN.
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname **] was the 810 gram
product of a 26 and [**1-24**] week gestation, born to a 36 year-
old, G4, P1 now 2 mother. Prenatal screens: 0 positive,
antibody negative, RPR nonreactive, Rubella immune, hepatitis
surface antigen negative, GBS unknown. This pregnancy was
uncomplicated until placement of cervical cerclage at 16
weeks gestation. At 24 weeks gestation, she was admitted to
[**Hospital6 2561**] with premature rupture of membranes.
She was transferred to [**Hospital1 69**]
and treated with betamethasone as well as antibiotics. There
was no amniotic fluid as seen on ultrasound. Cerclage was
removed as planned. Umbilical cord presentation was noted and
prompted delivery by c-section. due to cord prolapse. Mother
received general anesthesia. Infant emerged with some crying and
respiratory effort. Intubated shortly after birth. Apgars
were 6 and 7 and infant was admitted to the NICU.
Birth weight was 813 grams.
DISCHARGE EXAMINATION: Active on exam. Anterior fontanel
open and soft. Sutures approximated. Moves all extremities
times 4. Infant in room air. Breath sounds equal and clear
with mild subcostal retractions. Cardiovascular: Pink, well
perfused, no audible murmur. Pulses palpable, equal by four.
Capillary refill less than 3 seconds. Mucous membranes pink
and moist. Skin intact. No lesions, rashes or bruises on
exam. Abdomen soft, round, positive bowel sounds, no
hepatosplenomegaly, no palpable masses on examination.
Genitourinary: Voiding, stooling. Normal male genitalia.
Testes descended bilaterally.
HOSPITAL COURSE:
Respiratory: [**Known lastname **] was admitted to the Neonatal Intensive Care
Unit, intubated and received a total of 2 doses of Surfactant. He
was extubated by 24 hours of age and placed on CPAP. He remained
on CPAP for a total of 5 days, but then deteriorated and required
reintubation. He remained intubated at that time for a total of
50 days with conventional mechanical ventilation. He failed
trials of extubation several times, with airway edema noted with
reintubation procedures. Prior to last extubation attempt, he
was given a 3 day course of dexamethasone for airway edema, and
he was then successfully extubated to CPAP on day of life 56. He
remained stable in CPAP for a total of 4 days and transitioned to
high-flow nasal cannula. He continued on high-flow nasal cannula
for approximately 2 weeks, and then transitioned to low-flow
nasal cannula. He is currently receiving nasal cannula, 100% 02,
25 to 75 cc, and appears overall comfortable with mild work of
breathing.
He was treated with caffeine citrate which was discontinued on
[**5-2**]. He continues to have occasional apnea and bradycardia
spells, partly feeding related. [**Known lastname **] was started on Lasix three
times a week for evolving chronic lung disease on [**2170-3-13**],
and continues on lasix, currently receiving 2 mg/kg per day every
Monday, Wednesday and Friday.
Cardiovascular: He is status post indomethacin for patent
ductus arteriosus. Echocardiogram on [**2-26**] revealed no
patent ductus arteriosus with a patent foramen ovale present. The
infant continues to have intermittent audible murmur. He is
otherwise cardiovascularly stable.
Fluids, electrolytes and nutrition: Discharge weight is 2.765
kg. Length 47 cm. Head circumference 35 cm. He was admitted
to the NICU on parenteral nutrition and remained on
parenteral nutrition until he achieved full feedings. Enteral
feedings were initiated on day of life 8. He had brief stops
and starts of enteral feedings until he achieved full enteral
feedings on day of life 31. His maximum caloric intake was
130 cc/kg per day with special care 30 calorie. He is
currently receiving 140 cc/kg per day minimum of special care
24 calorie. PO intake has been advancing rapidly, and he has been
mostly PO for past several days prior to discharge.
Lytes were monitored weekly, and have remained within normal
limits. Most recent labs were on [**5-9**]: Sodium 138; potassium
6.1 (hemolyzed, prevous 5.2); chloride 109; total C02 23.
Gastrointestinal: His peak bilirubin was on day of life 5 of
3.3. he was treated with phototherapy. Issue has resolved.
Hematology: Blood type is 0 positive. He received a total of
4 transfusions, his last being on [**2170-3-10**]. His most
recent hematocrit on [**4-24**] was hematocrit of 28.1 with
reticulocyte count of 4.7%. He is currently receiving ferrous
sulfate supplementation.
Infectious disease: Initial CBC on admission was negative.
He received 48 hours of ampicillin and gentamycin with
negative blood culture. He had multiple episodes requiring
brief 48 hour coverage of Vancomycin and gentamycin to rule
out sepsis. He was treated for a total of 7 days with
Vancomycin and Cefotaxime due to increased respiratory
support needs. Cultures at that time remained negative and
antibiotics were discontinued on [**3-15**]. On [**4-11**], he
had nasal swabs sent for viral studies. The viral studies
were negative.
Neuro: All head ultrasounds have been within normal limits.
Sensory: Infant has not received his hearing screen which
should be performed prior to discharge.
Ophthalmology: His most recent eye examination was on [**5-7**],
revealing stage 1, zone 3. Recommended follow-up in 2 weeks.
The ophthalmologist following him here is Dr. [**Last Name (STitle) **] [**Name (STitle) **].
Telephone number is [**Telephone/Fax (1) 54018**].
Psychosocial: His parents are Portuguese speaking only. Very
invested and involved in this infant's care.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Level 2 hospital ([**Hospital6 42638**]).
PRIMARY PEDIATRICIAN: Not yet identified.
CARE RECOMMENDATIONS: Continue ad lib feeding; Special Care
24 calorie.
Medications:
Lasix 5.5 mg (2 mg/kg per day) every Monday, Wednesday and
Friday at 10 a.m.
Ferrous sulfate supplementation (25 mg/ml) .45 ml p.o. daily
for a total of 4 mg/kg per day.
Car seat position screening has not been performed.
State newborn screens have been sent per protocol and have
all been within normal limits.
Immunizations received: He received hepatitis B vaccine on
[**2170-3-18**]. PediaRx, HIB, HIV and Prevnar all were given
on [**2170-4-19**].
DISCHARGE DIAGNOSES:
1. Premature infant born at 26 and [**1-24**] week gestation.
2. Status post respiratory distress syndrome.
3. Chronic lung disease.
4. Status post patent ductus arteriosus.
5. Status post rule out sepsis with antibiotics.
6. Status post hyperbilirubinemia, resolved.
7. Apnea and bradycardia of prematurity.
8. Anemia of prematurity.
9. Retinopathy of prematurity.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2170-5-10**] 01:54:48
T: [**2170-5-10**] 04:57:28
Job#: [**Job Number 71727**]
|
[
"7742",
"V053"
] |
Admission Date: Discharge Date: [**2143-10-1**]
Date of Birth: [**2075-4-10**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 68-year-old white male has
been exertional chest pain for the week prior to admission.
He had symptoms when he was walking or mowing his lawn. He
denies any symptoms at rest. He had an exercise tolerance
test on [**2143-9-20**], which was positive for [**3-21**]
depressions in the anterolateral leads. He was referred by
Dr. [**Last Name (STitle) 2912**] for a cardiac catheterization.
PAST MEDICAL HISTORY: Significant for a history of
hypertension. History of hypercholesterolemia. History of
lymphoma, currently being observed. History of
hypothyroidism. History of gastroesophageal reflux disease.
History of nephrolithiasis. Status post left inguinal hernia
repair. Status post tonsillectomy. History of squamous cell
cancer of the groin.
ALLERGIES: PENICILLIN.
MEDICATIONS ON ADMISSION: Levoxyl 0.25 mg p.o. once daily
Prilosec 40 mg p.o. once daily
Aspirin 81 mg p.o. once daily
Plavix 75 mg p.o. once daily
Toprol XL 50 mg p.o. once daily
TriCor 160 mg p.o. once daily.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] does not smoke
cigarettes. He drinks alcohol rarely.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION: He is a well-developed, well-nourished
white male in no apparent distress. Vital signs are stable.
He is afebrile. HEENT exam: Normocephalic, atraumatic,
extraocular movements intact. Oropharynx benign. Neck
supple with a full range of motion, no thyromegaly. He had
bilateral lymphadenopathy. Lungs were clear to auscultation
and percussion. Cardiovascular examination revealed regular
rate and rhythm, normal S1 and S2 with no rubs, murmurs or
gallops. Abdomen was soft, nontender with positive bowel
sounds and no masses or hepatosplenomegaly. Extremities are
without clubbing, cyanosis or edema. The pulses were 2-plus
and equal bilaterally throughout with the exception of the
right femoral popliteal PT and DT which were all 1plus. His
neural exam was nonfocal.
HOSPITAL COURSE: On [**2143-9-25**] he underwent cardiac
catheterization, which revealed normal left main and 95
percent proximal left anterior descending lesion, 70 percent
mid left circumflex lesion and the RCA was a small,
nondominant vessel with no disease. His ejection fraction
was 65 percent. Dr. [**Last Name (STitle) 70**] was consulted. On [**2143-9-26**]
the patient underwent coronary artery bypass graft times two
with three LIMA to the left anterior descending and reverse
saphenous vein graft to the OM. The crossclamp time was 55
minutes. Total bypass time 76 minutes. He was on
nitroglycerine and propofol and was taken from the Operating
Room to the Catheterization Lab as he had poor doppler
signals in his graft. Catheterization revealed the LIMA had
spasm and he also had spasm of the OM. He had a Cypher stent
placed in the left anterior descending and another Cypher
stent placed in the left circumflex. He was then transferred
to the CSIU on nitroglycerine and propofol in stable
condition.
He was extubated on his postoperative night. He did have
some atrial fibrillation. He had an echocardiogram on
postoperative day number one, which showed that the left
atrium was mildly dilated. There was mild symmetric left
ventricular hypertrophy. Ejection fraction was 55 percent.
He also received a unit of blood that day for a hematocrit of
26. He continued to progress and postoperative day two had
his chest tubes discontinued. Postoperative day three his
wires were discontinued and he was ready for the floor, but
there was no bed. On postoperative day four his hematocrit
was 23.3 and he got a unit of blood and was transferred to
the floor. He continued to progress and on postoperative day
five he was discharged to home in stable condition.
LABS ON DISCHARGE: His labs on discharge were hematocrit
25.8, white count 7.3, platelets 209, sodium 142, potassium
4.2, chloride 103, carbon dioxide 29, BUN 23, creatinine 1.2,
blood sugar 108.
DISCHARGE MEDICATIONS: His medications on discharge were:
Lopressor 25 mg p.o. b.i.d.
Potassium 20 mEq p.o. b.i.d. for seven days.
Colace 100 mg p.o. b.i.d.
Aspirin 325 mg p.o. once daily
Percocet, [**1-18**] p.o. q.4-6h prn pain.
Plavix 75 mg p.o. once daily
Amiodarone 400 mg p.o. once a day for seven days, then
decrease to 200 mg p.o. once daily.
Vitamin C 500 mg p.o. b.i.d.
Ferrous gluconate 325 mg p.o. once daily
Levoxyl 25 mcg p.o. once daily
Lasix 20 mg p.o. b.i.d.
Multi-vitamin 1 p.o. once daily
Prilosec 40 mg p.o. once daily
TriCor 100 mg p.o. once daily.
DISCHARGE DIAGNOSES: Coronary artery disease, lymphoma,
hypothyroidism, gastroesophageal reflux disease,
postoperative atrial fibrillation.
DISCHARGE PLANS: He will be seen by Dr. [**First Name (STitle) 3510**] in one to
two weeks, Dr. [**Last Name (STitle) 2912**] in two to three weeks and Dr.
[**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2143-10-1**] 17:20:19
T: [**2143-10-1**] 21:16:54
Job#: [**Job Number 106318**]
|
[
"41401",
"9971",
"42731",
"4019",
"2720",
"2449",
"53081"
] |
Admission Date: [**2108-9-5**] Discharge Date: [**2108-9-11**]
Date of Birth: [**2039-9-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lamotrigine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Exertional dyspnea and worsening fatigue
Major Surgical or Invasive Procedure:
[**2108-9-5**]
1. Coronary bypass grafting x4 with left internal mammary
artery to left anterior descending coronary artery;
reverse saphenous vein single graft from aorta to first
diagonal coronary artery; reverse saphenous vein single
graft from aorta to first obtuse marginal coronary
artery; as well as reverse saphenous vein graft from
aorta to posterior left ventricular coronary artery.
2. Left anterior descending artery patch angioplasty with the
left internal mammary artery.
3. Left greater saphenous vein harvesting using the
endoscopic technique.
History of Present Illness:
This is a 68 year old woman with PMH notable for epilepsy,
cerebrovascular disease, and recent bilateral carotid stenting
presents today to discuss surgical revascularization. Her first
carotid stent in [**2108-5-16**] was complicated by right groin
hemorrhage and seizure. This created some demand ischemia and
catheterization showed multi-vessel occlusive coronary artery
disease. Her second stent placement in [**2108-6-15**] was uneventful.
Since leaving the hospital she has had no complaints. She denies
any lateralizing ocular or hemispheric symptoms, and there has
been no additional seizure activity. Her Plavix was recently
discontinued by [**Year (4 digits) 1106**] surgery, and she is now cleared to
proceed with surgical revascularization. Currently, she
complains
of worsening fatigue and exertional dyspnea. She denies chest
pain, orthopnea, PND, pedal edema, syncope and presyncope. ** Of
note, she has a suspected ovarian malignancy which will also
require surgery after her coronary surgery is
complete. **
Past Medical History:
Coronary artery disease, recent NSTEMI in [**2108-5-16**], Epilepsy
([**1-18**] trauma in her 20's), Cerebrovascular Disease, History of
Right Hemisphere watershed infarct, Carotid Disease, s/p
bilateral stenting, Right Ovarian Mass, Hyperlipidemia,
Hypertension, Hypothyroidism, History of Headaches, Possible
History of Atrial fibrillation, Obesity, Varicose Veins, s/p
[**Country **] stent ([**2108-5-18**]), s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stent ([**2108-6-19**])
Social History:
She is a widow. Her husband passed away from esophageal
cancer in [**2102**]. She does not have any children. She had 5
miscarriages. She used to work in a factory that made smoke
detectors. That is where she met her longtime friend who looks
after her.
Family History:
There is no family history of stroke or epilepsy. Her
father passed away from a ruptured aortic aneurysm. He had
insulin-dependent diabetes. Her mother passed away from an MI
at age
49.
Physical Exam:
Pulse: 58 Resp:18 O2 sat:100/RA BP Right: 126/100
Height:5' Weight:190 lbs
General: Appears older than stated age of 68. No acute distress.
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: None
Varicosities: Right GSV varicosities noted. Left GSV appears
suitable
Neuro: Gait slightly off balance and appeared to have some word
difficulty finding. Slight left facial weakness also noted. Exam
was otherwise nonfocal. She had FROM with equal strength
bilaterally.
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: d Left: d
PT [**Name (NI) 167**]: d Left: d
Radial Right: 1+ Left: 1+
Carotid Bruit: none bilaterally
Pertinent Results:
[**2108-9-11**] 05:47AM BLOOD WBC-8.5 RBC-3.53* Hgb-10.7* Hct-30.7*
MCV-87 MCH-30.4 MCHC-34.9 RDW-15.0 Plt Ct-543*
[**2108-9-10**] 05:50AM BLOOD WBC-9.8 RBC-2.92* Hgb-9.0* Hct-26.8*
MCV-92 MCH-30.9 MCHC-33.8 RDW-14.4 Plt Ct-379#
[**2108-9-11**] 05:47AM BLOOD Glucose-121* UreaN-11 Creat-0.7 Na-137
K-4.6 Cl-100 HCO3-27 AnGap-15
[**2108-9-10**] 05:50AM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-136
K-4.5 Cl-100 HCO3-28 AnGap-13
[**2108-9-11**] 05:47AM BLOOD Mg-2.2
[**2108-9-10**] 05:50AM BLOOD Mg-3.0*
[**2108-9-5**] Intra-op TEE
Conclusions
PRE-BYPASS:
-No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
-No spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage.
-There is mild (non-obstructive) focal hypertrophy of the basal
septum.
-There is mild regional left ventricular systolic dysfunction
with inerior wall hypokinesis. The remaining segments contract
normally (LVEF = 55 %).
- Doppler parameters are most consistent with Grade II
(moderate) left ventricular diastolic dysfunction.
-There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta.
-There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen.
-The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
-There is 1+ Tricuspid regurgitation which worsened prior to
commencement of bypass.
-There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified of the result at the time of the study.
POSTBYPASS:
The patient is AV paced on low dose phenylephrine infusion.
Biventricular function is maintained. The aorta is intact. The
valves remained unchanged with the exception of the tricuspid
regurgitation. The tricuspid regurgitation initially appeared 2+
& improved through the course of the study and was mild at the
end of the exam. No other significant changes
Brief Hospital Course:
The patient was brought to the Operating Room on [**2108-9-5**] where
the patient underwent Coronary Artery Bypass x 3 (LIMA-LAD,
SVG-OM, SVG-Diag, SVG-PLV). Overall the patient tolerated the
procedure well and post-operatively was transferred to the CVICU
in stable condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Plavix was started for poor targets. She does have a history of
seizure disorder, and anti-convulsants were resumed. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. She was deconditioned
and has no home support. It was felt that she would benefit
from a short rehab stay. She did receive 1 unit of PRBC on POD
5 for anemia and hypotension. Beta blocker was also decreased.
By the time of discharge on POD 6 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to [**Hospital 38**] Rehab in
good condition with appropriate follow up instructions.
Medications on Admission:
Aspirin 325mg daily, Zonisamide 400mg [**Hospital1 **], Phenobarbital 60mg
[**Hospital1 **], Lovastatin 80mg daily, Metoprolol 25mg daily, Levothyroxine
75mcg daily, MVI
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. phenobarbital 30 mg Tablet Sig: Two (2) Tablet 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. zonisamide 100 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
6. lovastatin 40 mg Tablet Sig: Two (2) Tablet PO once a day.
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
14. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
tbd
Discharge Diagnosis:
Coronary artery disease, recent NSTEMI in [**2108-5-16**], Epilepsy
([**1-18**] trauma in her 20's), Cerebrovascular Disease, History of
Right Hemisphere watershed infarct, Carotid Disease, s/p
bilateral stenting, Right Ovarian Mass, Hyperlipidemia,
Hypertension, Hypothyroidism, History of Headaches, Possible
History of Atrial fibrillation, Obesity, Varicose Veins, s/p
[**Country **] stent ([**2108-5-18**]), s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stent ([**2108-6-19**])
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with Unsteady gait and assist
Incisional pain managed with ultram and percocet
Incisions:
Sternal - healing well, no erythema or drainage
Left leg- 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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2108-9-18**] 11:15 in the
[**Hospital **] medical office building [**Hospital Unit Name **]
Surgeon: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2108-10-23**] 1:15
in the [**Hospital **] medical office building [**Hospital Unit Name **]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 5285**] Date/Time:[**2108-9-20**] 2:00
Please call to schedule appointments with your
Primary Care Dr.[**First Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 21975**] in [**3-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2108-9-11**]
|
[
"41401",
"2859",
"412"
] |
Admission Date: [**2128-10-18**] Discharge Date: [**2128-10-22**]
Date of Birth: [**2091-7-7**] Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain X 3 days with N/V
Major Surgical or Invasive Procedure:
INDICATIONS FOR CATHETERIZATION:
Coronary artery disease, Canadian Heart Class IV, unstable. ETT
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Mild diastolic ventricular dysfunction.
COMMENTS: 1. Selective coronary angiography revealed a
right-dominant system. The LMCA, LAD, and Lcx all had mild
non-flow
limiting disease. The RCA was totally occluded in the mid-vessel
with
thrombus.
2. Left ventriculography was deferred.
3. Opening hemodyanamics revealed a mildly elevated right and
left-sided filling pressure (RA mean 7mmHg, PA mean 17mmHg, PCWP
mean
8mmHg). The calculated cardiac index was 4.5 l/min/m2.
4. Successful PTCA/stenting of the proximal RCA with a 4.5x13mm
Hepacoat bare metal stent, mid RCA with a 4.0x18mm and 4.0x23mm
postdilated with a 4.5mm balloon
History of Present Illness:
37 year old female with ESRD on Peritoneal dialysis (?lupus
nephritis) and s/p R hip arthoplasty [**9-23**] for coag. neg. staph
infection, h/o HTN, tobacco use, who p/w intermittent CP for 3
days PTA. The CP was sub-sternal and accompanied by nausea and
dry heaves. The patient states that she never had chest pain
prior to this AM. Denies Orthopnea, PND, SOB. EKG showed
Inferior STEMI.
Past Medical History:
1. S/P Subtotal Parathyroidectomy d/t tertiary
Hyperparathyroidism
2. SLE?
3. ESRD thought to be d/t Lupus nephritis
4. S/P Subtotal Parathyroidectomy leaving left lower gland [**2109**]
5. S/P Cadeveric Renal transplant x 1 [**2115**]
6. Peritoneal Dialysis x 1.5 years
7. Right Pathologic Hip Fracture [**2128-1-20**] after bending over to
put on sock, s/p pinning
8. Osteoporosis d/t Renal Osteodystrophy
9. HTN
10. Tumoral calcinosis on left palm, wrist, and right shoulder
over last 6 months, and bilateral buttocks which resolved
11. Hysterectomy x 1
Social History:
Lives with husband and 2 kids. Smokes 1 PPD X >20 yrs. No
ETOH.
Family History:
No significant CAD. No family history of thryoid, parathyroid,
or calcium disease. Mother with ESRD.
Physical Exam:
VS: T=100.1 HR=100 R=60 BP=117/41
Gen: NAD
Neck: 6 cm JVD
Heart: RRR, no m/r/g
Lungs: CTAB with mildly decreased BS in RLL
Abd: S/NT/ND/+BS, PD Cath noted
Extrem: No c/c/e
Neuro/Psy: Alert and oriented X3
Pertinent Results:
[**2128-10-18**] 12:15PM PT-12.7 PTT-26.2 INR(PT)-1.0
[**2128-10-18**] 12:15PM PLT COUNT-411
[**2128-10-18**] 12:15PM HYPOCHROM-3+ ANISOCYT-2+ MACROCYT-1+
MICROCYT-1+
[**2128-10-18**] 12:15PM NEUTS-82.9* LYMPHS-11.0* MONOS-4.3 EOS-1.3
BASOS-0.4
[**2128-10-18**] 12:15PM WBC-7.9 RBC-3.40* HGB-9.3* HCT-30.1*# MCV-89
MCH-27.2 MCHC-30.7* RDW-18.0*
[**2128-10-18**] 12:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2128-10-18**] 12:15PM CALCIUM-9.8 PHOSPHATE-5.5* MAGNESIUM-2.4
[**2128-10-18**] 12:15PM CK-MB-92* MB INDX-17.0*
[**2128-10-18**] 12:15PM cTropnT-15.92*
[**2128-10-18**] 12:15PM CK(CPK)-542*
[**2128-10-18**] 12:15PM GLUCOSE-82 UREA N-42* CREAT-9.6* SODIUM-138
POTASSIUM-5.5* CHLORIDE-101 TOTAL CO2-23 ANION GAP-20
[**2128-10-18**] 12:34PM LACTATE-1.1
[**2128-10-18**] 09:18PM PT-13.2 PTT-28.3 INR(PT)-1.1
[**2128-10-18**] 09:18PM PLT COUNT-385
[**2128-10-18**] 09:18PM WBC-6.6 RBC-2.62* HGB-7.2* HCT-23.0* MCV-88
MCH-27.5 MCHC-31.3 RDW-18.0*
[**2128-10-18**] 09:18PM VANCO-32.0
[**2128-10-18**] 09:18PM CALCIUM-8.9 PHOSPHATE-6.2* MAGNESIUM-2.1
[**2128-10-18**] 09:18PM CK-MB-95* MB INDX-15.2* cTropnT-24.97*
[**2128-10-18**] 09:18PM CK(CPK)-625*
[**2128-10-18**] 09:18PM GLUCOSE-75 UREA N-42* CREAT-9.3* SODIUM-132*
POTASSIUM-5.9* CHLORIDE-99 TOTAL CO2-22 ANION GAP-17
Brief Hospital Course:
Cardiac: Pt taken to Cath lab where found to have dilated RCA to
5mm and mid-thrombus occlusion. 3 stents placed in RCA.
Admitted to CCU where started on plavix, metoprolol, captopril,
and atorvastatin. BB and ACE-I titrated up to goal HR=70 and
SBP<130. Discharged on Toprol XL 175mg PO QD and lisinopril
20mg PO QD.
Peak TrpT=24.8, persistent Inferior ST elevation on EKG. TTE
was negative for ventricular aneurysm. Patient remained CP free
with the exception of the evening of HD#4 when she did c/o some
atypical CP. Negative cardiac enzymesX2, no EKG changes from
chest-pain free baseline post-MI. Pt to f/u w/ Dr. [**Last Name (STitle) **].
Renal: Patient followed by renal service while inpatient. PD
continued on regular nightly schedule. Upon d/c, setting was
1.5% for 5L X2. Nephrocaps added to meds. Sevelamer increased
to 1600 mg PO TID. Lytes stable.
SLE w/u: Rheumatology consulted re:possible SLE dx. Serologies
pending, pt to F/u as outpt.
Medications on Admission:
Calcitrol 25 mcg
Prednisone 3mg
Vanco dosed to <15
Dilaudid prn
Epogen 4000mg SC qwk
FeSO4 325mg PO QD
fluconazole 250mg PO QD
vitamins
Calcium carbonate 500 mg PO TID
hydromorphone 2mg PO q4-6 hrs PRN
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Inferior STEMI
ESRD on PD
HTN
Discharge Condition:
Afebrile, tolerating oral diet, ambulatory with crutches,
without cardiac chest pain.
Discharge Instructions:
Take nitroglycerin tablet as prescribed for chest pain as
prescribed. Seek immediate treatment if pain does not resolve.
Continue on your prior outpatient medications with the addition
of Toprol XL, Lisinopril, Plavix, Aspirin, and Lipitor for
management of your coronary artery disease. Please note your
Renegel dose has been increased per Dr. [**Last Name (STitle) **] since your
admission. Continue on a low salt, low cholesterol diet. Return
to the ED incase of recurrent chest pain, shortness of breath,
inability to tolerate oral diet, or onset fevers.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: LM [**Hospital Unit Name 16933**]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2128-11-17**] 8:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2128-11-22**] 11:30
-Call PCP to schedule hospital follow up appointment within 1
month
-Call your regular kidney doctor within 1 week.
Follow up with cardiologist Dr. [**Last Name (STitle) **] on [**11-18**] at
10:30 on [**Hospital Ward Name 23**] 7 (#[**Telephone/Fax (1) 6197**])
Completed by:[**2128-10-26**]
|
[
"41071",
"40391",
"4241",
"4240",
"2859",
"3051"
] |
Admission Date: [**2109-2-25**] Discharge Date: [**2109-2-28**]
Date of Birth: [**2059-4-15**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization.
Intera-aortic balloon pump placement.
History of Present Illness:
This is a 49 y/o F with history of HTN who presented on [**2109-2-22**]
to OSH with chest pain.
.
Patient was admitted to [**Hospital3 3583**] with 1 day of chest
pain. She refers [**2112-5-24**] chest pain that started right after she
had been on the treadmill for a couple of minutes. It was a
pressure radiated to her jaw. It lasted about 6 minutes and it
went away. No SOB, nausea, palpitations or diaphoresis. She had
a second episode while carrying her grosseries. Later at night,
while watching tv had a new episode of similar features that
also lasted about an hour. She decided to present to the
Emergency department given persistent chest pain. She denied any
similar episodes in the past.
.
In the OSH, had a Bp 160/100 and she received nitro paste,
aspirin with improvement of her BP. Patient actually refered
that her pain went away while waiting to be seen in the ED.
Initial set of enzymes CK 186, second set CK 188 Trop 0.76, then
Trop I 2.17 Ck 222. She did have recurrence of chest pain in the
hospital and dynamic EKg changes in the anterior leads. It was
decided to transfer her for cardiac catheterization.
.
In the Cath lab, mildly elevated LVEDP, LVEF ~70%, right
dominant, two vessel premature CAD with ulcerated disrupted mid
LAD plaque, balloon angioplasty of mid LAD complicated with
spiral grade E dissection of the distal LAD with distal abrupt
closure of the apical LAD. A IABP was placed, heparin and
Integrillin were continued.
.
Currently had a 5/10 chest pain, not radiated. + nausea. Denied
palpitations.
.
On review of symptoms, 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. He denies exertional buttock or calf pain. All of the
other review of systems were negative.
*** Cardiac review of systems is notable for absence of chest
pain, paroxysmal nocturnal dyspnea, orthopnea, palpitations,
syncope or presyncope. She does report that over the last week
she was feeling a little more short of breath when going
upstairs.
Past Medical History:
HTN
Anemia
s/p c section
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
She lives with her husband. She has one duaghter age 30. She
works as a hair dresser.
Family History:
There is Family history of father MI at age 50. No history of
sudden death.
Physical Exam:
BP 147/78 Hr 71 RR 14, Sats 100% 4 L nasal canula.
General: Well developed, well nourished. non aparent distress.
HEENT: pupiles equal and reactive to light. Neck supple. No JVP
appreciated. no thyromegaly.
Chest: no deformities.
Lungs: Clear to auscultation anteriorly.
Cardiac: Regular rate and rhythm, ballon pump click audible.
Palpation of the heart revealed PMI in the 5th intercostal
space.
Abdomen: BS+, soft, non tender non distended. no hepatomegaly
appreciated.
Extremities: No pallor, cyanosis or clubbing. Distal pulses
preserved. Right groin with dressing, + femoral intraaortic
balloon pump. Mildy ozzing.
Skin: no lesions.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2109-2-25**] 09:30PM BLOOD WBC-11.0 RBC-4.43 Hgb-11.8* Hct-35.5*
MCV-80* MCH-26.7* MCHC-33.3 RDW-18.7* Plt Ct-332
[**2109-2-28**] 07:10AM BLOOD WBC-9.9 RBC-4.16* Hgb-11.1* Hct-34.2*
MCV-82 MCH-26.8* MCHC-32.6 RDW-18.5* Plt Ct-283
[**2109-2-28**] 07:10AM BLOOD PT-12.6 PTT-29.8 INR(PT)-1.1
[**2109-2-25**] 09:30PM BLOOD Glucose-109* UreaN-10 Creat-0.6 Na-137
K-3.8 Cl-98 HCO3-28 AnGap-15
[**2109-2-28**] 07:10AM BLOOD Glucose-97 UreaN-12 Creat-0.6 Na-139
K-4.1 Cl-102
[**2109-2-25**] 09:30PM BLOOD CK(CPK)-73
[**2109-2-26**] 04:22AM BLOOD CK(CPK)-147*
[**2109-2-26**] 11:21AM BLOOD CK(CPK)-241*
[**2109-2-26**] 06:29PM BLOOD CK(CPK)-251*
[**2109-2-27**] 04:14AM BLOOD CK(CPK)-197*
[**2109-2-28**] 07:10AM BLOOD CK(CPK)-162*
[**2109-2-25**] 09:30PM BLOOD CK-MB-4 cTropnT-0.07*
[**2109-2-26**] 04:22AM BLOOD CK-MB-18* MB Indx-12.2* cTropnT-0.15*
[**2109-2-26**] 11:21AM BLOOD CK-MB-31* MB Indx-12.9* cTropnT-0.23*
[**2109-2-26**] 06:29PM BLOOD CK-MB-26* MB Indx-10.4* cTropnT-0.43*
[**2109-2-27**] 04:14AM BLOOD CK-MB-17* MB Indx-8.6*
[**2109-2-28**] 07:10AM BLOOD CK-MB-9
[**2109-2-25**] 09:30PM BLOOD Calcium-9.1 Phos-4.0 Mg-2.3
[**2109-2-28**] 07:10AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.7*
[**2109-2-26**] 04:22AM BLOOD calTIBC-350 Ferritn-19 TRF-269
[**2109-2-26**] 04:22AM BLOOD Triglyc-153* HDL-54 CHOL/HD-3.0
LDLcalc-76
.
[**2-25**] Cath
COMMENTS:
1. Selective coronary angiography of this right dominant system
demonstrated two vessel coronary artery disease. The LMCA had
distal
tapering to 30%. The LAD had ulcerated 90% stenosis in the mid
vessel
after tortuous major D1 with diffuse disease beyond to 80% prior
to
larger caliber apical LAD. The LCX was a tortuous vessel with
mild
plaquing at the origin of major OM1. The RCA had proximal 50%
stenosis
with catheter induced spasm that improved with IC nitro.
2. Limited resting hemodynamics were performed. The left sided
filling
pressures were elevated (LVEDP was 18mmHg). The systemic
arterial
pressures were within normal range measuring 139/76mmHg. There
was no
significant gradient across the aortic valve upon pull back of
the
catheter from the left ventricle to the ascending aorta.
3. Contrast ventriculography revealed a normal left ventricular
ejection
fraction of 70% with normal wall motion. There was trace mitral
regurgitation noted.
4. Balloon angioplasty with a 2.0 ballon of the mid to distal
LAD
complicated by sprial dissection and occlusion of the apical
LAD. Final
angiography showed TIMI II flow in the distal vessel. (See PTCA
comments)
5. Placement of intr-aortic balloon pump.
FINAL DIAGNOSIS:
1. 2 vessel coronary artery disease.
2. Elevated left sided filling pressures.
3. Normal LVEF.
4. Spiral dissection of the mid-distal left anterior descending
coronary
artery as a complication of balloon angioplasty.
5. Hemodynamic support and analgesia for chest pain.
.
[**2-26**] ECHO
Conclusions:
The left atrium is normal in size. The estimated right atrial
pressure is
0-5mmHg. Left ventricular wall thickness, cavity size, and
systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
an anterior space which most likely represents a fat pad.
IMPRESSION: Preserved regional and global biventricular systolic
function. Mild mitral regurgitation.
.
[**2-27**] CXR
CHEST, ONE VIEW: Compared with [**2109-2-26**], there is no
change in the bilateral linear atelectasis in the mid and lower
lung zones. The intraaortic balloon pump is positioned between
the apex of the aortic knob and left main stem bronchus. There
is no new pneumothorax, effusion, pulmonary edema, or
consolidation. The cardiac and mediastinal contours are stable.
IMPRESSION: Stable bilateral atelectasis.
Brief Hospital Course:
This is a 49 y/o F h/o HTN who presents with NSTMI s/p cardiac
catheterization complicated by spiral disection of LAD.
Cardiac
# CAD/NSTEMI -- > STEMI after disection of LAD: Patient with
dynamic EKG changes and + troponin s/p cardiac cath c/b spiral
disection of LAD. IABP was continued until she stopped having
chest pain and CKs began to trend down. Peak CK 251.
- received Heparin/Integrillin per protocol
- aspirin / plavix 12 months.
- continue BB as tolerated
- High dose statin
- added ace inhibitor
- was briefly on ISMN but this was stopped as she was feeling
light-headed and she had completed her infarct
.
# Pump: Patient appears euvolemic. ECHO with EF of 60%.
.
# Rhytm: normal sinus rhythm
.
# HTN: now on Lisinopril, B-blocker, titrate up as outpatient
PRN
.
# Dispo: will follow-up with Dr. [**First Name (STitle) 437**] and outpatient PCP
.
Medications on Admission:
Hydrochlorotiazide 25 mg/day
Naproxen PRN
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain: [**Month (only) 116**] use
X 2, please seek medical attention.
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
STEMI
NSTEMI
HTN
Anemia
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
You were admitted with a heart attack. Several of your
medications have been changed.
.
Please seek medical attention if you develop a fever > 101 F,
chest pain, shortness of breath, groin swelling or any other
concerning symptoms.
Followup Instructions:
Please make a follow-up appointment with Dr. [**First Name (STitle) **] within the
next 2 weeks. Tel ([**Telephone/Fax (1) 72155**].
.
You have an appointment with Dr. [**First Name (STitle) 437**] on [**3-27**] at 9:00 am.
[**Hospital Ward Name 23**] Bldg., [**Location (un) 436**].
|
[
"41071",
"9971",
"5180",
"41401",
"4019",
"2859"
] |
Admission Date: [**2127-6-9**] Discharge Date: [**2127-6-18**]
Service: MEDICINE
Allergies:
Zestril / Keflex
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
dyspnea, cough
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram
Cardioversion
History of Present Illness:
Patient is an 87yo male with PMH of CAD s/p CABGx4, chronic
dCHF, HTN, and COPD who presents with 3d of cough and fevers.
Patient was last in his USOH until approximately 1 week PTA when
he began to feel general malaise. His wife has been recovering
over the past 3 weeks from an upper respiratory tract infection.
Then, about 3 days PTA, patient felt feverish at home and had
prodressive shortness of breath and cough. He also had
increasing production of yellow sputum. The dyspnea, cough, and
sputum production increased to the point where he presented to
the ED for evaluation.
In the ED, initial VS were: 98.6 132 124/58 22 100% 10LNC, but
hypoxic to low 80s on room air. He had no chest pain, abd pain,
nausea, vomiting, dysuria, diarrhea. Patient was given dilt 20mg
x 1, 25mg x 1 for a flutter, then dropped pressures to 70s. They
were then 90s after starting dopamine, but patient became tachy.
He was off dopamine before transfer to the floor. He recieved
levofloxacin for PNA and lasix 20 IV. He received aspirin as
well. He did not give levophed though listed. He has an 18x2 and
20PIV, and left IJ for access. His BNP was elevated at 6800 and
troponin was 0.02.
On arrival to the MICU, Vital signs: T97.2, HR127, BP134/58,
RR21, O2sat: 99%NRB. Patient had dyspnea but was speaking in
full sentences. He was A+O and able to participate in exam and
in mild respiratory distress.
Review of systems:
(+) Per HPI
(-) Denies headache, Denies chest pain, chest pressure, 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.
Positive right hemiscrotal pain with coughing
Past Medical History:
1. Coronary artery disease s/p CABG [**2119**], LIMA to the LAD, SVG
to O1, SVG to the PDA to the OM1.
2. Hyperlipidemia.
3. Hypertension.
4. Benign prostatic hypertrophy.
5. Gastroesophageal reflux disease.
6. Asthma.
7. Allergic rhinitis.
8. Mod b/l tibial aa occlusive dz, dx'd [**3-23**]
Social History:
The patient lives with his wife, is a nonsmoker, former heavy
alcohol usage - last heavy use >10 years ago, up to 1 L
vodka/QOD. Denies current alcohol abuse, Denies any IVDU.
Family History:
several family members with diabetes
Physical Exam:
Physical Exam on Admission:
Vitals: 98.6 132 124/58 22 100% 10LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: rapid rate and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: no wheezes, ronchi, poor air movement in posterior fields
bilaterally with rare rales at the bases
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no organomegaly, small umbilical hernia, small bulge
with cough in the right hemiscrotum
GU: foley catheter in place
Ext: warm, well perfused, 2+ pulses, no clubbing or cyanosis, 1+
pitting edema in the right lower extremity and trace pitting
edema in the left lower extremity, surgical scar of saphenous
vein removal in the right lower extremity
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Physical Exam on Discharge:
VS: T 97.4 HR 69-74 BP 103-123/42-52 RR 18-20 O2at 96(2L)
Weight 69.2kg
I/O: +95/-425
General: Well-appearing man in bed in no acute distress
HEENT: PERRL, EOMI, oropharynx clear, no JVD
Heart: RRR, nl s1 and s2, no murmurs
Lungs: CTAB with no crackles or wheezes
Abd: normoactive bowel sounds, nontender, nondistendfed, no
organomegaly
Ext: no peripheral edema, warm
Pertinent Results:
Admission labs:
[**2127-6-9**] 01:30PM BLOOD WBC-7.3 RBC-4.24* Hgb-12.6* Hct-39.1*
MCV-92 MCH-29.6 MCHC-32.1 RDW-13.6 Plt Ct-237#
[**2127-6-9**] 01:30PM BLOOD Neuts-79.6* Lymphs-15.9* Monos-4.2 Eos-0
Baso-0.3
[**2127-6-9**] 01:30PM BLOOD PT-14.4* PTT-27.3 INR(PT)-1.3*
[**2127-6-9**] 01:30PM BLOOD Glucose-182* UreaN-48* Creat-1.4* Na-136
K-5.3* Cl-99 HCO3-27 AnGap-15
[**2127-6-9**] 01:30PM BLOOD proBNP-6808*
[**2127-6-9**] 01:30PM BLOOD cTropnT-0.02*
[**2127-6-9**] 09:00PM BLOOD cTropnT-0.01
[**2127-6-9**] 08:51PM BLOOD Type-ART pO2-100 pCO2-51* pH-7.37
calTCO2-31* Base XS-2
[**2127-6-9**] 01:44PM BLOOD Lactate-1.6
Pertinent labs:
[**2127-6-9**] 01:30PM BLOOD proBNP-6808*
[**2127-6-9**] 01:30PM BLOOD cTropnT-0.02*
[**2127-6-9**] 09:00PM BLOOD cTropnT-0.01
[**2127-6-10**] 05:11AM BLOOD cTropnT-0.01
[**2127-6-10**] 05:11AM BLOOD ALT-25 AST-23 AlkPhos-72 TotBili-0.4
[**2127-6-9**] 08:51PM BLOOD Type-ART pO2-100 pCO2-51* pH-7.37
calTCO2-31* Base XS-2
[**2127-6-9**] 01:44PM BLOOD Lactate-1.6
Labs on Discharge:
[**2127-6-18**] 07:05AM BLOOD WBC-11.6* RBC-4.45* Hgb-13.1* Hct-40.1
MCV-90 MCH-29.5 MCHC-32.7 RDW-13.5 Plt Ct-306
[**2127-6-18**] 07:05AM BLOOD PT-23.9* PTT-31.5 INR(PT)-2.3*
[**2127-6-18**] 07:05AM BLOOD Glucose-149* UreaN-42* Creat-1.2 Na-140
K-4.1 Cl-100 HCO3-34* AnGap-10
Urine
[**2127-6-9**] 04:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2127-6-9**] 04:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2127-6-9**] 04:20PM URINE RBC-<1 WBC-0 Bacteri-NONE Yeast-NONE
Epi-0
[**2127-6-9**] 04:20PM URINE CastHy-1*
Micro
Blood Culture, Routine (Final [**2127-6-15**]): NO GROWTH.
URINE CULTURE (Final [**2127-6-10**]): NO GROWTH.
[**2127-6-10**] 6:08 am SPUTUM
Source: Expectorated.
GRAM STAIN (Final [**2127-6-10**]):
[**11-13**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CHAINS.
RESPIRATORY CULTURE (Preliminary):
MODERATE GROWTH Commensal Respiratory Flora.
.
Imaging:
CHEST (PORTABLE AP) Study Date of [**2127-6-9**] 1:38 PM
IMPRESSION: Mild pulmonary edema. Left base opacity may be
atelectasis,
however, pneumonia should be excluded in the appropriate
clinical setting.
Post-diuresis films would be of utility in excluding underlying
infection.
CHEST PORT. LINE PLACEMENT Study Date of [**2127-6-9**] 5:08 PM
FINDINGS: As compared to the previous radiograph, the patient
has received a
new left internal jugular vein catheter. The tip of the
catheter projects
over the upper to mid SVC. The course of the catheter is
unremarkable. There is no evidence of complications, notably no
pneumothorax.
Otherwise, the radiograph is unchanged as compared to 1:32 p.m.
on the same day.
TTE (Complete) Done [**2127-6-10**] at 3:43:44 PM FINAL
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF 65%). There is considerable
beat-to-beat variability of the left ventricular ejection
fraction due to an irregular rhythm. 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. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**1-20**]+) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
ECHO [**6-13**]:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is good (>20 cm/s). Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are complex (>4mm)
atheroma in the aortic arch. There are complex (>4mm) atheroma
in the descending thoracic at 35cm from incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. There is no pericardial effusion.
IMPRESSION:No intracardiac clot was found. Mild MR was noticed
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is an 87yo male with
PMH of CAD s/p CABGx4, COPD, and chronic dCHF who presented from
home with cough and shortness of breath for 3 days with oxygen
sats in the 80's on room air.
Active Diagnoses:
1. COPD exacerbation: Patient had viral prodrome for one week,
then for 3 days prior to admission had cough, dyspnea, and
increased production of sputum that was purulent. His wife, a
lifelong smoker, also had a syndrome of malaise and URI the week
preceeding his illness. He also has a history of PFT's
suggestive of COPD. He was started on Bipap on admission, and
had an ABG which showed hypercarbia to pCO2 51. He was treated
with a 5-day course of prednisone, levofloxacin, and ipratropium
nebs with improvement. The pt was difficult to wean off oxygen.
After further diuresis, by the time of discharge, he was on room
air.
2. Atrial fibrillation/flutter: Patient presented in atrial
flutter. Echocardiogram revealed mitral and aortic regurgitation
and dilated atria. This, in conjuction with his COPD and acute
distress in the context of COPD exacerbation, is likely what led
to the onset of aflutter. He required diltiazem gtt for rate
control with gradual transition to oral dosing. He went for TEE
which did not show thrombus and then completed cardioversion. He
went into sinus rhythm afterwads with some bigeminy. He was
taken off diltiazem and restarted on lopressor 50mg [**Hospital1 **].
Subsequently, he went back into afib with RVR and required a
second cardioversion with amiodarone loading. He was discharged
on amiodarone and off of diltiazem and metoprolol.
.
3. Acute diastolic CHF: Patient has history of dCHF and in the
setting of tachycardia and pulmonary edema likely has acute on
chronic exacerbation. A-flutter was a likely precipitant which
may be seen in a heart exposed to chronic lung disease and
hypertension. His admission chest xray confirmed pulmonary edema
and echo showed normal EF with mild aortic regurgitation and
mild to moderate MR. [**First Name (Titles) **] [**Last Name (Titles) 1834**] lasix diuresis with
improvement in oxygen saturation and physical exam. At
discharge, his O2 sat was 98 on room air. He was discharged
home with PO lasix 20mg daily, and he will follow-up with his
PCP regarding dosing adjustments.
4. HTN: Patient was taken of his home diovan. and restarted on
nifedipine as tolerated and on lopressor. After second
cardioversion when patient returned to [**Location 213**] sinus rhythm, he
was taken off of nifedipine and lopressor. He remained
normotensive.
5. Diarrhea: Patient has hx of diarrhea at home for which he
takes imodium [**Hospital1 **]. He has not been having diarrhea in the
setting of imodium. 3 days prior to discharge, patient had one
episode of watery diarrhea, in the setting of having imodium
held during hospitalization. Since he did not have a fever or
leukocytosis, and diarrhea resolved, C diff was not sent. Has
did not have any more diarrhea by the time of discharge.
.
6.CAD: He was continued on daily simvastatin and ASA.
7.GERD: He was continued on omeprazole.
Transitional Issues:
Patient was started on anticoagulation, which will be managed by
his primary care doctor.
He should undergo cardiac catheterization sometime in the
future.
Medications on Admission:
LOPERAMIDE - (On Hold from [**2126-5-6**] to unknown for on
lomotil)
- 2 mg Capsule - 1 Capsule(s) by mouth twice a day as needed for
diarrhea
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr -
0.5
(One half) Tablet(s) by mouth once a day bp, CHF presumed
diastolic
NIFEDIPINE - 30 mg Tablet Extended Release - 1 Tablet(s) by
mouth
once a day for bp
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day gerd
OXYBUTYNIN CHLORIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a
day for urinating
SIMVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
chol
VALSARTAN [DIOVAN] - 80 mg Tablet - 1 Tablet(s) by mouth once a
day bp, correct dose
Medications - OTC
ASPIRIN - (OTC) - 325 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day prevention
GUAR GUM [BENEFIBER (GUAR GUM)] - (OTC) - Dosage uncertain
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day
prevention
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - 1,000 mg Capsule - 1
Capsule(s) by mouth once a day prevention1
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. multivitamin 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 DAILY (Daily).
4. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
5. Outpatient Lab Work
INR
Take with you to B.I. [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] (Dr. [**Last Name (STitle) **]on
[**2127-6-20**]
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) inhalation Inhalation once a day.
Disp:*1 device* Refills:*2*
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg twice/day for 2 weeks (until [**2127-7-1**]), 200mg
twice/day for 2 weeks (until 626/12) and 200mg daily thereafter.
Disp:*60 Tablet(s)* Refills:*0*
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Atrial Flutter/Fib
COPD exacerbation
Acute on chronic diastolic heart failure
Atrial Fibrillation
Secondary:
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 449**],
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted to the hospital after presenting with a cough
a fever. You were found to have an elevated heart rate and low
oxygen saturation. You heart rhythm was in atrial flutter
(irregular rhythm). You were also found to be in a COPD
exacerbation and CHF exacerbation.
To get your heart rate under control you were initially given IV
medications and eventually you were transitioned to an oral
regimen. Your heart rate remained high, and you were taken for
cardioversion twice, the second time with a new medication
called amiodarone. The procedure went well without
complications. You were started on coumadin to prevent clots
from forming by thinning your blood.
For your COPD exacerbation, you were given steroids, nebulizer
treatments, and antibiotics. You completed a steroid burst and
full antibiotic course in the hospital.
For your heart failure, you were diuresed with lasix. We are not
discharging you with lasix, but you should discuss whether you
need to be on lasix with your PCP when you go for follow-up.
You should have your INR checked on [**6-18**] at the Dr.[**Name (NI) 10822**]
clinic. This is very important that you follow up on this
appointment.
Please note that the following changes have been made to your
medications:
CHANGE Aspirin 325mg to 81mg once daily
START Spiriva (tiotropium) for COPD
START Coumadin 4mg once daily; you must follow up with your PCP
regarding your INR
START Amiodarone 400mg twice/day for 2 weeks, then 200mg
twice/day for 2 weeks, then 200mg daily
START Furosemide 20mg by mouth daily
STOP Diovan
STOP Oxybutynin
STOP Metoprolol succinate
STOP nifedipine
Followup Instructions:
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: Friday [**2127-6-20**] at 11:00 AM
With: ADULT MEDICINE NURSE [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
*This appointment is for a coumadin check. Dr. [**Last Name (STitle) **] is
working on an additional appointment for you for next week. You
will receive a call from his office with appointment details.
Department: CARDIAC SERVICES
When: TUESDAY [**2127-7-22**] at 1:20 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
Please call Dr.[**Name (NI) 10822**] office at [**Telephone/Fax (1) 1144**] to schedule
a followup appointment within the next week.
Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED
When: WEDNESDAY [**2127-7-30**] at 10:25 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: RADIOLOGY
When: MONDAY [**2127-7-21**] at 10:00 AM
With: RADIOLOGY [**Telephone/Fax (1) 9045**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2127-6-19**]
|
[
"42731",
"4280",
"4240",
"53081",
"V4581",
"40390",
"2724"
] |
Admission Date: [**2113-4-10**] Discharge Date: [**2113-4-19**]
Date of Birth: [**2069-8-16**] Sex: M
Service:
DISCHARGE DIAGNOSIS: Left renal mass.
PROCEDURE: Left renal artery embolization and left
nephrectomy with lymph node dissection.
DISCHARGE MEDICATIONS: Percocet.
HISTORY OF PRESENT ILLNESS: This is a 43 year old man with a
history of left renal mass found in response to a new left
varicocele diagnosed in [**2111**]. The varicocele was repaired in
the spring of [**2112**], but he complained of lethargy for several
months in association with anemia. He also had low back
pain. CT scan was performed which revealed a left renal mass
with metastasis. He underwent IL2 therapy for two weeks in
[**2112-12-2**] and has had a 30 pound weight loss. He was
angio-infarcted in [**2113-4-2**] and presents now for debulking
nephrectomy.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: Right shoulder surgery. Left
varicocele repair.
ALLERGIES: None.
SOCIAL HISTORY: Smoking half pack per day for 15 years.
PHYSICAL EXAMINATION: In no acute distress. Abdomen was
soft and nondistended. He had some tenderness in the left
lower quadrant. No peritoneal signs.
LABORATORY DATA: Notable for abdominal and pelvic CT which
revealed this large left renal mass as well as lumbar
metastasis. He had retroperitoneal adenopathy. There was
left adrenal metastasis. Laboratory data were notable for
hematocrit of 35.8, creatinine 0.8.
HOSPITAL COURSE: On [**2113-4-11**] the patient underwent
uncomplicated left nephrectomy and lymph node dissection by
Dr. [**Last Name (STitle) **] with assistance from Dr. [**Last Name (STitle) 33031**]. He received two
units of packed red cells intraoperatively and had 3 liters
estimated blood loss. Postoperatively he was kept intubated
and sedated overnight. He was extubated without difficulty.
Postoperatively hematocrit was stable, but he had some
persistent tachycardia. A VQ scan was obtained and was
indeterminate.
He was transferred from the SICU on [**2113-4-13**]. He remained
comfortable on Dilaudid PCA. He was administered Lasix and
had brisk diuresis. NG tube was maintained until [**2113-4-17**].
It was clamped with low residual at that time and his diet
was slowly advanced. By [**4-19**] he was tolerating a regular
diet and prepared for discharge home. He will follow up with
Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**]
Dictated By:[**Name8 (MD) 33032**]
MEDQUIST36
D: [**2113-6-1**] 08:59
T: [**2113-6-3**] 08:02
JOB#: [**Job Number 11497**]
|
[
"53081"
] |
Admission Date: [**2115-7-10**] Discharge Date: [**2115-7-19**]
Date of Birth: [**2031-3-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increasing dyspnea on exertion
Major Surgical or Invasive Procedure:
[**7-10**] Cardiac catheterization
[**7-15**] Aortic Valve Replacement ([**Street Address(2) 6158**]. [**Hospital 923**] Medical Epic
Biocor tissue valve), Coronary artery bypass grafting x 1 with
reverse saphenous vein graft to the right coronary artery
History of Present Illness:
Ms. [**Known lastname 41323**] is an 84 year-old woman with history of atrial
fibrillation (not anticoagulated), aortic stenosis, CHF, COPD,
and pulmonary hypertension. For the past several months she has
been having increasing symptoms of dyspnea on exertion. In
[**4-30**], she was admitted to [**Hospital3 2737**] with a CHF
exacerbation in the context of an infection (pt unsure of nature
of infection). She received IV lasix and was discharged on PO
lasix. Two weeks ago, Ms. [**Known lastname 41323**] [**Last Name (Titles) 46101**] the NP who works
with her cardiologist (Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] and Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**]) who
recommended that she stop lasix given absence of peripheral
edema, and she planned to take it PRN which she has not
required.
Although she was previously able to ambulate through the grocery
store without difficulty, her current baseline respiratory
status is notable for dyspnea on exertion half-way across a room
in her home, causing her to sit down and rest. She has
previously led a very active lifestyle. Because her symptoms
were thought to be in large part secondary to her AS and
limiting her ADLs, she was referred for catheterization in
anticipation of possible AVR. She denies any recent chest pain,
light-headedness, or syncope. She further denies claudication,
LE edema, orthopnea, or PND.
.
She was taken for cath on [**7-10**] demonstrating an 80% ostial RCA
lesion and valve area 0.5 cm2. After the case the patient
developed bleeding from groin with hypotension 60s systolic, HR
40s - received fluids and atropine. After this her SBP rose
into the 130s with HR 70s. She was sent to the CCU for
observation overnight.
Past Medical History:
Meniere's disease
Leukemia in [**2097**] treated with Chemotherapy
Myelodysplastic syndrome
COPD
Paroxsymal Atrial Fibrillation - She did not know of this
diagnosis. Denied ever taking Coumadin.
Aortic Stenosis with valve area 0.7 cm2
Pulmonary Hypertension
Hemorrhoidectomy
Tonsillectomy
Appendectomy
GERD
Chronic Diarrhea
Frequent Urination
Previous UTI's
Degenerative Disc Disease
Social History:
Ms. [**Name14 (STitle) 55821**] alone in [**Location (un) 2498**] MA. She recently had a
visiting nurse [**First Name8 (NamePattern2) 767**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Health Agency for three weeks
after her hospitalization in [**Month (only) **]. Her contact person in her
stepson [**Name (NI) **] [**Name (NI) 41323**]; his home number is [**Telephone/Fax (1) 55822**]. The
patient still drives. She has bilateral hearing aides. She
occasionally uses a cane when she is out of her house and has to
go some distances.
Family History:
Mother died at 103 of old age. Father died with stomach CA.
Physical Exam:
VS: T= 94.6, BP= 143/79, HR=85, RR= 16, O2 sat=92%
GENERAL: appropriate, pleasant elderly woman lying flat on her
back
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP 7 cm
CARDIAC: normal PMI, irregular, harsh 4/6 systolic murmur heard
best at RUSB
LUNGS: lungs clear anteriorly.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. DP pulses intact
bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Preop labs
[**2115-7-10**] 10:12PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.037*
[**2115-7-10**] 10:12PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2115-7-10**] 10:12PM URINE RBC-[**5-1**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-0-2
[**2115-7-10**] 03:50PM HCT-29.7*
[**2115-7-10**] 12:45PM GLUCOSE-98 UREA N-26* CREAT-1.0 SODIUM-136
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-22 ANION GAP-12
[**2115-7-10**] 12:45PM ALT(SGPT)-14 AST(SGOT)-24 ALK PHOS-68
AMYLASE-73 TOT BILI-0.5 DIR BILI-0.1 INDIR BIL-0.4
[**2115-7-10**] 12:45PM ALBUMIN-4.0 CALCIUM-8.8 CHOLEST-113
[**2115-7-10**] 12:45PM %HbA1c-5.5
[**2115-7-10**] 12:45PM WBC-3.4* RBC-2.91* HGB-9.3* HCT-29.3*
MCV-101* MCH-32.1* MCHC-31.9 RDW-17.6*
[**2115-7-10**] 12:45PM PLT SMR-NORMAL PLT COUNT-344#
[**2115-7-10**] 12:45PM PT-14.7* PTT-83.8* INR(PT)-1.3*
Discharge labs
[**2115-7-18**] 04:55AM BLOOD WBC-7.8 RBC-3.21* Hgb-9.9* Hct-28.8*
MCV-90 MCH-30.7 MCHC-34.2 RDW-17.5* Plt Ct-213
[**2115-7-18**] 04:55AM BLOOD Plt Smr-NORMAL Plt Ct-213 LPlt-2+
[**2115-7-16**] 02:57AM BLOOD PT-16.1* PTT-39.9* INR(PT)-1.4*
[**2115-7-18**] 04:55AM BLOOD Glucose-106* UreaN-20 Creat-1.1 Na-136
K-4.5 Cl-102 HCO3-26 AnGap-13
[**2115-7-10**] Cardiac Catheterization: 1. Coronary angiography in this
right dominant system demonstrated single vessel coronary artery
disease. The LMCA had no angiographically apparent disease.
The LAD and the LCX had no angiographically significant
stenosis. The RCA had a 90% ostial calcified stenosis, and
supplied small PDA and PL arteries. The distal RCA before the
crux appears to be a good target for bypass. 2. Resting
hemodynamics revealed normal right atrial and right ventricular
filling pressures with mean RA pressure of 6 mmHg and
end-diastolic RV pressure of 5 mmHg. There was mild pulmonary
arterial hypertension with mean PA pressure of 26 mmHg and
elevated pulmonary vascular resistance of 150 dynes-sec/cm5.
The left ventricular filling pressure was slightly elevated with
mean PCW pressure of 17 mmHg. There was no evidence of mitral
stenosis. Severe aortic stenosis was present, with a peak
aortic gradient of 66 mmHg, mean gradient of 49 mmHg, and
estimated aortic valve area of 0.59 cm2. The cardiac output was
normal at 4.8 L/min. There was no evidence of a left-to-right
shunt based on oxygen saturation data.
[**2115-7-11**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
<40%
EKG: sinus at 75 bpm, NL axis, 1st degree AV block, no ST-T wave
changes
[**2115-7-15**] ECHO: PRE-BYPASS: The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). No atrial septal
defect is seen by 2D or color Doppler. Right ventricular chamber
size and free wall motion are normal. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**11-23**]+) mitral regurgitation is seen.
There is no prolapse of flailing [**Last Name (un) **] leaflets. There is no
pericardial effusion. Dr. [**Last Name (STitle) 55823**] was notified in person of the
results on Ms.[**Known lastname 41323**] at 8AM before incision. Post_Bypass:
Patient on infusion of epinephrine 0.04 mcg/kg/min, mild RV and
global LV hypokinesis. LVEF 45%. There is a bioprosthesis in the
native aortic position with stable and well functioning
leaflets. Thoracic aorta is intact. There is minimal MR.
Brief Hospital Course:
Ms. [**Known lastname 41323**] is an 84 year-old woman with aortic stenosis,
recent admission to outside hospital for CHF/flash pulmonary
edema with subsequent ongoing shortness of breath, now s/p
catheterization on [**7-10**] demonstrating 90% ostial RCA lesion and
[**Location (un) 109**] 0.5cm2. As mentioned in the HPI, she was hypotensive with
bleeding post-cath requiring fluids and atropine. CT abdomen
done en route to the CCU did not show any signs of
retroperitoneal bleeding. Cardiac surgery was consulted and she
underwent pore-operative work-up which included echo, carotid
u/s, vein mapping and usual lab studies. While awaiting surgery
she was medically managed. On [**7-15**] she was brought to the
operating room where she underwent a coronary artery bypass x 1
and aortic valve replacement. Please see operative report for
surgical details. Following surgery she was transferred to the
CVICU for invasive monitoring in stable condition.
Post-operatively she required large amount of fluid
resuscitation, transfusion, and pressors for bleeding and
hypotension. Repeat echo was performed and ruled out tamponade.
On post-operatively day one she was weaned off sedation, awoke
neurologically intact and extubated. Post-operative day two her
chest tubes were removed and she was transferred to the
telemetry floor for further care. Epicardial pacing wires were
removed on post-op day three. The remainder of her post-op
course was unremarkable and she worked with physical therapy for
strength and mobility. On post-op day four she was discharged to
rehab facility with appropriate follow-up appointments.
Medications on Admission:
Coreg 3.125 mg tablet [**Hospital1 **], Epogen 40,000 units SQ Bimonthly,
Folic Acid 1 mg tablet daily qhs, Combivent 90 mcg 2 puffs QID,
Meclizine 25 mg tablet [**Hospital1 **], Simvastatin 20 mg tablet qhs,
Multivitamin tablet daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Meclizine 25 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for dizziness.
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours) as needed for shortness
of breath.
7. Epogen 40,000 unit/mL Solution Sig: One (1) injection
Injection every other Wednesday.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks.
13. Aspirin 81 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable PO
DAILY (Daily).
14. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 5165**]
Discharge Diagnosis:
Coronary artery Disease s/p Coronary Artery Bypass Graft x 1
Severe Aortic stenosis s/p Aortic Valve replacement
Chronic Diastolic congestive heart Failure EF 55%
Chronic Obstructive Pulmonary Disease
Past Medical History: Meniere's disease, Leukemia in [**2097**]
treated with Chemotherapy, Myelodysplastic syndrome, Atrial
Fibrillation, Pulmonary Hypertension, Gastroesophageal reflux
disease, Chronic Diarrhea, Previous UTI's, Degenerative Disc
Disease, CVA found by MRI in [**2099**], Anemia, Bilateral cataracts,
s/p Tonsillectomy, s/p Appendectomy, s/p Hemorrhoidectomy
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] (Cardiac Surgeon) in 4 weeks Phone: [**Telephone/Fax (1) 170**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8098**] (Cardiology) in [**12-25**] weeks Phone: [**Telephone/Fax (1) **]
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] (Primary Care) in [**11-23**] weeks Phone: [**Telephone/Fax (1) 55824**]
Completed by:[**2115-7-19**]
|
[
"4241",
"41401",
"42731",
"4168",
"496",
"4280"
] |
Admission Date: [**2184-10-27**] Discharge Date: [**2184-11-2**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
left hip pain
Major Surgical or Invasive Procedure:
removal of left femur intramedullary rod and left hip
hemiarthroplasty with open reduction internal fixation of
greater trochanter on [**2184-10-27**]
History of Present Illness:
[**Known firstname **] is a [**Age over 90 **]-year-old woman with multiple medical problems
including diabetes, chf, cerebrovascular disease and chronic
renal insufficiency, who about 5 months ago, sustained a
multiple part intertrochanteric femur fracture that extended
down into the subtrochanteric level, calcar. This was treated by
another surgeon with an open reduction and internal fixation
utilizing an intramedullary rod. Unfortunately, the patient has
had cut out of the hardware
with complete failure, nonunion of the 4 part fracture,
shortening of the leg, persistent pain and no evidence of
ongoing healing. In order for the patient to become ambulatory
again and to restore leg length, it is necessary to remove
the hardware and to perform a complex revision operation. The
patient is thus admitted electively following medical clearance
for the above procedure.
Past Medical History:
Hypertension
right ICA stenosis
right-sided stroke
Bell's Palsy on left
diabetes mellitus
diabetic retinopathy
chronic renal insufficiency
peripheral edema
total abdominal hysterectomy
cholecystectomy
congestive heart failure - [**4-/2184**] LVEF 45%
open reduction internal fixation left hip [**2184-5-11**]
Social History:
nursing home resident
Family History:
deferred
Physical Exam:
General: Awake, Alert, Orientedx3, NAD
HEENT: PERRL, MMM, wears glasses
CV: regular s1,s2. no m/r/g
LUNGS: CTA B, occasional fine rales at bases
ABD: +bs, soft, nt/nd
PERIPHERAL: 1+ le edema.
EXT: wwp, 5/5 strength-gastroc/at, sensation intact to light
touch in sural/deep peroneal/superficial perneal/tibial nerve
distributions
Pertinent Results:
chest x-ray: mild vasc redist, small L pleural effusion
EKG: 60 bpm, L axis, TwI avL, unchanged
[**2184-10-27**] 10:27PM GLUCOSE-165* UREA N-30* CREAT-0.9 SODIUM-143
POTASSIUM-3.5 CHLORIDE-112* TOTAL CO2-21* ANION GAP-14
[**2184-10-27**] 10:27PM CALCIUM-8.0* PHOSPHATE-3.7 MAGNESIUM-2.1
[**2184-10-27**] 10:27PM WBC-12.1*# RBC-3.44* HGB-10.7* HCT-30.5*
MCV-89# MCH-31.3 MCHC-35.3*# RDW-15.1
[**2184-10-29**] 12:24PM BLOOD CK-MB-2 cTropnT-0.02*
[**2184-10-29**] 08:12PM BLOOD CK-MB-2 cTropnT-0.02*
[**2184-10-30**] 02:50AM BLOOD CK-MB-2 cTropnT-0.03*
[**2184-11-1**] 06:20AM BLOOD Hct-30.4*
[**2184-11-1**] 06:20AM BLOOD Glucose-148* UreaN-26* Creat-1.1 Na-142
K-4.2 Cl-105
[**2184-11-1**] 06:20AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1
Brief Hospital Course:
[**Age over 90 **] year-old female with past medical history cad, CHF, DM, and
cri underwent removal of left intramedullary nail and
hemiarthroplasty without complication. She had an estimated
blood loss of one liter and received three liters of LR, two
units of PRBCs intraoperatively. She spent the night following
surgery in the intensive care unit intubated. She was extubated
without difficulty on post-operative day number one and her
hospitalization was complicated only by a brief episode of
demand ischemia. She was transferred out of the MICU on
post-operative day number four. The geriatric service followed
the patient for her entire hospital course. Her hospital course
by problems is as follows:
1) Respiratory Support: The patient spent the first night
following surgery on SIMV and was converted to pressure support
in the morning. On pressure support she had excellent tidal
volumes and was breathing spontaneously. She was thus extubated
without difficulty on post-operative day number one. Her oxygen
requirement was subsequently weaned and at the time of discharge
she had a good saturation on room air.
2) S/p hemiarthroplasty: The patient tolerated the procedure
well, although she did require transfusion of several units of
packed red blood cells post-operatively especially in the
setting of demand ischemia. However, by postoperative day
number three her hematocrit had stabilized at between 27 and 30.
She received one dose vancomycin postoperatively and 48 hours
of Ancef as prophylaxis. When she began tolerating POs,
Coumadin was started with a Lovenox bridge. She was maintained
in an abduction pillow at all times, with anterior hip
precautions, no active abduction, and 33% weightbearing.
However, as of post-operative day number five physical therapy
was only able to get the patient to sit at the edge of the bed.
The therapists attributed her slow progress to a combination of
deconditioning, pain, and her weight. She was given oxycodone,
Tylenol, and tramadol for pain.
3) CHF with EF 40-45%: The patient was over one liter positive
early in her postoperative course and had a chest x-ray
consistent with mild volume overload. However, diuresis was
restarted with Lasix on post-operative day number two. At no
point did she clinically appear to be acutely in heart failure.
4) Type II DM: The patient's blood sugars were slightly high
usually in the mid 100s and occasionally in the low 300s.
However, given that her oral intake was less than usual we
decided to err on the side of conservative management by keeping
her on half of her usual dose of standing NPH and a gentle
regular insulin sliding scale.
5) CRI: The patient's creatinine remained below baseline for
the majority of her admission. She did require several fluid
boluses early in her post-operative course.
6) Demand Ischemia: On postoperative day number two the patient
began to complain of chest pressure. Her EKG demonstrated some
mild ST depression. This pressure quickly abated after
sublingual nitrate. Her troponin increased to 0.2 and was 0.2
and 0.3 on subsequent tests. The cardiology service was
consulted and they attributed her symptoms to ischemia secondary
to demand. They recommended only restarting aspirin, her
statin, and titrating up her beta blocker.
Medications on Admission:
asa ec 325mg qday
furosemide 80 qam, 40 qpm
insulin 70/30 44 qam, 29 qpm
imdur 30mg qday
lorazepam 1mg qhs
MOM
[**Name (NI) 31013**] 50 tid
oxycodone 2.5 q6h prn
simvastatin 20 qpm
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q24H (every 24 hours): Please d/c when therapeutic
with coumadin (INR=2-2.5). mg
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
for 6 weeks: Please check INR at least twice weekly with
goal=2-2.5.
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO QHS (once a day (at bedtime)).
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for breakthrough pain.
17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig:
Eighteen (18) units Subcutaneous QAM.
18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eleven
(11) units Subcutaneous QPM.
19. Regular insulin sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
left hip fracture nonunion
diabetes mellitus
hypertension
demand ischemia
congestive heart failur
chronic renal insufficiency
cerebrovascular disease
Discharge Condition:
stable
Discharge Instructions:
1) Please keep wound covered with dry sterile dressing. OK to
shower. Do not bathe.
2) Please take lovenox to prevent blood clot until INR is
between
2 and 2.5 and then take coumadin for 6 weeks.
3) Please follow-up with Dr. [**Last Name (STitle) **] as directed for staple
removal Call doctor sooner if you devlop fevers, shaking
chills, or increasing wound redness, drainage, or pain not
controlled by pain medications.
4) Only bear 33% weight on left leg, no active abduction, and
anterior hip precautions.
Physical Therapy:
Activity: Out of bed to chair tid
Pneumatic boots
Right lower extremity: Full weight bearing
Left lower extremity: Partial weight bearing
Right upper extremity: Full weight bearing
Left upper extremity: Full weight bearing
33% WEIGHTBEARING ON LEFT LOWER EXTREMITY, ANTERIOR HIP
PRECAUTIONS, NO ACTIVE ABDUCTION, PLEASE KEEP TOWEL UNDER CALF
TO KEEP HEELS OFF THE BED
Treatments Frequency:
Site: LEFT HIP
Type: Surgical
Comment: SURGERY WILL CHANGE
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2184-11-8**] 8:30
|
[
"2851",
"4280",
"5859",
"4019"
] |
Admission Date: [**2105-5-2**] Discharge Date: [**2105-5-31**]
Date of Birth: [**2048-2-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
fever, back pain
Major Surgical or Invasive Procedure:
1. L2 bilateral hemilaminotomy.
2. L3 laminectomy without facetectomy.
3. L4 laminectomy with far lateral decompression, psoas
debridement.
4. L5 laminectomy.
5. S1 laminectomy.
6. Removal of intraspinal abscess.
7. Deep biopsy, bone.
8. Fluoroscopic-guided abscess drainage x2
History of Present Illness:
Pt is a 57Y F with Hx of SLE on Prednisone 10mg daily at
baseline who is transferred from [**First Name4 (NamePattern1) 11560**] [**Last Name (NamePattern1) **] with low back
pain and bilateral LE weakness. History is obtained from pt and
what is available from outside records. She states that for the
past 3 months, she has experienced increased fatigue, anorexia,
malaise, and an approximate 20lb unintentional weight loss. She
also notes that she has increased back pain. On [**2105-3-10**], she
received an epidural injection for back pain and, per report,
received an additional 2 injections the week before [**4-14**]. Since
[**Month (only) 958**], she has been having weakness of her bilateral LE and dull
(not burning) pain in her thighs that has been getting
progressively worse. The pain is now [**8-18**] in intensity with
movement; she denies any bowel or bladder incontenance or
anesthesia.
.
She went to [**Last Name (un) 11560**] on [**4-14**] where an MRI showed a fluid
epidural collection L5-S1 causing lateral recess stenosis at S1;
DDx included hematoma vs. abscess. She was admitted to [**Last Name (un) 11560**]
on [**4-14**] where Neurosurgery, IR, and ID all felt that the risks of
draining the collection outweighed the benefits; Neurosurgery
thought that the collections were a result of the injections
themselves and not abscesses. After receiving IV ABX(per her
report), she was discharged on the 10th. The patient was, by
her report, admitted again from [**4-22**] - [**4-24**] and had a repeat MRI
which showed "Interval significant decreasein the size of
bilateral epidural fluid collections at the S1 level. The
degree of stenosis is markedly reduced. However, there is
slight residual encroachment on the S1 nerve root. Clinical
correlation is suggested." She was given pain control and again
discharged without any other interventions. She saw her
Rheumatologist as an outpatient who both said her pain and fluid
collection was not the result of SLE and did not change any
medications.
She represented to LGH on [**4-30**] for pain control and weakness.
Her prednisone was increased from 20 to 40mg daily. EMG
confirmed an extensive sensorimotor neuropathy. She received
blood cultures and an echo out of concern for occult infection
and was transferred to [**Hospital1 18**] for rheum consult and a second
opinion. Of note, she states that she had a temp of 102 at the
beginning of [**Month (only) 958**], Temps 99-100 throughout the month, and was
noted to have a T of 101.3 at the time of transfer. She also
notes "fogginess" in her thinking and times where her "mind goes
blank" which has been going on through the past 3 months and she
thinks is caused by her increased stress. She has no auditory
or visual hallucinations and only minor tension headaches for
the past 3-4 months. Her thinking has not improved on
prednisone.
On arrival to [**Hospital1 18**], she is requesting to take a shower and has
[**8-18**] pain. She states that her pain was initially
well-controlled with MSIR 15mg PO before transfer.
Review of Systems:
(+) Per HPI, chronic, mild, diffuse, abdominal pain and diarrhea
after ABX which has now stopped
(-) Denies chills, night sweats, recent weight gain. Denies
blurry vision, diplopia, loss of vision, photophobia. Denies
sinus tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations, lower extremity edema, PND. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
constipation, melena, hematemesis, hematochezia. Denies dysuria,
stool or urine incontinence. Denies arthralgias or myalgias.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. No SI, overwhelming anxiety, or anhedonia. All
other systems negative.
Past Medical History:
SLE diagnosed in [**2078**]
Ex-Lap in [**2091**] for menorrhagia
Skin grafts to LE in [**2098**] secondary to medication reaction
Total teeth extraction
Social History:
Lives with her husband in [**Name (NI) **], [**2-9**] EtOH/day, smokes 1 pack
per day x 10 years, no illegal drugs.
Family History:
No connective tissue diseases known; sister had Leukemia, father
had Lymphoma
Physical Exam:
Admission Exam:
VS: 97.4 bp 120/65 HR 51 RR 17 SaO2 100RA
GEN: frail, cachectic, slightly fatigued, awake, alert, head
bobbing while talking which she states has been going on for [**4-12**]
years for unknown reasons
HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and
without lesion; bruise on bridge of nose
NECK: Supple, no JVD
CV: Reg rate and rhythm, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone and bulk
SPINE: point tenderness near L5
EXT: No c/c/e, 2+ DP/PT bilaterally
SKIN: No rash, warm skin
NEURO: oriented x 3, CN II-XII intact, 5/5 strength throughout,
intact sensation to light touch
PSYCH: tangential thought process at times, normal thought
content, appropriate, slightly flat affect
On discharge she was afebrile, blood pressure stable at
90s-100s/40s-50s. No neurologic deficits.
Pertinent Results:
Admission Labs:
[**2105-5-2**] 10:45PM GLUCOSE-105* UREA N-19 CREAT-0.6 SODIUM-133
POTASSIUM-4.5 CHLORIDE-92* TOTAL CO2-29 ANION GAP-17
[**2105-5-2**] 10:45PM ALT(SGPT)-18 AST(SGOT)-24 LD(LDH)-152 ALK
PHOS-64 TOT BILI-0.3
[**2105-5-2**] 10:45PM ALBUMIN-3.6 CALCIUM-9.5 PHOSPHATE-3.9
MAGNESIUM-1.6
[**2105-5-2**] 10:45PM CRP-195.2*
[**2105-5-2**] 10:45PM WBC-11.8* RBC-3.79* HGB-11.8* HCT-34.6*
MCV-91 MCH-31.2 MCHC-34.2 RDW-12.3
[**2105-5-2**] 10:45PM NEUTS-89.9* LYMPHS-6.1* MONOS-3.1 EOS-0.8
BASOS-0.1
[**2105-5-2**] 10:45PM PLT COUNT-403
[**2105-5-2**] 10:45PM PT-11.1 PTT-29.9 INR(PT)-1.0
[**2105-5-2**] 10:45PM SED RATE-105*
[**2105-5-2**] 10:45PM BLOOD CRP-195.2*
[**2105-5-3**] 04:03AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80
[**2105-5-3**] 02:05PM BLOOD dsDNA-POSITIVE *
Cardiac Enzymes
[**2105-5-11**] 08:32PM BLOOD CK-MB-10 MB Indx-13.2* cTropnT-0.25*
[**2105-5-12**] 02:14AM BLOOD CK-MB-14* MB Indx-8.0* cTropnT-0.41*
[**2105-5-12**] 12:02PM BLOOD CK-MB-12* MB Indx-7.4* cTropnT-0.20*
[**2105-5-12**] 07:28PM BLOOD CK-MB-7 cTropnT-0.14*
[**2105-5-13**] 03:34AM BLOOD CK-MB-5 cTropnT-0.09*
CSF
[**2105-5-13**] 08:14AM CEREBROSPINAL FLUID (CSF) WBC-110 RBC-20*
Polys-74 Lymphs-15 Monos-11
[**2105-5-13**] 08:14AM CEREBROSPINAL FLUID (CSF) WBC-105 RBC-35*
Polys-84 Lymphs-13 Monos-3
[**2105-5-13**] 08:14AM CEREBROSPINAL FLUID (CSF) TotProt-252*
Glucose-71 LD(LDH)-91
Anemia Studies:
[**2105-5-26**] 05:57AM BLOOD calTIBC-222* VitB12-288 Folate-6.7
Hapto-173 Ferritn-373* TRF-171*
Hypercoagulability Studies:
[**2105-5-13**] 10:00PM BLOOD Thrombn-43.8*
[**2105-5-10**] 05:25AM BLOOD QG6PD-9.6
[**2105-5-15**] 05:12AM BLOOD b2micro-1.5
[**2105-5-15**] 05:12AM BLOOD ACA IgG-1.6 ACA IgM-4.8
Rheum Studies:
[**2105-5-2**] 10:45PM BLOOD ESR-105*
[**2105-5-3**] 02:05PM BLOOD dsDNA-POSITIVE *
[**2105-5-3**] 04:03AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80
[**2105-5-2**] 10:45PM BLOOD CRP-195.2*
[**2105-5-3**] 05:30AM BLOOD C3-123 C4-20
[**Last Name (un) **] Stim Testing:
[**2105-5-28**] 06:20AM BLOOD Cortsol-7.9
[**2105-5-28**] 06:36AM BLOOD Cortsol-15.0
[**2105-5-28**] 08:39AM BLOOD Cortsol-18.2
MICROBIOLOGY:
**LUMBAR EPIDURAL ABSCESS SWAB FINAL REPORT [**2105-5-27**]**
GRAM STAIN (Final [**2105-5-4**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2105-5-11**]):
NOCARDIA FARCINICA. SPARSE GROWTH.
IDENTIFIED BY [**Hospital1 4534**] LABORATORIES [**2105-5-19**].
ACID FAST SMEAR (Final [**2105-5-5**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Final [**2105-5-21**]):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
NOCARDIA FARCINICA. IDENTIFIED IN ACID FAST CULTURE.
POTASSIUM HYDROXIDE PREPARATION (Final [**2105-5-4**]):
Test cancelled by laboratory.
PATIENT CREDITED.
Inappropriate specimen collection (swab) for Fungal Smear
(KOH).
ACID FAST CULTURE (Final [**2105-5-27**]):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
.
NO MYCOBACTERIA ISOLATED.
DUE TO OVERGROWTH OF NOCARDIA FARCINICA UNABLE TO CONTINUE
MONITORING
FOR AFB FOR 8 WEEKS.
NOCARDIA FARCINICA. IDENTIFIED BY [**Hospital1 4534**] LABORATORIES
[**2105-5-19**].
Sensitivities performed by [**Hospital1 **] laboratories ([**2105-5-25**]).
FINAL SENSITIVITIES. SENSITIVE TO AMOX/CLAV (MIC: [**9-12**]
MCG/ML).
RESISTANT TO CEFEPIME (MIC: >32 MCG/ML).
RESISTANT TO CEFTRIAXONE (MIC: >64 MCG/ML).
SENSITIVE TO IMIPENEM (MIC: 4 MCG/ML).
SENSITIVE TO CIPROFLOXACIN (MIC: 1 MCG/ML).
[**Month/Day (4) 110509**] MIC: <= 0.25 MCG/ML: NO INTERPRETATION
AVAILABLE.
RESISTANT TO CLARITHROMYCIN (MIC: > 16 MCG/ML).
SENSITIVE TO AMIKACIN (MIC: <= 1 MCG/ML).
RESISTANT TO TOBRAMYCIN (MIC: > 16 MCG/ML).
Intermediate TO: DOXYCYCLINE (MIC: 4 MCG/ML).
Intermediate TO: MINOCYCLINE (MIC: 4 MCG/ML).
SENSITIVE TO TMP/SMX (MIC: <= 0.25/4.75 MCG/ML).
SENSITIVE TO LINEZOLID (MIC: 2 MCG/ML).
ANAEROBIC CULTURE (Final [**2105-5-11**]): NO ANAEROBES ISOLATED.
[**2105-5-13**] 8:14 am CSF;SPINAL FLUID SOURCE: LP,TUBE#3.
**FINAL REPORT [**2105-5-13**]**
CRYPTOCOCCAL ANTIGEN (Final [**2105-5-13**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
Results should be evaluated in light of culture results
and clinical
presentation.
[**2105-5-13**] 8:14 am CSF;SPINAL FLUID SOURCE: LP,TUBE#3.
GRAM STAIN (Final [**2105-5-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2105-5-16**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take 3-8 weeks to grow..
NO MYCOBACTERIA ISOLATED.
GRAM POSITIVE RODS. BRANCHING RODS.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
[**2105-5-13**] 9:00 am ABSCESS Source: epidural.
GRAM STAIN (Final [**2105-5-13**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2105-5-16**]):
NOCARDIA SPECIES. SPARSE GROWTH. NOCARDIA FARCINICA.
IDENTIFICATION PERFORMED ON CULTURE # 343-5173G
([**2105-5-4**]).
ANAEROBIC CULTURE (Final [**2105-5-17**]): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Final [**2105-5-29**]):
NOCARDIA FARCINICA.
IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 110510**] [**2105-5-4**].
ACID FAST SMEAR (Final [**2105-5-14**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
NO MYCOBACTERIA ISOLATED.
NOCARDIA FARCINICA.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
343-5173G,
[**2105-5-4**].
[**2105-5-21**] 3:45 pm ABSCESS Source: Epidural abscess.
**FINAL REPORT [**2105-5-27**]**
GRAM STAIN (Final [**2105-5-21**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2105-5-24**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2105-5-27**]): NO GROWTH.
MRI L SPINE [**5-3**]
IMPRESSION:
1. Large extensive spinal abscess involving the inferior aspect
to the
thoracic spine and lumbar spine ,involving the epidural and
intradural spaces with anterior displacement of the terminal
spinal cord and nerve roots.The findings in the intradural space
may represent arachnoiditis with loculated collections. There is
associated arachnoiditis and extension of the abscess into the
right psoas muscle. Findings are significantly worse since the
prior exam.
2. Complex fluid collection with rim enhancement involving the
left posterior paraspinal soft tissues, suspicious for an
abscess. There is extensive edema and soft tissue inflammation
in the posterior paraspinal soft tissues, worse on the left.
MRI SPINE [**5-8**]
IMPRESSION:
1. There is no evidence of focal or diffuse lesions throughout
the cervical or thoracic spinal cord to indicate a spinal cord
edema or cord expansion, there is no evidence of spinal cord
compression.
2. Minimal degenerative changes identified at C7/T1, consistent
with
posterior disc bulge, causing mild right side neural foraminal
narrowing.
Apparently, there is no evidence of abnormal enhancement
throughout the
cervical and thoracic spine, however, the examination is limited
due to
patient motion.
3. The patient is status post abscess removal and drainage in
the lumbar
region with laminectomies from L2 through L5/S1 levels as
described above,
fluid collection is noted posteriorly in the surgical bed,
possibly consistent with a post-surgical fluid/phlegmon,
formally a CSF leak cannot be completely excluded, persistent
focus with fluid and air noted in the right psoas, with a far
lateral surgical change and pattern of enhancement surrounding
the thecal sac, possibly consistent with residual abscess
formation, close followup is advised, the previously noted
abscess in the left paraspinal musculature has been reduced in
size.
HEAD CT [**2105-5-12**]
IMPRESSION: Large bilateral thalamic hypodensities, bilateral
occipital pole hypodensities, and possible left frontal
hypodensity. The differential diagnosis includes venous
ischemia, perhaps due to deep cerebral vein or dural sinus
thrombosis; vasculitis caused by meningitis; basilar tip
thrombosis, or PRES. MRI may help clarify the nature of the
abnormalities and determine patency of the veins and sinuses.
.
Brain MRI/MRA/MRV [**2105-5-12**]
IMPRESSION:
1. Extensive increased T2 FLAIR signal involving bilateral
thalami as well as the parieto-occipital white matter with areas
of slow diffusion in the
bilateral thalami and just posterior to the left occipital [**Doctor Last Name 534**]
representing ischemia/infarct. Differential diagnosis includes
PRESS versus less likely venous ischemia. MRV sequences
demonstrate a questionable filling defect in the posterior
aspect of the superior sagittal sinus, but with likely artifact
since the post-contrast MPRAGE demonstrates normal venous
enhancement in this region.
2. Global dural enhancement also present in the prior exam,
which may be
related to recent lumbar puncture versus inflammatory/infectious
meningitis.
BRAIN MRI [**2105-5-21**]:
1. Decrease in the previously noted FLAIR hyperintense areas in
the
periventricular white matter, with near-complete resolution of
the FLAIR
hyperintense areas involving the thalami and adjacent
parenchyma. Correlate
clinically and f/u as clinically indicated- etiology uncertain
and includes
PRES/Seizure related changes/ other etiology.
2. Interval development of increased signal in the transverse
and sigmoid
sinuses on some of the sequences, question slow
flow/artifact/related to
venous sinus thrombosis. Consider MR venogram for better
assessment, as the
present study is limited due to motion artifacts.
3. Interval development of small bilateral subdural fluid
collections, ?
related to intracranial hypotension given the h/o recent
cisternal puncture. Correlate clinically and consider followup.
BRAIN MRV [**2105-5-21**]: No evidence of dural venous sinus thrombosis.
MR [**Name13 (STitle) 6452**] [**2105-5-19**]:
1. Redemonstration of a large fluid collection in the posterior
spinous soft tissues, which is irregular in shape, in close
proximity to the thecal sac margins at some levels. This is
mildly decreased in some areas; however, no significant change
is noted. Assessment is somewhat limited due to motion-related
artifacts. The possibilities include simple fluid
collection/abscess/pseudomeningocele. Correlate clinically to
decide on the
need for further workup. There is also reactive edema to changes
noted in the posterior spinous soft tissues in the lower
thoracic and in the lumbar and in the sacral regions.
2. Decrease in the areas of fluid collection/abscess in the
right psoas
muscle.
3. Unchanged appearance of the thickened cauda equina nerves
related to
arachnoiditis.
4. Renal lesions- likely cysts- correlate with prior studies/US
TTE [**2105-5-29**]:
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Increased
PCPW.
Compared with the prior study (images reviewed) of [**2105-5-11**], the
findings are similar.
CLINICAL IMPLICATIONS:
Based on [**2100**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
Primary Reason for Hospitalization:
57yoF with a h/o SLE on prednisone transferred from OSH with
fever and lumbar epidural abscess
Active Issues:
# Lumbar epidural abcess: Pt was transferred from OSH due to
concern for lumbar epidural abscess given her fevers and
worsening epidural fluid collection on MRI with extension to the
psoas and paraspinal soft tissue. On [**5-4**] she underwent L3-S1
laminectomy, incision and drainage and was transferred to the
ortho spine service. The infectious disease service was
consulted and she was initially treated with IV vancomycin and
cefepime. Intraoperative cultures subsequently grew beaded gram
positive rods and partial acid-fast bacilli concerning for
either non-tuberculin mycobacteria vs nocardia, and her
antibiotics were changed to imipinem, linezolid, and amikacin.
On [**5-11**] her course was complicated by intractable nausea/vomiting
and mental status changed, then had 3 generalized tonic-clonic
seizures. She was given IV ativan and keppra load and was
transferred to the medical ICU. Her seizures were felt most
likely [**3-12**] imipinem but also raised concern for possible CNS
involvement of her infection. Imipenem was discontinued and her
seizures resolved, however she continued to have altered mental
status. She was electively intubated to obtain an MRI/MRA/MRV
which showed thalamic and white matter changes of unclear
etiology as well as dural enhancement, felt most c/w PRESS. CSF
sample was obtained from a sub-cisternal puncture and initially
showed no organisms, WBC 110, Prot 252, Gluc 71. She was
empirically started on IV acyclovir, which was then discontinued
once CSF HSV PCR returned negative. Repeat cultures of the
epidural abscess were obtained by fluoroscopic drainage on [**5-13**],
gram stain showed gram positive rods. Cultures were sent to [**Hospital1 **] for speciation and ultimately the organism was identified
as Nocardia farcinica. Sensitivity data showed susceptibility
to Bactrim and fluoroquinolones. Given her sulfa allergy, she
required monitored Bactrim desensitization in the ICU, which she
tolerated well. She was transitioned to IV Bactrim and PO
[**Hospital1 **], and will likely require several months of
antibiotic therapy. There was discussion of repeating surgical
washout of the abscess, however given her clinical improvement
the risk of the surgery was felt to outweigh the benefit. She
is scheduled to follow up in the infectious disease [**Hospital 4898**] clinic
and orthopedic clinic. She should have labs monitored closely
while on antibiotics, including CBC, electrolytes, and LFTs with
results faxed to the Infectious Disease RNs.
MRI prior to d/c showed a worsening psoas abscess. After
discussion with ortho spine and Infectious disease, it was felt
surgery would not be an effective treatment for this patient and
may make the infection worse. She will be treated with IV
antibiotics for now with close ortho-spine and ID follow up.
# Seizures: As noted above, [**Hospital **] hospital course was complicated
by seizure activity requiring ICU transfer. This was felt most
likely [**3-12**] imipenem. Her seizure activity resolved after
starting Keppra and stopping imipenem. Per [**State 350**] state
law, she is prohibited from driving for the next 6 months. She
is scheduled to follow up in neurology clinic.
# EKG changes with elevated troponin: In the context of the
patient's seizures, she had elevated cardiac enzymes with
Troponin-T peaking at 0.41. She was also noted to have EKG
changes with depressions in the lateral and inferior leads and a
<1mm elevation in V3-V4. These findings were felt most likely
[**3-12**] seizure activity. Her cardiac enzymes were trended and
returned to [**Location 213**]. Later in her hospital course she had an
episode of orthostatic hypotension, complained of "indigestion"
(had just eaten) and was noted to have ST elevations (appearing
like Jpoint elevations) on telemetry and on V3-V5 on 12 lead
EKG. She was otherwise hemodynamically stable. Her symptoms
improved with Maalox and the ST changes resolved. Repeat EKG
later in her hospitalization showed Q waves in lead II, which
were not seen previously. Cardiac enzymes were again cycled and
were normal. She had a TTE which showed preserved systolic
function and no focal wall motion abnormality. She never
endorsed chest pain or pressure during her hospitalization,
although at times c/o "indigestion" associated with meals. On
discharge, she was started on ASA 81mg daily. She was not
started on a statin given her expected long course of antibiotic
therapy. Would recommend further cardiac evaluation within the
next month as an outpatient with a stress echo once her
functional status improves.
#HA: Pt c/o frequent headache which is worse with standing after
her subcisternal puncture, felt c/w post-LP headache. Blood
patch was considered but given infectious risk this was
deferred. She was treated with fioricet as needed.
#SLE on chronic steroids: Pt has taken prednisone 10mg daily for
SLE for many years. She received stress dose hydrocortisone
peri-operatively and then was rapidly tapered. She later
received additional stress dose steroids in MICU due to her
seizure activity and acute deterioration, and was again tapered
to prednisone 10mg daily after she clinically improved. She
developed orthostatic hypotension which raised concern for
possible adrenal insufficiency, however [**Last Name (un) 104**] stim test was
reassuring. The endocrinology service was consulted and did not
feel there was indication to increase her steroid regimen. She
was continued on her home prednisone 10mg daily at discharge.
# Pleural effusion: Pt had small left sided pleural effusion
incidentally noted on chest X-ray on [**2105-5-10**]. She denied
dyspnea, hypoxia, or chest pain. Repeat CXR on [**2105-5-20**] showed
stability of the effusion. Given that she was asymptomatic,
thoracentesis was deferred. Would recommend repeat CXR in [**5-15**]
weeks to monitor for change.
Transitional issues:
- She was discharged on IV Bactrim and PO [**Last Name (LF) **], [**First Name3 (LF) **]
likely require several months of antibiotics. She is scheduled
to f/u in [**Hospital **] clinic and ortho clinic.
- She was discharged on PO Keppra for seizure activity during
her hospitalization. Per MA state law she cannot drive for 6
months. She is sched to f/u in neurology clinic.
- Given EKG changes during hospitalization, she was started on
ASA 81mg daily. Statin was deferred due her expected prolonged
course of antibiotics. Would recommend further cardiac eval
with exercise stress testing in the outpatient setting once her
functional status improves.
- She should have repeat CXR to monitor small left pleural
effusion
- F/u R femur sclerotic lesion seen on Xray [**2105-5-3**]
- Full code
Medications on Admission:
Prednisone 10mg PO daily
Naprosen PRN pain
Percocet 1 tab q4 PRN pain
Discharge Medications:
1. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Max dose 3g daily.
3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache: max
acetaminophen 3 gm day .
4. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. [**Month/Day/Year **] 400 mg Tablet Sig: One (1) Tablet PO daily ().
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. sulfamethoxazole-trimethoprim 400-80 mg/5 mL Solution Sig:
Two Hundred (200) mg Intravenous Q8H (every 8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Lumbar epidural abscess
Seizure
Orthostatic hypotension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 18**] because of an infection in your
spine. You had surgery to wash out the infection and were
started on antibiotics. You will need to continue the
antibiotics for several weeks after leaving the hospital. You
should follow up with the infectious disease service and the
orthopedic surgery service for continued monitoring and
treatment of your infection.
While you were here, you had a seizure requiring monitoring in
the intensive care unit. This likely happened because of
antibiotic you were taking for your infection. You are no
longer taking that antibiotic, and you were started on
medication to prevent further seizures. According to
[**State 350**] state law, you cannot drive for 6 months after
your seizure. We have scheduled an appointment for you to
follow up in the neurology clinic.
Please note the following changes to your medications:
-START Bactrim 200mg by IV every 8 hours
-START [**State **] 400mg by mouth daily
-START Fioricet 1 tab every 6 hours as needed for headache
-START aspirin 81mg daily
-START Levetiracetam (Keppra) 1000mg twice daily
-START omeprazole 20mg once daily
You should also continue your prednisone 10mg daily.
Please see below for your currently scheduled follow up
appointments.
It has been a pleasure taking care of you at [**Hospital1 18**] and we wish
you a speedy recovery.
Followup Instructions:
Department: Orthopedics (Spine Center)
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**]
When: Dr. [**Last Name (STitle) 25817**] office is working on a follow up appointment
for 9-15 days after your hospital discharge. If you have not
heard from Dr. [**Last Name (STitle) 25817**] office in 2 business days please call the
office number listed below.
Location: [**Hospital1 18**] ORTHOPEDICS
Address: [**Location (un) **], [**Hospital Ward Name **] 2, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 8603**]
Department: INFECTIOUS DISEASE
When: THURSDAY [**2105-6-11**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) 32437**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: FRIDAY [**2105-6-12**] at 1 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] HAERENTS [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
|
[
"5119"
] |
Admission Date: [**2154-5-14**] Discharge Date: [**2154-5-20**]
Date of Birth: [**2082-8-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Morphine Sulfate
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2154-5-15**] Coronary Artery Bypass Graft x 3 (LIMA to Diag, SVG to
OM, SVG to PDA)
History of Present Illness:
71 y/o female with known coronary artery disease s/p myocardial
infarction in [**2132**] with PCI to RCA in [**2140**]. Since then she has
been doing well, but since [**4-6**] after a viral illness she has
developed chest pain and dyspnea on exertion. Recent stress test
was positive and therefor underwent a cardiac cath. Cath showed
severe three vessel coronary artery disease and she was
transferred from [**Hospital1 **] to [**Hospital1 18**] for surgical intervention.
Past Medical History:
Coronary Artery Disease s/p Myocardial Infarction [**2132**], PCI of
RCA [**2140**], Hypertension, Hypercholesterolemia, Hypothyroidism,
Gastroesophageal Reflux Disease, s/p Hysterectomy, s/p Bladder
suspension, s/p Cholecystectomy, s/p Cochlear implant
Social History:
Quit smoking in [**2132**] after 1ppd x 36yrs. Rare ETOH use.
Family History:
+Multiple brothers with MI in 40-50's.
Physical Exam:
Gen: WDWN elderly female in NAD, lying supione in bed.
Skin: W/D intact
HEENT: EOMI, PERRL, NCAT
Neck: Supple, FROM -JVD, -Carotid bruit
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND, +BS
Ext: Warm, well-perfused, -edema, superficial varicosities
bilat.
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
CHEST (PA & LAT) [**2154-5-20**] 10:14 AM
CHEST (PA & LAT)
Reason: pna / effussions / pmneumo
[**Hospital 93**] MEDICAL CONDITION:
71 year old woman with s/p cabg
REASON FOR THIS EXAMINATION:
pna / effussions / pmneumo
HISTORY: Pneumonia.
PA and lateral radiographs of the chest demonstrate interval
removal of the right internal jugular central venous catheter
seen on [**2154-5-18**]. No pneumothorax. The appearance of the heart
and lungs is unchanged. There are persistent bilateral small
pleural effusions. Trachea is midline. Patient is again noted to
be status post CABG.
[**2154-5-20**] 08:10AM BLOOD WBC-9.7 RBC-3.08* Hgb-9.8* Hct-28.4*
MCV-92 MCH-31.9 MCHC-34.6 RDW-13.2 Plt Ct-177
[**2154-5-15**] 04:48PM BLOOD PT-13.9* PTT-30.9 INR(PT)-1.2*
[**2154-5-20**] 08:10AM BLOOD Glucose-121* UreaN-9 Creat-0.6 Na-144
K-4.4 Cl-107 HCO3-31 AnGap-10
[**2154-5-14**] 12:50PM BLOOD ALT-14 AST-20 LD(LDH)-141 CK(CPK)-44
AlkPhos-76 Amylase-44 TotBili-0.6
Brief Hospital Course:
As mentioned in the HPI, Mrs. [**Known lastname 77891**] was transferred from
[**Hospital1 **] to [**Hospital1 18**] for surgery. Upon admission she underwent
usual pre-operative work-up. On [**5-15**] she was brought to the
operating room where she underwent a coronary artery bypass
graft x 3. Please see operative report for surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours she was weaned
from sedation, awoke neurologically intact and extubated. On
post-op day one she was restarted on pre-op medications along
with beta blockers and diuretics. She was gently diuresed
towards he pre-op weight. Later on this day she was transferred
to the telemetry floor for further care. Her chest tubes were
removed on post-op day two. Epicardial pacing wires were removed
on post-op day three. She continued to recover well while
working with physical therapy for strength and mobility. On
post-op day 5 she was discharged to rehab with the appropriate
medications and follow-up appointments.
Medications on Admission:
Aspirin 81mg qd, Synthroid .112mcg qd, Omeprazole 20mg qam,
Crestor 20mg qd, Folic acid qd, MVI qd, Nadolol 20mg qd
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. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 tablets* Refills:*0*
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
PMH: Myocardial Infarction [**2132**], PCI of RCA [**2140**], Hypertension,
Hypercholesterolemia, Hypothyroidism, Gastroesophageal Reflux
Disease, s/p Hysterectomy, s/p Bladder suspension, s/p
Cholecystectomy, s/p Cochlear implant
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 27117**] in [**3-3**] weeks
Dr. [**Last Name (STitle) **] in [**1-30**] weeks
Completed by:[**2154-5-21**]
|
[
"41401",
"4019",
"2720",
"53081",
"2449",
"412",
"V4582",
"V1582"
] |
Admission Date: [**2160-8-14**] Discharge Date: [**2160-8-18**]
Date of Birth: [**2091-3-18**] Sex: M
Service:
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes mellitus.
ALLERGIES: Shell fish and dye.
MEDICATIONS:
1. Aspirin 325 mg q day.
2. Univasc 7.5 mg q day.
3. Atenolol 50 mg q day.
4. Glyburide 2.5 mg q day.
5. Hydrochlorothiazide 25 mg q day.
6. Lipitor 10 mg q day.
7. Norvasc 5 mg q day.
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old man
with diabetes and known coronary artery disease presents for
routine physical where he had electrocardiogram changes
consistent with prior silent myocardial infarction. The
patient had an echocardiogram which showed inferior posterior
hypokinesis and ejection fraction of 40 to 45% The patient
underwent coronary artery catheterization which showed three
vessel disease with left anterior descending diffusely
disease proximally and anterior, 70 to 80% stenosis. 50%
stenosis in V1, left circumflex has 50% stenosis. After
coronary artery bypass graft the patient was sent to [**Hospital1 1444**] for rehabilitation and
treatment.
HOSPITAL COURSE: The patient was taken to an operating room
on [**2160-8-14**] where coronary artery bypass graft times four was
performed with left internal mammary artery to the left
anterior descending, SVG to OM and intermediate SVG to D1.
The operation went without complications. The patient was
transferred to Post Anesthesia Care Unit in stable condition.
Chest tube was placed intraoperative. On postop day one, the
patient was extubated without complications. He was weaned
off drips and started ambulating with physical therapy.
On postop day two the patient's chest tube and Foley catheter
were removed. The patient remained tachycardiac in high
90's. Treated with increased dose of Lopressor and
Magnesium. Remained stable, ambulated. Postop day three the
patient is stable, occasional tachycardia, his Lopressor was
increased again. On postop day four the patient remained
stable, worked with physical therapy, did well on stairs and
was discharged home in stable condition.
DISCHARGE CONDITION: Good.
DISCHARGE MEDICATIONS:
1. Ranitidine 150 mg p.o. b.i.d.
2. Aspirin entericoated 325 mg p.o. q day.
3. Tylenol 650 mg p.o. q 4 hours p.r.n.
4. Ibuprofen 400 mg q 6 hours p.r.n.
5. Glyburide 25 mg p.o.q day.
6. Torvostatin 10 mg p.o. q day.
7. Lopressor 75 mg p.o. b.i.d.
8. Hydrochlorothiazide 25 mg p.o. q day.
DISCHARGE STATUS: The patient is discharged home. The
patient should follow-up with Dr. [**Last Name (STitle) 1537**] for postoperative
check in four weeks. The patient should visit his primary
care physician in three to four weeks for blood pressure
check and medication adjustment.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post silent myocardial infarction.
3. Status post coronary artery bypass graft times four.
4. Diabetes mellitus.
5. Hypertension.
6. Hypercholesterolemia.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2160-8-18**] 13:40
T: [**2160-8-18**] 15:50
JOB#: [**Job Number 42887**]
|
[
"41401",
"25000",
"4019",
"2720",
"412"
] |
Admission Date: [**2172-7-15**] Discharge Date: [**2172-7-30**]
Date of Birth: [**2111-5-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Colchicine / Bactrim
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
61 y/o F with PMH of NF, COPD on 2L home O2, adrenal
insufficiency [**12-18**] chronic steroid use, presents from [**Hospital 4199**]
hospital with altered mental status, fevers and increased oxygen
requirement.
.
Patient was recently discharged from [**Hospital 4199**] hospital 48hrs ago
to rehab facility. Today at rehab found to be desatting to 85%
on 2L and possibly more confused. Temperature 100.8 in am. She
was sent to [**Last Name (un) 4199**] ED for further evaluation. UA there grossly
positive (althoguh [**Last Name (un) **] ++) and CXR concerning for pneumonia.
She also had Head CT and LP with 0-2 WBC. She was given
vancomycin and ertapenem at 3PM, given 3L NS and transported to
[**Hospital1 18**] for further management.
.
In the ED at [**Hospital1 18**], initial vs were: 99.5 110 113/85 20 96%3L.
Exam notable for Labs notable for WBC of 11.4 (no bands), HCT
32.9 (baseline low thirties), sodium of 146, anion gap of 12,
lactate 1.8, creatinine 1.3 (baseline 0.8-1.0), calcium 10.6,
Alk phos 162 (low 100s previously), AST 42. UA showed >182 WBC
w/ moderate bacteria. Urine and [**Hospital1 **] cultures obtained. CXR
showed left lower lobe consolidation, mild alveolar edema,
possible small left pleural effusion. Patient was given
hydrocortisone 100mg IV given recently completed steroid taper.
Given 1L IVF. Vitals on transfer 99.5 99 113/55 100%3L. 22 and
18G for access.
.
On arrival to the ICU, patient was somnolent but rousable.
Responded to voice, but non-cooperative for examination,
history-taking.
vitals were: 96.6, 114, 152/84, 18, 98% 3L.
.
Review of systems:
Unable to obtain from patient given somnolence. She denied any
pain.
Past Medical History:
1. Coronary artery disease s/p revascularization, with STEMI
[**3-19**], BMS x 2 in [**2165**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2, in [**2165**] and [**2170**] (RCA)
2. Congestive heart failure with LVEF 30%
3. Moderate COPD on home oxygen
4. Pulmonary embolism [**2158**]
5. Neurofibromatosis Type 1
6. Malignant nerve sheath tumor (s/p removal from left anterior
chest wall [**6-18**] and radiation [**2172**])
7. Depression
8. Hypothyroidism
9. Adrenal insuficiency [**12-18**] chronic steroid use for COPD
exacerbation
10. Hypercalcemia
11. Alcoholism per omr (patient denies current ETOH abuse)
12. Schizoaffective disorder
13. Gout
14. C. diff colitis [**1-/2172**], recurred [**3-/2172**]
Social History:
Ms. [**Known lastname 805**] lives with her boyfriend in a trailer in [**Name (NI) 3146**],
MA. Boyfriend has MR secondary to seizures. She is on
disability, used to work as a nursing aide. Is visited 2x/week
by VNA.
Tobacco: Quit smoking in past 2.5 weeks. Smoked for >30 years.
ETOH: Reports <1 drink a week.
Drugs: Denies IVDU.
Family History:
Mother/sister/nephew/son with Neurofibromatosis, Type I.
Father w/COPD.
Sister w/COPD.
Mother w/asthma.
Mother died of MI at age 72.
Father died of MI at age 86.
Physical Exam:
Admission PEx:
Vitals: 96.6, 114, 152/84, 18, 98% 3L
General: Obese, multiple neurofibromatoses all over face, body.
Somnolent but rousable. Unable to cooperate with examination.
HEENT: Small oral orifice. Dry-appearing mouth.
Neck: supple, JVP not elevated, no LAD
Lungs: Bilateral basal crackles. No wheeze appreciated but
patietn unable to take deep breaths.
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 with dark urine in bag.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
==========================================
Discharge PEx:
Pertinent Results:
Labs on Admission:
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] WBC-11.4* RBC-3.61* Hgb-10.7* Hct-32.9*
MCV-91 MCH-29.8 MCHC-32.7 RDW-18.0* Plt Ct-522*#
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] Neuts-70.1* Lymphs-22.9 Monos-5.4 Eos-1.0
Baso-0.6
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] PT-14.5* PTT-23.5 INR(PT)-1.3*
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] Glucose-93 UreaN-23* Creat-1.3* Na-146*
K-4.4 Cl-117* HCO3-17* AnGap-16
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] ALT-14 AST-41* LD(LDH)-421* AlkPhos-162*
TotBili-0.2
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] Lipase-21
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] Albumin-2.3* Calcium-10.6* Phos-4.3
Mg-2.2
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] TSH-12*
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] T4-5.6 T3-93
[**2172-7-16**] 01:36AM [**Month/Day/Year 3143**] Type-[**Last Name (un) **] pO2-52* pCO2-34* pH-7.37
calTCO2-20* Base XS--4
[**2172-7-16**] 10:42AM [**Month/Day/Year 3143**] Type-ART pO2-89 pCO2-24* pH-7.46*
calTCO2-18* Base XS--4
[**2172-7-15**] 09:15PM [**Month/Day/Year 3143**] Glucose-94 Lactate-1.8 Na-146* K-3.6
Cl-120* calHCO3-18*
[**2172-7-16**] 10:42AM [**Month/Day/Year 3143**] freeCa-1.37*
[**2172-7-15**] 09:50PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2172-7-15**] 09:50PM URINE [**Month/Day/Year **]-LG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
[**2172-7-15**] 09:50PM URINE RBC->182* WBC->182* Bacteri-MOD
Yeast-NONE Epi-0
[**2172-7-15**] 09:50PM URINE CastHy-10* CastWBC-10*
[**2172-7-15**] 09:50PM URINE Mucous-MANY
[**2172-7-16**] 03:31AM URINE Eos-POSITIVE
[**2172-7-16**] 03:31AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
[**2172-7-16**] 03:31AM URINE U-PEP-PND Osmolal-476
[**2172-7-16**] 03:31AM URINE Hours-RANDOM UreaN-371 Creat-45 Na-106
K-66 Cl-141 TotProt-33 HCO3-LESS THAN Prot/Cr-0.7*
Brief Hospital Course:
61 y/o F with PMH of neurofibromatosis, COPD on 2L home O2,
adrenal insufficiency [**12-18**] chronic steroid use, presented from
[**Hospital 4199**] hospital with altered mental status, fevers and
increased oxygen requirement.
.
Urinary Tract Infection: Patient completed a course of meropenem
(10 days ending [**7-25**]) for a citrobacter & ECOLI UTI. Her foley
catheter was removed.
.
Pneumonia: CXR findings suggestive of left lower lobe
consolidation with mild alveolar edema and small left pleural
effusion; however these findings appear only marginally changed
from prior. Received IV vancomycin, levaquin, and meropenem
empirically (patient is allergic to penecillins). IV vancomycin
and levaquin were discontinued ([**7-19**]) when CXR findings resolved
with diuresis.
.
Metabolic encephalopathy: Likely related to infection, uremia,
hypercalcemia. OSH CT head was negative. LP showed 2 WBCs only,
so not likely CNS source. Tox screen was negative. Electrolyte
abnormalities were corrected. infection was treated with
antibiotics. Her mental status improved during the course of the
admission. On discharge the pt was alert, oriented to name and
date.
.
Acute Kidney Injury: Likely related to sepsis and decompensated
heart failure. Her renal function improved with IVF initially
when septic and later diuresis.
.
Acute on chronic systolic heart failure: on [**7-17**] she
decompensated with IVF given for [**Last Name (un) **], but responded to lasix.
Most of her cardiac meds had been held in the ICU and were
restarted on [**7-17**]. Since then her heart failure symptoms have
improved. She returned to her baseline home oxygen
requirements. TTE demonstrated a globally depressed LVEF
consistent with cardiomyopathy of sepsis (discussed with
interpreting cardiologist, multivessel CAD also a possibility,
but felt to be less likely given clinical scenario).
.
COPD/adrenal insufficiency: Her last outpatient PFTs on [**2172-5-5**]
indicate moderate to severe COPD. Given COPD, recent steroid
taper, patient received hydrocortisone 100mg IV in the ED. She
was changed to PO prednisone 60 mg on [**7-17**], then slowly weaned to
20mg on [**2172-7-28**] with no decompensation in her respiratory
status. Albuterol and ipratropium nebs were continued. At
baseline she is on home O2 for COPD, 2L via NC. G6PD was checked
and when deficiency was ruled out, she was switched from
atovaquone to dapsone for PCP [**Name Initial (PRE) 1102**].
.
Acute pancreatitis - on [**7-18**] she developed significant tenderness
to palpation in RUQ of the abdomen. Abdominal ultrasound showed:
"Cholelithiasis (a single 2 cm gallstone) without evidence of
acute cholecystitis. CBD was not dilated. Portal vein patent."
It was a technically limited study. LFTs were normal with the
exception of a slightly elevated alk phos, which was unchanged.
However, lipase was elevated to 586 (was 21 three days earlier).
An abdominal CT was ordered (IV contrast could not be given due
to limitations of her PICC line). It showed stranding consistent
with acute pancreatitis. Symptomatically, this improved on [**7-19**],
and on discharge the pt was tolerating a normal diet.
.
Leukocytosis/diarrhea: After most of her abdominal pain had
begun to resolve, she developed a rapid rise in her WBC to 25
accompanied by voluminous diarrhea. As she had been treated for
CDIFF at [**Hospital1 18**] within the last month and at OSH within the last
two weeks, she was empirically started on po vancomycin and IV
flagyl. CDIFF toxin was negative x 2 and PCR finally returned
negative as well. ID was consulted and recommended treating
with PO vanco and IV flagyl for a full 14 day course
([**Date range (1) **]). Furthermore, she should receive po flagyl whenever
receiving broad spectrum abx in the future. That said, they
felt that the resolving pancreatitis was more likely the cause
of her leukocytosis.
Leukocytosis: The pt had persistent leukocytosis (ranging from
WBC of 15-19) during the last week of the hospitalization
without any localizing signs or symptoms. Heme onc reviewed her
smear and it was consistent with the effect of steroids (many
mature polys and lymphs). Her WBC should be checked one and two
weeks after discharge, and if it is peristently high she should
be referred to heme-onc as an outpatient.
Adrenal Insufficiency: On prednisone 60mg for almost 1 month,
tapered to 40 on [**7-21**]->30 on [**7-25**], then to 20 on [**7-28**].
Long-term basal dose is 10mg daily. She will be due to taper
down to 10 on [**8-4**].
.
Hypothyroidism: Continued on Levothyroxine.
IV Access:
Please d/c Left PICC on [**7-8**] after the pt's final dose of
metronidazole.
Medications on Admission:
Rosuvastatin 5mg qd
Furosemide 10mg qd
Prednisone 5mg qd
Spironolactone 25mg
Tiotropium 18 mcg 1capsule inh daily
Aspirin 325mg EC qday
Allopurinol 200mg qd
Clopidogrel 75 mg PO qd
Ferrous sulphate 325mg PO qd
Advair-diskus 250-50 1 puff po bid
Metoprolol 50 [**Hospital1 **]
Albuterol 2.5mg nebuliser qid
Calcium carbonate 500mg po bid
Gabapentin 300 mg po bid
Lantus 20 u subcut at night, regular insulin sliding scale
Levothyroxine 100 mcg qd
Oxycodone 5mg q4h prn
Ranitidine 150 mg po qd
Florastor probiotic supplement
Milk of magnesia PO qd PRN
Bisacodyl 10 mg PR qd
Fleet's enema qd prn
Prune juice po qd prn
Discharge Medications:
1. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Please taper down to 10mg daily on [**8-4**].
4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet PO DAILY (Daily).
7. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
10. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheezing.
13. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO twice a day.
14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
15. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
17. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): STOP ON [**8-8**].
19. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
20. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
21. heparin (porcine) 5,000 unit/mL Cartridge Sig: One (1) inj
Injection three times a day: Please continue until patient is
ambulatory/participating with PT tid.
22. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
23. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for groin rash.
24. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2251**] Nursing rehab center
Discharge Diagnosis:
Toxic-metabolic encephalopathy
Urinary tract infection
Acute pancreatitis
Acute of chronic systolic heart failure
Hypercalcemia, symptomatic
Clostridium difficile colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 805**],
You were admitted to [**Hospital1 18**] for the treatment of multiple
infections. While you were here, you were also treated for heart
failure and acute pancreatitis.
Several changes have been made to your medications and a full
list of what you should be taking will be provided to the
rehabilitation facility to which we are transferring you.
Here are the changes that were made:
prednisone was increased
vancomycin po and metronidazole IV were started and will
continue until [**8-8**]
A PICC line was placed and should be removed on [**8-8**] after your
final dose of metronidazole.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2172-8-21**] at 3:50 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2172-10-21**] at 9:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"0389",
"5070",
"5990",
"5849",
"2760",
"496",
"99592",
"4280",
"311",
"2449",
"32723",
"42789",
"41401",
"V4582"
] |
Admission Date: [**2201-2-24**] Discharge Date: [**2201-3-2**]
Date of Birth: [**2118-2-5**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Consult for: hydrocephalus
Major Surgical or Invasive Procedure:
LUMBAR PUNCTURE
History of Present Illness:
83yo M who was recently admitted to the neurosurgery service
from [**2203-2-12**] after a traumatic L SDH/SAH, with no surgical
intervention pursued, who was discharged to [**Hospital1 **]. He was
slowly recovering, speaking in short sentences that were
appropriate, until two days ago. His wife reports that since
this
time, he has been "mute" with only the occasional "okay" spoken
and he has been much sleepier, difficult to arouse. Prior to
this, he had not complained of headache, diplopia or N/V.
Otherwise, his course has been complicated lately by gout flare,
for which he has been taking indomethacin. His dilantin has been
slowly tapered, due to decrease today to 25mg TID; there has
been
no suspicion of seizure activity.
He was sent in for head CT today, which revealed stable L SDH
but
moderately increased ventricular size, consistent with
hydrocephalus.
Past Medical History:
HTN
Social History:
lives w/ wife
Family History:
nc
Physical Exam:
VS 97.3 108/58 68 16 98%
Gen NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted
NEURO
MS Opens eyes to sternal rub only. Falls back asleep after 1
second. Non-verbal. Does not follow commands.
CN
CN I: not tested
CN II: BTT bilaterally. Pupils 3->2 b/l. Fundi obscurred by
cataracts
CN III, IV, VI: he does not bury the sclera to horizontal doll's
eye maneuver; there is no upgaze to doll's and no Bell's
phenomenon with attempted blink with his eyes held open
CN V: b/l corneals intact
CN VII: full facial symmetry
CN VIII: hearing intact to FR b/l
CN IX, X: palate rises symmetrically
CN [**Doctor First Name 81**]: shrug [**4-14**] and symmetric
CN XII: tongue midline and agile
Motor
Normal bulk and tone. No pronator drift
Holds both arms antigravity x 10 seconds and localizes to pain;
legs held x 5 sec b/l
Sensory grimaces to noxious throughout
Reflexes
Br [**Hospital1 **] Tri Pat Ach Toes
L 2 2 2 2 2 down
R 2 2 2 2 2 down
Coordination unable to assess
Gait deferred
ON DISCHARGE:
pt awake alert , feeding self with minimal assist, oriented to
self and place, speach clear without facial assymetry, tongue
ML, no drift, motor on UE full, gait not tested by this examiner
this am.
Pertinent Results:
[**2201-2-27**] 06:40AM BLOOD WBC-6.5 RBC-3.67* Hgb-10.5* Hct-31.2*
MCV-85 MCH-28.6 MCHC-33.7 RDW-13.2 Plt Ct-399
[**2201-2-27**] 06:40AM BLOOD PT-14.7* PTT-25.4 INR(PT)-1.3*
[**2201-2-27**] 06:40AM BLOOD Glucose-103 UreaN-20 Creat-1.0 Na-139
K-4.4 Cl-105 HCO3-28 AnGap-10
[**2201-2-27**] 06:40AM BLOOD Calcium-9.7 Phos-3.3 Mg-2.0
[**2201-2-26**] 01:00PM URINE RBC-[**10-30**]* WBC-21-50* Bacteri-MANY
Yeast-NONE Epi-0 TransE-0-2
[**Known lastname **],[**Known firstname **] [**Medical Record Number 80783**] M 83 [**2118-2-5**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2201-2-26**]
4:45 PM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG TSICU [**2201-2-26**] 4:45 PM
MR HEAD W/O CONTRAST; -52 REDUCED SERVICES Clip # [**Clip Number (Radiology) 80794**]
Reason: assess transependymal flow, r/o hydrocephalus
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with hydrocephalus
REASON FOR THIS EXAMINATION:
assess transependymal flow, r/o hydrocephalus
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: AFSN FRI [**2201-2-27**] 12:46 PM
11 mm left parietooccipital subdural which appears subacute by
appearances. A
tiny 2-mm subdural is also seen in the right parietooccipital
region. Left
temporal contusion is identified. There is ventriculomegaly
without
transependymal flow. The ventriculomegaly may be due to atrophy.
The
ventricular dilatation is proportion to the size of the sulci.
Final Report
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with question of hydrocephalus.
TECHNIQUE: T1 sagittal and FLAIR, T2 susceptibility and
diffusion axial
images of the brain were acquired. Correlation was made with the
CT
examination of [**2201-2-24**].
FINDINGS: There is no acute infarct identified. There is a
subacute
appearing subdural hematoma identified in the left parietal
region with a
maximal width of 11 mm. In addition, there is a tiny subdural
seen in the
right parietal region measuring approximately 2 mm. There is an
area of
subarachnoid hemorrhage and hyperintensity possibly due to
contusion seen in
the left anterior temporal region. There is moderate
ventriculomegaly without
evidence of periventricular edema. The temporal horns are
minimally dilated.
No midline shift is identified. No acute infarcts are seen.
There is mild
mucosal thickening in both maxillary sinuses right greater than
left side.
IMPRESSION: Subacute left parietal subdural hematoma measuring
11 mm with a
tiny right parietooccipital subdural hematoma measuring 2 mm in
thickness. No
midline shift seen. Ventriculomegaly is seen which is not out of
proportion
for sulci and could be due to brain atrophy. However clinical
correlation
recommended. Left temporal signal changes could be due to
contusion.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 80783**] M 83 [**2118-2-5**]
Neurophysiology Report EEG Study Date of [**2201-2-25**]
OBJECT: EVALUATE EPILEPSY.
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
FINDINGS:
ABNORMALITY #1: There was attenuation of the amplitude in the
left
central and posterior quadrant.
ABNORMALITY #2: There was diffuse excess theta activity
throughout the
recording.
BACKGROUND: The patient remained drowsy for the majority of the
recording. During the most awake state, the background showed a
9 Hz
posterior predominant rhythm.
HYPERVENTILATION: Could not be performed.
INTERMITTENT PHOTIC STIMULATION: Could not be performed.
SLEEP: The patient was drowsy for the majority of the recording
and
briefly awakened towards the end. He did not achieve stage II
sleep.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 72 bpm.
IMPRESSION: This is an abnormal routine EEG in the waking and
drowsy
states due to the presence of voltage attenuation in the left
central
and posterior quadrants indicative of a structural abnormality
impeding
the signal in these regions. In addition, there was mild diffuse
background slowing, which is indicative of an etiologically
nonspecific
mild encephalopathy. There were no epileptiform features noted.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] T.
(09-0747W)
[**Known lastname **],[**Known firstname **] [**Medical Record Number 80783**] M 83 [**2118-2-5**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2201-2-24**] 6:15
PM
[**Last Name (LF) **],[**First Name3 (LF) **] EU [**2201-2-24**] 6:15 PM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 80795**]
Reason: Evaluate for infiltrate/edema
[**Hospital 93**] MEDICAL CONDITION:
83 year old man with altered mental status
REASON FOR THIS EXAMINATION:
Evaluate for infiltrate/edema
Final Report
HISTORY: Altered mental status.
COMPARISON: Chest radiograph, [**2201-2-17**].
UPRIGHT AP VIEW OF THE CHEST: Cardiac and mediastinal contours
are unchanged from the previous exam, with tortuosity of the
aorta again demonstrated. The pulmonary vascularity and hilar
contours are within normal limits. Low lung volumes are present.
The lungs are clear. There is no focal consolidation, pleural
effusion or pneumothorax. Osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary abnormality.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2201-2-24**] 9:10 PM
Imaging Lab
[**Known lastname **],[**Known firstname **] [**Medical Record Number 80783**] M 83 [**2118-2-5**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2201-2-24**]
4:36 PM
[**Last Name (LF) **],[**First Name3 (LF) 61546**] OPT [**2201-2-24**] 4:36 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 80796**]
Reason: *pls send cd w/ old and new head ct images back to
[**Hospital1 **]
[**Hospital 93**] MEDICAL CONDITION:
subdural hematoma
REASON FOR THIS EXAMINATION:
*pls send cd w/ old and new head ct images back to [**Hospital1 **]*
altered mental status,? expansion of sdh
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: Subdural and subarachnoid hemorrhage.
COMPARISON: [**2201-2-12**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: Previously noted left subdural and subarachnoid blood
products have decreased in density. There is no evidence of new
blood products. The
subdural collection along the left convexity appears minimally
larger
posteriorly. This may represent redistribution of the collection
due to
supine positioning, rather than true enlargement. There is no
shift of
normally midline structures. There is no evidence of new edema
or a new large infarction in the brain. There is moderate
enlargement of the ventricles, slightly increased in extent
since the previous study.
Calcifications are again seen in the internal carotid and
vertebral arteries. The imaged bones appear unremarkable. There
is fluid and aerosolized secretions in the right maxillary
sinus. There is mild mucosal thickening in the left maxillary
sinus. There is moderate mucosal thickening in the left ethmoid
air cells. There is mild mucosal thickening in the left frontal
sinus.
IMPRESSION:
1. Expected evolution of intracranial blood products without
evidence of
rebleeding.
2. Slight interval enlargement of the posterior aspect of the
subdural
collection along the left convexity, which may be related to
positional
redistribution of the collection.
3. Moderate diffuse ventriculomegaly, slightly increased in the
interim.
Findings discussed with Dr. [**First Name (STitle) **] at 5:15 p.m. on [**2201-2-24**].
DR. [**First Name11 (Name Pattern1) 95**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 96**]
Approved: TUE [**2201-2-24**] 9:09 PM
Imaging Lab
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
[**2201-2-26**] 01:00PM LG NEG 30 NEG TR SM 8* 5.0 MOD
Source: Catheter
[**2201-2-24**] 06:45PM LG NEG NEG NEG NEG NEG 1 5.0 SM
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2201-2-26**] 01:00PM [**10-30**]* 21-50* MANY NONE 0 0-2
Source: Catheter
[**2201-2-24**] 06:45PM 21-50* [**5-20**]* FEW NONE 0-2
URINE CASTS CastHy
[**2201-2-26**] 01:00PM [**2-12**]*
Source: Catheter
URINE CRYSTALS CaOxalX
[**2201-2-26**] 01:00PM OCC
Brief Hospital Course:
He was admitted to the ICU for further work-up for question of
hydrocephalus. He had large volume tap of 27cc's however without
improvement. He also had an EEG which did not show seizure
activity and MRI showed no transependymal flow. Work-up of
hydrocephalus was negative. He was found to have a UTI and was
started on a 10 day course of Ciprofloxacin. His dilantin was
increased to 100mg TID. His mental status improved he was
evaluated and seen by PT/OT and will be sent to [**Hospital3 **].
His right wrist fracture was reIMAGED ON [**2201-3-2**]. He DOES need
to be seen in the clinic on [**2201-3-3**] for casting.
Medications on Admission:
Indomethacin 25mg TID
Modafenil 300mg qam
lisinopril 5
Omeprazole 20
MVI
Atenolol 50
Colace
Heparin SQ
DPH 25mg TID
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day/Year **]: [**12-12**] PO BID (2 times a
day).
2. Atenolol 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever.
4. Lisinopril 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
6. Ciprofloxacin 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q12H
(every 12 hours) for 10 days.
7. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO twice a
day.
8. Multivitamin Capsule [**Month/Day (2) **]: One (1) Capsule PO once a day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Dilantin Extended 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO
three times a day.
11. ISS
Please follow nusring insulin sliding scale
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Prior L SDH/SAH
ALTERED MENTAL STATUS
URINARY TRACT INFECTION
URINARY RETENTION
VENTRICULOMEGALY
Discharge Condition:
Neurologically IMPROVED
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. THE LEVELS WILL BE FOLLOWED AT YOUR
REHAB FACILITY THEREAFTER, BY YOUR PRIMARY CARE PHYSICIAN.
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:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], 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.
Provider: [**Name10 (NameIs) **] CLINIC Phone:[**Telephone/Fax (1) 3009**] Date/Time:[**2201-3-3**] 9:00
YOUR XRAY FOR THIS APPOINTMENT WAS ALREADY DONE.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2201-3-2**]
|
[
"5990",
"4019"
] |
Admission Date: [**2119-1-16**] Discharge Date: [**2119-1-20**]
Date of Birth: [**2051-9-2**] Sex: M
Service: MEDICINE
Allergies:
Zestril / Lopid / Shellfish / Radioactive Diagnostics, General
Classif
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Substernal chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 20858**] is a 67 yo male with CAD s/p CABG, multiple stents
and PCIs, HTN who presented to [**Hospital6 33**] with SSCP
radiating to both arms during the Superbowl. He was sitting and
watching TV when he developed sharp [**9-22**] SSCP in a bandlike
distribution that spanned both the right and left sides of his
chest. He had similar symptoms 2 weeks ago and was transferred
from [**Hospital1 34**] to [**Hospital1 18**] for cath, but that was not performed for
unclear reasons. His pain initially was non radiating, but then
progressed to involve both his arms. He notes being nauseous and
sweaty and vomited in the [**Hospital1 18**] ED. He notes that he has had
this similar pain for many years and is similar to episodes in
the past when he has had MIs; he reports that this episode may
have been more severe. At home, he took 3 SL NTGs without relief
and called EMS. The EMTs provided additional nitroglycerin with
minimal relief. At [**Hospital1 34**], he was given nitroglycerin, heparin and
plavix loaded and transferred to [**Hospital1 18**]. Apparently, his pain was
relieved only with dilaudid.
.
On admission to [**Hospital1 18**], he was continued on nitro gtt and heparin
gtt, and was chest pain free. He was 99% on a NRB on admission
to the [**Hospital1 18**] ED. He was given 40mg IV lasix x 1 for potential
pulmonary edema.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, or rigors, but
did admit to chills yesterday. He denied heartburn (initially
also took maalox without relief).
.
He also noted SOB that was not changed from his baseline SOB. He
notes that he is SOB with minimal exertion - his ADLs cause him
to be SOB. He can still climb a flight of stairs, but becomes
SOB with this. 1 month ago, he was able to walk [**12-16**] mile per
day, but is no longer able to do so. His LE swelling is
unchanged, and 2 pillow orthopnea is baseline for him. He denied
medication noncompliance or dietary indiscretion. Denied
palpitations.
Past Medical History:
Hypertension
Hyperlipidemia
COPD
.
CAD, s/p CABG X4, MI X2, PCI's above. [**2106-3-13**] with a LIMA to
the LAD, SVG to the D2, OM1, OM2 and RCA
[**12/2104**] IMI
[**2105**]: MI
[**2107**] MI
.
Diabetes.
OSA - on CPAP but does not know home settings
[**2115-4-22**]: ? Seizure per patient's wife. She reports coming home
and finding her husband on the floor awake but incoherent, dried
blood on his body. Neuro workup was negative. No further events
since that time.
.
CABG, in [**2105**]: LIMA to the LAD, SVG to the D2, OM1, OM2 and RCA.
See cath report for recent anatomy.
Social History:
Cigarette smoking, 4 packs a day since age 9, quit 12 years ago.
Family History:
Mother died in her 60's from an MI. One cousin died at age 48
from an MI.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T:98.4 , BP: 150/83 , HR: 81 , RR:20 , O2 98 % on 6L NC
Gen: Pleasant NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP up to ear.
CV: + S1, + S2. RRR No M/R/G
Chest: No crackles. No wheezing. Good air movement through all
lung fields.
Abd: Soft, obese. NTND.
Ext: No c/c. 2+ edema in pretibial regions.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses: 2+ DP and PT pulses
Pertinent Results:
ADMISSION LABS:
[**2119-1-16**] 12:25AM BLOOD WBC-15.3* RBC-4.13* Hgb-11.3*# Hct-34.7*
MCV-84 MCH-27.4 MCHC-32.6 RDW-15.9* Plt Ct-315
[**2119-1-16**] 12:25AM BLOOD Neuts-84.5* Lymphs-10.4* Monos-3.2
Eos-1.5 Baso-0.3
[**2119-1-16**] 12:25AM BLOOD Plt Ct-315
[**2119-1-16**] 12:10PM BLOOD PT-13.6* PTT-34.5 INR(PT)-1.2*
[**2119-1-16**] 12:25AM BLOOD Glucose-378* UreaN-19 Creat-0.9 Na-142
K-4.6 Cl-103 HCO3-27 AnGap-17
[**2119-1-16**] 12:25AM BLOOD ALT-20 AST-34 LD(LDH)-174 CK(CPK)-220*
AlkPhos-119* TotBili-0.4
[**2119-1-16**] 05:21PM BLOOD Calcium-9.4 Phos-4.2 Mg-2.0
[**2119-1-16**] 12:25AM BLOOD Albumin-4.2
[**2119-1-17**] 05:22AM BLOOD calTIBC-497* VitB12-137* Folate-12.6
Ferritn-92 TRF-382*
[**2119-1-17**] 05:22AM BLOOD %HbA1c-8.7*
[**2119-1-17**] 05:22AM BLOOD Triglyc-216* HDL-41 CHOL/HD-2.4
LDLcalc-15 LDLmeas-<50
CARDIAC ENZYMES:
[**2119-1-16**] 12:25AM BLOOD CK-MB-15* MB Indx-6.8* proBNP-568*
[**2119-1-16**] 12:25AM BLOOD cTropnT-0.10*
[**2119-1-16**] 12:10PM BLOOD CK-MB-18* MB Indx-6.6 cTropnT-0.70*
[**2119-1-17**] 05:22AM BLOOD CK-MB-6 cTropnT-0.33*
EKG's demonstrated:
(1) At [**Hospital6 33**]: sinus tach @ 100 with TWI in I,
aVL, V6 (all old).
(2) At [**Hospital1 18**]: EKG showed NSR @ 87 with STD in I, aVL and V6 with
1mm STD in V3-V6.
[**2119-1-16**] TTE:
The left atrium is dilated. There is mild regional left
ventricular systolic dysfunction with [**Month/Day/Year 39407**] of the basal
to mid inferior and inferolateral segments. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve is not well seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Mild regional left ventricular systolic
dysfunction. Moderate to severe mitral regurgitation. Reduced
ejection fraction - intrinsic LV function is likely more
depressed given the severity of regurgitation.
Brief Hospital Course:
Mr. [**Known lastname 20858**] was admitted with chest pain and found to have an
NSTEMI. He has known CAD with graft disease, but had
post-radiation skin changes from prior interventions and,
therefore, was not a candiate for invasive intervention this
hospitalization. He was placed on heparin for 48 hours after
admission as well as a nitroglycerin drip for relief of the
chest pain. Echocardiogram showed a decreased ejection fraction
(40-50%) with 3+ MR [**First Name (Titles) **] [**Last Name (Titles) 39407**] of basal and inferolateral
segments. He was continued on plavix, aspirin, lipitor (dose
increased from 40 mg to 80 mg), ramipril (dose changed from 5 mg
TID to 20 mg QD), metoprolol (dose increased from 50 mg [**Hospital1 **] to
100 mg TID), amlodipine and imdur (once the NG was
discontinued). He was also started on HCTZ. Of note, he had a
transient leukocytosis on admission, thought to be a stress
response to the MI and not infectious in nature; it resolved by
the time of discharge.
His hospital course was complicated by shortness of breath on
exertion and relative hypoxia with ambulatory sats 88-89% on
room air even after aggressive diuresis with IV Lasix. His
oxygen saturation inproved with 2 L NC supplementation, and he
was discharged with home oxygen. He was sent home on lasix 40
mg QD to maintain an even fluid balance. He was also sent home
with pulmonary follow-up for care of his COPD (he is not
currently on any medicines for his lung disease and has not had
PFT's).
Medications on Admission:
Lantus 85 units pm + SSI
ramipril 5mg tid
Plavix 75 mg qd.
Imdur 120 mg am
Norvasc 10 mg am.
Tricor 145 mg am.
Lopressor 50 mg [**Hospital1 **].
Ecotrin 325 mg daily.
Zantac 150 mg am.
Lipitor 40 mg pm.
Discharge Medications:
1. Home Oxygen
Home oxygen @ 2LPM continuous via nasal cannula conserving
device for portability.
2. Insulin
Take Lantus (also called Glarine) 85U every evening. Also take
humalog insulin according to sliding scale.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*2*
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:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Disp:*180 Tablet(s)* Refills:*2*
9. Metformin 850 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed): Take one pill every 5
minutes as needed for chest pain. Seek medical attention if you
require 3 pills or more.
Disp:*20 Tablet, Sublingual(s)* Refills:*2*
11. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
13. Ramipril 10 mg Capsule Sig: Two (2) Capsule PO once a day.
Disp:*60 Capsule(s)* Refills:*2*
14. Imdur 120 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
15. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Non-ST Elevation Mycardial Infarction
Discharge Condition:
Stable-- no chest pain or shortness of breath at rest.
Patient's oxygen saturations in the mid-90's on room air at
rest; decreases as low as 88 - 89% on room air with ambulation.
Discharge Instructions:
You were admitted with chest pain and found to have a heart
attack.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if your weight increases
more than 3 lbs.
Adhere to 2 gm sodium diet (low salt)
Fluid Restriction: 1.5L
Increase your home ramipril from 5mg three times daily to 20mg
once daily. Increase your home metoprolol (also called
lopressor) from 50mg twice daily to 100mg three times daily.
Increase your home lipitor (also called atorvastatin) from 40mg
daily to 80mg daily. New medications started during this
hospitalization and should be continued at home are hydralazine
20mg every 8 hours, hydrochlorothiazide 25mg daily and lasix 40
mg daily. You also may take nitroglycerin dissolving tablets as
needed for chest pain. If you require more than 3 pills for
chest pain you must call an ambulance or come to the hospital.
Followup Instructions:
(1) Cardiology appointment with Dr. [**Last Name (STitle) 39408**] ([**Telephone/Fax (1) **])
[**2119-1-24**] 3:15PM-- please have your blood drawn to check
salt levels and blood cell count at this appointment.
(2) Appointment with Lung Doctor
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2119-1-23**] 4:10
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2119-1-23**] 4:30
|
[
"41071",
"41401",
"4280",
"25000",
"4240",
"4019",
"496",
"2724",
"V4581",
"V4582"
] |
Admission Date: [**2171-8-13**] Discharge Date: [**2171-8-21**]
Date of Birth: Sex: F
Service:
ADMITTING DIAGNOSIS: C. difficile colitis.
HISTORY OF PRESENT ILLNESS: The patient is an 85-year-old
female with a past medical history of "diastolic
dysfunction", left ventricular hypertrophy, hypertension,
hypothyroidism, who presented from [**Location (un) 3844**] with a
temperature of 99, white blood cells of 26 and complaints of
weakness. The patient denied any cough, dysuria, headache,
photophobia, stiff neck, or diarrhea. However, the patient
reported decreased p.o. intake over the four weeks prior to
admission, though she takes 40 of p.o. Lasix q. day. In [**Location (un) 7498**] the patient was recently treated for pneumonia with
levofloxacin x 1 week and a urinary tract infection with
Macrodantin.
She was admitted to [**Hospital1 69**] and
noted right foot pain. Osteomyelitis was not evidence on
x-ray of her foot. The patient was treated for gout with
prednisone, and urinary retention with straight
catheterization.
In the Emergency Department she had blood pressure of 75/38.
The patient received four liters of normal saline and blood
pressure increased to 105-110 systolic. A urine culture was
drawn and she was admitted to the [**Hospital Unit Name 153**].
PAST MEDICAL HISTORY: 1. Pulmonary hypertension. 2.
Diastolic dysfunction. 3. Left ventricular hypertrophy. 4.
Hypertension. 5. Hypothyroidism. 6. Osteoarthritis. 7.
Osteoporosis. 8. Irritable bowel syndrome. 9. Pancreatitis.
10. Status post appendectomy. 11. Status post
cholecystectomy. 12. Peptic ulcer disease. 13.
Diverticulosis. 14. Venous insufficiency. 15. Diabetes.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS: 1. Atenolol 100 q. day. 2. Calcitonin nasal
spray 200 q. day. 3. Ambien 5 q.h.s. 4. Aspirin 81 q. day.
5. Amlodipine 10 q. day. 6. Lisinopril 10 q. day. 7.
Regular Insulin sliding scale. 8. Iron sulfate. 9. Lasix 40
q. day. 10. Synthroid 60 q. day.
PHYSICAL EXAMINATION: On admission heart rate was 62, blood
pressure 108/75, temperature maximum 96.3, 98% on room air.
General: No apparent distress, sitting. HEENT: Extraocular
movements intact. Neck: Jugular venous distension 4 cm,
supple. Cardiovascular: Regular rate and rhythm, S1 and S2,
2/6 systolic ejection murmur at the left lower sternal
border. Chest: Crackles at the bilateral bases, 1/5 up.
Abdomen: Soft, mildly tender, nondistended. Extremities:
No cyanosis, clubbing or edema. Neurologic: Awake, alert,
oriented x 3. Cranial nerves II-XII were intact.
Musculoskeletal: Left heel dressing, painful bilateral knees
and ankles, left knee full and warm, pain with motion.
LABORATORY DATA: CBC showed WBC of 26.3. Chest x-ray showed
no congestive heart failure, no infiltrates. EKG showed
sinus rhythm at 66 with a normal axis, and left ventricular
hypertrophy.
HOSPITAL COURSE: 1. Leukocytosis: The patient was found to
have C. difficile colitis. The patient throughout
hospitalization had decreasing abdominal pain until on
discharge was able to tolerate a p.o. diet and had no
abdominal pain. The patient's white blood cells decreased
throughout the hospitalization. The patient was sent home
with metronidazole 500 mg t.i.d. x 10-14 days. The patient
was also kept on C. difficile precautions throughout the
hospitalization.
2. Urinary retention: The patient has had several trials in
the [**Hospital Unit Name 153**] in which the patient's Foley catheter was
discontinued and the patient was not able to urinate. She
failed several voiding trials. The patient was also not on
any anticholinergics. Urology was consulted and stated to
follow up with Dr. [**Last Name (STitle) 9125**] in one to two weeks for a voiding
trial as an outpatient.
3. Knee pain: The patient was status post two attempted knee
taps, failed by rheumatology. The patient's pain was well
controlled with scheduled Tylenol and Ultram p.r.n. This was
felt to be most likely secondary to osteoarthritis. The
patient had no increasing warmth or swelling during the last
few days of hospitalization.
4. Hypothyroidism: The patient was stable throughout the
hospitalization on her thyroid replacement regimen.
5. Anemia: Her hematocrit was stable throughout the
hospitalization, will need outpatient iron studies.
6. Hypotension: The patient's blood pressures were stable
over the last few days of hospitalization. The patient's
atenolol was increased slowly throughout hospitalization to
25 mg q. day. The patient was on atenolol 100 q. day as an
outpatient. Will need follow up for titrating blood pressure
medications.
7. Coronary artery disease: The patient was started on
Plavix and stopped aspirin secondary to increased troponin
levels and recommendation of staff.
A beta blocker was increased as tolerated. The patient was
also ruled out for an myocardial infarction during this
hospitalization.
DISCHARGE DIAGNOSES:
1. C. difficile colitis.
2. Anemia.
3. Coronary artery disease.
4. Urinary retention.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient may be discharged to
rehabilitation.
DISCHARGE STATUS: The patient remained DNR/DNI throughout
the hospitalization.
DISCHARGE MEDICATIONS:
1. Calcitonin 200 units q. day.
2. Trazodone 25 mg p.o. q.h.s. p.r.n. sleep.
3. Famotidine 20 mg p.o. b.i.d.
4. Thyroid 60 mg p.o. q. day.
5. Vitamin D 400 units p.o. q. day.
6. Calcium carbonate 500 mg t.i.d.
7. Metronidazole 500 mg p.o. t.i.d. x 14 days.
8. Tylenol 500 mg p.o. q. 6 h.
9. Tramadol 50 mg p.o. t.i.d. p.r.n.
10. Docusate 100 mg p.o. b.i.d.
11. Senna one tablet p.o. b.i.d. p.r.n.
12. Plavix 75 mg p.o. q. day.
13. Metoprolol 25 mg p.o. b.i.d.
FOLLOW-UP PLANS:
1. The patient is to follow up with primary care physician in
one to two weeks.
2. The patient is to follow up with urology in one to two
weeks.
Dictated By:[**Last Name (STitle) 27342**]
MEDQUIST36
D: [**2171-8-17**] 09:20
T: [**2171-8-17**] 09:47
JOB#: [**Job Number 27343**]
|
[
"5849",
"4280",
"41401"
] |
Admission Date: [**2103-9-6**] Discharge Date: [**2103-9-12**]
Date of Birth: [**2036-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortmness of Breath
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x3 (Left internal mammary -> left
anterior descending, saphaneous vein graft -> obtuse marginal,
saphaneous vein graft -> posterior descending artery) [**2103-9-6**]
History of Present Illness:
67 y/o male with worsening shortness of breath. Had abnormal ETT
and referred for cath. Cath revealed severe 3 vessel disease.
Then referred for surgical intervention.
Past Medical History:
Carpal tunnel syndrome, Hypertension, Hyperlipidemia, Arthritis,
h/o Bell's Palsy, HOH, s/p Tonsillectomy
Social History:
Denies ETOH, rare Tobacco. Electrician.
Family History:
Father with MI in 50's and underwent CABG.
Physical Exam:
VS: 65 20 160/100 5'7" 180#
General: WD/WN male in NAD
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD, -carotid bruits
Chest: CTAB -w/r/r
Heart: RRR -c/r/m/g
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused -edema, -varicosities
Neuro: A&Ox3, MAE, non-focal
Pertinent Results:
Echo [**9-6**]: PRE-BYPASS: Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
mild inferior wall hypokinesis. There is akinesis/dyskinesis and
thinning of the mid to distal inferior septum and the apex.
Overall left ventricular systolic function is mildly depressed.
Right ventricular chamber size and free wall motion are normal.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. There is no aortic valve stenosis.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen.
POST-BYPASS: LV and RV function is unchanged. Aorta is
unchanged. Other findings are unchanged.
CXR [**9-11**]: Left lower lobe atelectasis has partially cleared.
Upper lungs are clear. Mild postoperative widening of the
cardiomediastinal silhouette is stable. No pneumothorax.
[**2103-9-6**] 11:15AM BLOOD WBC-18.3*# RBC-3.42* Hgb-10.9* Hct-31.6*
MCV-92 MCH-31.7 MCHC-34.4 RDW-13.3 Plt Ct-134*
[**2103-9-12**] 06:25AM BLOOD WBC-13.6* RBC-2.72* Hgb-8.6* Hct-24.6*
MCV-91 MCH-31.7 MCHC-35.0 RDW-14.0 Plt Ct-314
[**2103-9-6**] 11:15AM BLOOD PT-13.3* PTT-30.0 INR(PT)-1.2*
[**2103-9-10**] 06:50AM BLOOD PT-11.9 INR(PT)-1.0
[**2103-9-6**] 12:36PM BLOOD UreaN-17 Creat-0.7 Cl-111* HCO3-23
[**2103-9-12**] 06:25AM BLOOD Glucose-91 UreaN-19 Creat-0.8 Na-134
K-4.0 Cl-98 HCO3-26 AnGap-14
Brief Hospital Course:
Mr. [**Known lastname 68649**] was a same day admit and on [**9-6**] was brought to the
operating room where he underwent a coronary artery bypass graft
x 3. Please see operative report for surgical details. He
tolerated the procedure well and was transferred to the CSRU for
invasive monitoring in stable condition. Later on op day he was
weaned from sedation, awoke neurologically intact, and
extubated. Beta blockers and diuretics were initiated on post-op
day one. He was diuresed towards his pre-op weight. He appeared
to be doing well and was transferred to the SDU on this day. He
did have burst of atrial fibrillation and was started on a
Amiodarone gtt. His beta blockers were also titrated for maximal
BP and HR control. Chest tubes were removed on post-op day two
and epicardial pacing wires on post-op day three. Over the next
several days he continued to improve his ambulation and mobility
with physical therapy. He had no further episodes of AFIB while
on po Amiodarone. On post-op day five he appeared to have left
arm phlebitis and was started on antibiotics. He was discharged
home on post-op day six with antibiotics and appropriate meds.
He will have VNA services and make the appropriate follow-up
appointments.
Medications on Admission:
Aspirin 81mg qd, Toprol XL 50mg qd, MVI, Flexeril 10mg qhs,
Plavix 75mg qd (last on [**8-30**])
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. 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*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): please take 400mg twice a day until [**9-14**] then decrease
to 400mg once a day for 1 week and then decrease to 200mg once a
day .
Disp:*40 Tablet(s)* Refills:*0*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*0*
8. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 6 days: please complete full course.
Disp:*24 Capsule(s)* Refills:*0*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO DAILY (Daily) for 2 weeks.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Graft x3
PMH: Carpal tunnel syndrome, Hypertension, Hyperlipidemia,
Arthritis
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] shower, 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
Left Arm continue with elevation, ice, and complete all
antibiotics
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 17025**] in 1 week ([**Telephone/Fax (1) 3183**]) please call for
appointment
Dr [**First Name8 (NamePattern2) 122**] [**Last Name (NamePattern1) **] in [**1-5**] weeks please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
For surgical incision and left arm
Completed by:[**2103-10-1**]
|
[
"41401",
"5180",
"42731",
"4019",
"2724"
] |
Admission Date: [**2186-7-22**] Discharge Date: [**2186-7-27**]
Date of Birth: [**2138-12-19**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Fall: left sided chest wall pain
Major Surgical or Invasive Procedure:
exploratory laparotomy
splenectomy
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 47 year old female who complains of
SPLENIC LAC. Patient with history of seizure disorder. Had a
seizure 4 days ago and hit her L side on the bathroom
vanity. Had continued L sided chest wall pain. Went to
outside ED where she was diagnosed with a rib fracture. Was
discharged home. At home became lightheaded, diaphoretic and
near syncopal. Returned to outside hospital No HA, visual
changes, neck pain. +CP, SOB. No abdominal pain. + back
pain. No paresthesias, no weakness. Transferred with PRBC
unit #[**Unit Number **] infusing.
Timing: Sudden Onset
Quality: Sharp
Severity: Moderate
Duration: Days
Location: L chest
Past Medical History:
seizure disorder
Social History:
unknown
Family History:
NC
Physical Exam:
PHYSICAL EXAMINATION upon admission: [**2186-7-22**]
Temp: 95.4 HR: 128 BP: 121/56 Resp: 15 O(2)Sat: 97 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: tachycardic, RR
Abdominal: Soft, Nontender, Nondistended
Extr/Back: No cyanosis, clubbing or edema, + pulses
Skin: No rash, Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2186-7-26**] 05:00AM BLOOD WBC-10.2 RBC-3.12* Hgb-9.6* Hct-26.9*
MCV-86 MCH-30.8 MCHC-35.8* RDW-14.9 Plt Ct-373#
[**2186-7-25**] 04:28PM BLOOD Hct-28.0*
[**2186-7-25**] 04:40AM BLOOD WBC-11.2* RBC-2.99* Hgb-9.4* Hct-25.5*
MCV-85 MCH-31.4 MCHC-36.8* RDW-14.4 Plt Ct-227
[**2186-7-25**] 12:03AM BLOOD Hct-24.5*
[**2186-7-23**] 01:48AM BLOOD WBC-23.7*# RBC-3.12*# Hgb-9.6*#
Hct-27.2*# MCV-87 MCH-30.8 MCHC-35.3* RDW-13.8 Plt Ct-151
[**2186-7-22**] 10:40PM BLOOD WBC-14.4* RBC-2.31* Hgb-7.3* Hct-20.5*
MCV-89 MCH-31.7 MCHC-35.8* RDW-13.5 Plt Ct-247
[**2186-7-23**] 01:48AM BLOOD Neuts-89.3* Lymphs-6.9* Monos-3.5 Eos-0.2
Baso-0.1
[**2186-7-22**] 10:40PM BLOOD Neuts-85.7* Lymphs-8.9* Monos-5.0 Eos-0.3
Baso-0.1
[**2186-7-26**] 05:00AM BLOOD Plt Ct-373#
[**2186-7-25**] 04:40AM BLOOD Plt Ct-227
[**2186-7-24**] 05:09PM BLOOD PT-11.7 PTT-23.5 INR(PT)-1.0
[**2186-7-23**] 01:48AM BLOOD PT-13.7* PTT-38.5* INR(PT)-1.2*
[**2186-7-22**] 10:40PM BLOOD PT-13.0 PTT-21.2* INR(PT)-1.1
[**2186-7-26**] 05:00AM BLOOD Glucose-86 UreaN-5* Creat-0.5 Na-136
K-3.8 Cl-106 HCO3-22 AnGap-12
[**2186-7-25**] 04:40AM BLOOD Glucose-90 UreaN-5* Creat-0.5 Na-140
K-3.3 Cl-106 HCO3-25 AnGap-12
[**2186-7-23**] 01:48AM BLOOD Glucose-126* UreaN-18 Creat-1.3* Na-142
K-5.2* Cl-118* HCO3-18* AnGap-11
[**2186-7-22**] 10:40PM BLOOD Glucose-117* UreaN-22* Creat-1.3* Na-139
K-5.5* Cl-111* HCO3-19* AnGap-15
[**2186-7-26**] 05:00AM BLOOD Calcium-7.8* Phos-2.7 Mg-2.0
[**2186-7-25**] 04:40AM BLOOD Calcium-7.5* Phos-2.1* Mg-1.8
[**2186-7-23**] 12:00PM BLOOD Lactate-1.1 K-4.3
[**2186-7-23**] 12:53AM BLOOD Hgb-6.2* calcHCT-19 O2 Sat-97
[**2186-7-24**] 05:19PM BLOOD freeCa-1.11*
[**2186-7-22**]: chest x-ray:
IMPRESSION: Low lung volumes with bibasilar atelectasis. Mild
prominence of the interstitium is likely due to crowding as
pulmonary edema is less likely.
No radiographic evidence of traumatic injury.
[**2186-7-22**]: CTA pelvis:
IMPRESSION:
1. Extensive subcapsular splenic hematoma with hemorrhagic
ascites in the
abdomen and pelvis with pooling of extravasted contrast noted on
delayed phase only. Given the preservation of splenic hilum
vascularization, this likely represents a severe grade 3 splenic
injury.
2. Superior mesenteric artery focal dissection seen in proximity
to the
previously L1 burst fracture. Although true acuity unknown, the
features and proximity to the apparently chronic L1 fracture
suggest a chronic injury.
[**2186-7-23**]: chest x-ray:
FINDINGS: There continue to be low lung volumes, bibasilar
subsegmental
atelectasis. Infiltrates could be present in the lower lobes.
The ET tube
tip is 4.9 cm above the carina. The NG tube tip is off the film,
at least in the stomach.
[**2186-7-23**] 1:48 am MRSA SCREEN Source: Line-a.
**FINAL REPORT [**2186-7-25**]**
MRSA SCREEN (Final [**2186-7-25**]): No MRSA isolated.
Brief Hospital Course:
47 year old female admitted to the acute care service with left
sided chest wall pain after a fall related to a seizure. She was
reported to have a splenic laceration. She was transferred from
an outside hospital with a hematocrit of 20 and with blood
infusing. Upon admission, she was normotensive and underwent
radiographic imaging. She was found to have a Grade III splenic
injury with extensive perisplenic hematoma. Her hematocrit was
monitored. She was also found to have left 6th anterior rib
fracture.
She was taken to the operating room immediately after the CT
scan findings which including blush from continued bleeding, and
she underwent an exploratory laparotomy and open splenectomy.
She had a 3.5 liters of blood loss in her abdominal cavity upon
opening her peritoneum but was hemodynamically stable. She
received additional blood products intra-op to compensate for
this loss together with 1200cc of cell [**Doctor Last Name 10105**] blood. She was
admitted to the intensive care unit after the surgery because of
her fluid shifts. She was extubated on POD #1. She required
additional blood products for a hematocrit 22. Her hematocrit
stablized at 27. Her pain regimen was changed to a PCA.
She was transferrd to the surgical floor on POD # 1. She was
started on clear liquids with advancment to a regular diet. Her
seizure medication was resumed. She did report back pain and
there was concern for a new vs old burst fracture which was
identified on cat scan. Neurology was consulted and determined
that no intervention was warrented. She will follow up with
Ortho-spine, Dr. [**Last Name (STitle) **] in [**11-20**] weeks.
She is preparing for dishcarge home. Her vital signs are stable
and she is afebrile. She is tolerating a regular diet. Her
hematocrit has stablized 27. She did receive her
post-splenectomy vaccines prior to discharge and she has been
instucted to follow-up with her primary care provider [**Last Name (NamePattern4) **] 2 weeks
for repeat of vaccines. She will follow-up with the acute care
service in 1 week for staple removal.
Medications on Admission:
[**Last Name (un) 1724**]: Kepra 1500 QAM, 1000QPM
Discharge Medications:
1
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation: hold for loose stool.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)).
4. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: may cause drowsiness, avoid driving while on
this medication.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
ruptured spleen
Left anterior 6th rib fracture
OLD L1 burst fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after you had a seizure and
fell onto your left side. You were found to have a laceration in
your spleen. You went to the operating room where you had you
spleen removed. Your vital signs are stable and you are now
preparing for discharge home with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* 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.
Activity:
No heavy lifting of items [**9-2**] pounds for 6 weeks. No strenous
exercise.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Because of your rib fracture, it is important to take deep
breaths and cough. Please use your incentive spirometer every 2
hours while awake; if you note the following, please let us
know:
*increased shortness of breath
*congested cough with yellow or green sputum
Followup Instructions:
Please follow up with the acute care service in 1 week so you
can have your staples removed. You can scheudule your
appointment 24 hours after discharge. The telephone number is #
[**Telephone/Fax (1) 600**].
You will also need to follow-up with your primary care provider
[**Last Name (NamePattern4) **] 2 weeks to have repeat immunizations of pneumococcal,
meningococcal, and h. flu vaccine. Please schedule that
appointment.
Please follow-up with Dr. [**Last Name (STitle) 1352**] in [**11-20**] weeks. The telephone
number to schedule your appointment is #[**Telephone/Fax (1) 3736**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2186-8-1**]
|
[
"3051"
] |
Admission Date: [**2115-3-23**] Discharge Date: [**2115-4-1**]
Date of Birth: [**2067-10-16**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
change in mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 47 yo man with Addison's Disease, ESRD on HD, IDDM, CAD,
s/p debridement of LLE foot ulcer on [**2115-3-20**] was noted to have
fluctuating glucose and lethargy on day of admission. He missed
HD secondary to oversleeping. It is unclear who called EMS, but
[**Name (NI) 31567**] was critically high in the field and he was noted to have
increased somnolence. In the ED, patient continued to be
somnolent, able to answer only some questions regarding himself,
but unable to discuss his medical condition. He was found to
have blood glucose >1000 with anion gap 22, K 6.6 and Na 111
(corrected 135). He was started on an insulin gtt and was
intubated secondary to altered mental status/delirium despite
normal ABG. In ED, patient received Vanco and Ceftriaxone.
Past Medical History:
1. Addison??????s Disease, dx [**2099**], on Hydrocortisone and florinef
2. IDDM- dx age 29, brittle diabetic h/o DKA and hyperglycemic
Sz
3. ESRD on HD , awaiting transplant from his sister (but not
with infxn)
4. AOCD, on procrit at dialysis
5. Peripheral Neuropathy
6. Peripheral Edema -chronic LE edema
7. CAD: s/p NSTEMI, echo [**5-20**] nl EF 1+ TR
8. ETT MIBI (-) at RPP of 18,000 in [**4-20**]. s/p right retinal hemorrhage repair
10. Hypothyroidism
11. Hypercholesterolemia
12. htn- poorly controlled
13. medicine non compliance [**12-19**] insurance issues?
14. recent non displaced left distal radial fracture s/p fall on
ice, in cast since [**2115-1-27**]
Social History:
No tob, Etoh, illicits, He is single w/ no kids and lives in
[**Location 3146**]. He was a former clerk/supervisor but is currently on
disability.
Family History:
Family History:
Father died age 50 due to cancer
Mother died age 60 due to breast cancer
4 brothers, 3 sisters: 2 siblings w/ DM
Physical Exam:
Physical Exam on Transfer to Floor [**2115-3-28**]
VS: T98.4 HR67reg BP110/78 RR13 SO298%RA
GEN: NAD
HEENT: eomi, perrla, mmm
NECK: no jvd, bruits, lad
CHEST: CTAB, no r/r/w
CV: rrr, s1/s2 nml, no m/r/g
ABD: +BS, s/nt/nd
EXT: LLE bandages C/D; brawny skin changes bilaterally; 1+ edema
LLE
NEURO: nonfocal
Pertinent Results:
[**2115-3-23**] 12:21PM GLUCOSE-1072* UREA N-55* CREAT-5.8*
SODIUM-111* POTASSIUM-6.6* CHLORIDE-71* TOTAL CO2-18* ANION
GAP-29*
[**2115-3-23**] 12:21PM ALT(SGPT)-11 AST(SGOT)-10 ALK PHOS-314*
AMYLASE-31 TOT BILI-0.4
[**2115-3-23**] 12:21PM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-6.1*
MAGNESIUM-1.8
[**2115-3-23**] 12:21PM WBC-10.4 RBC-4.00* HGB-12.3* HCT-39.9*
MCV-100*# MCH-30.7 MCHC-30.8* RDW-14.5
[**2115-3-23**] 12:21PM PLT COUNT-346
studies:
UNILAT LOWER EXT VEINS LEFT: no DVT
Left wrist: IMPRESSION: 1. Questionable cortical irregularity
along the dorsal surface of distal left radius. No acute
fracture plane visible. Recommend correlation with physical exam
findings of pain localized over the dorsum of the distal radius.
cxr: Congestive failure with possible infiltrate developing at
the left base
Brief Hospital Course:
A/P: 47 yo man with ESRD on HD, IDDM, admitted with delirium in
setting of HONK/DKA and found to have LLL PNA and other
metabolic derrangements.
1) Delirium - patient had inattentiveness and fluctuation in
level of consciousness on examination, likely due to his
metabolic derrangements (hyperglycemia, hyperkalemia, uremia).
He was initially intubated for airway protection. CT head
negative for ICH. He was extubated on [**3-28**]. His mental status
cleared after infection and hyperglycemia were treated.
2) Respiratory Failure - intubated for airway protection in
setting of altered mental status. ABG once intubated was fine.
3) Hyperosmolar non-ketotic hyperglycemia: On admission blood
glucose was 1017 with anion gap of 22. ABG at the time was
7.35/38/87. Given his normal pH, the relatively low gap for the
given glucose (gap likely [**12-19**] uremia), and the severity of the
hyperglycemia, this was thought to be HONK. He was started on an
insulin drig and given aggressive hydration. His glucose
improved and he was restarted on insulin. The [**Last Name (un) **] was
consulted and his insulin was titrated. He will follow up with
the [**Last Name (un) **] as an outpatient.
4) LLL PNA - Found on x ray. Patient received ceftriaxone and
azithromycin initially. He completed a 10 day course of
antibiotics. He did not require oxygen and ws feeling well on
discharge.
5) LLE cellulitis - Patient was noted to have ulceration on left
foot and lower extremity cellulitis. He was started on
vancomycin. Podiatry was consulted. He was advised as to be non
weight bearin on left. His wound was dressed with wet to dry
dressings. He was discharged on vancomycin to be dosed at
hemodialysis for a total of 14 days. He also had a LE ultrasound
that was negative for DVT.
6) ESRD - Patient was dialyzed without complication.
7) s/p L wrist fracture - Patient had swollen wrist. X rays were
performed and showed possible fracture. He will continue to wear
a splint and follow up with orthopedics as an outpatient.
Medications on Admission:
1. Epogen at HD prn
2. Gabapentin 100 mg po tid
3. Sevelamer HCl 1200 mg po tid
4. Atorvastatin 20 mg po qd
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One Cap PO
DAILY
6. Levothyroxine 50 mcq po qd
7. Aspirin 325 mg po qd
8. Amlodipine 10 mg po qd
9. Pantoprazole 40 mg po qd
10. Labetalol HCl 600 mg po q6h
11. Hydrocortisone 20 mg po qam
12. Calcium Carbonate 500 mg po tid
13. Fludrocortisone 0.1 mg po bid
14. Hydrocortisone 5 mg po qpm
15. Lantus 25 U SC qhs
16. HISS
Discharge Medications:
1. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Sevelamer HCl 400 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
5. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Labetalol HCl 200 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
10. Hydrocortisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
11. Hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO QPM (once
a day (in the evening)).
12. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO
three times a day.
13. Fludrocortisone Acetate 0.1 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
14. Insulin Glargine 100 unit/mL Solution Sig: One (1)
injections Subcutaneous twice a day: 24 units qAM, 40 units qhs.
15. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous QHD (each hemodialysis): discontinue on
[**2115-4-5**].
16. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous four times a day: sliding scale per josline.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1468**] VNA
Discharge Diagnosis:
left lower lobe pneumonia
hyperosmolar non ketotic hyperglycemia
Delirium
Respiratory Failure
left lower extremity cellulitis
end stage renal disease on hemodialysis
diabetes mellitus type I
Addison's disease
Discharge Condition:
stable, tolerating po, walking with walker
Discharge Instructions:
- Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
- Adhere to 2 gm sodium diet and diabetic diet
- Check your fingersticks four times daily
- Take all medications as prescribed
- keep wound clean
- It is important to keep all of your follow up appointments
with Dr. [**Last Name (STitle) **], the [**Last Name (un) **], and with Nephrology.
Followup Instructions:
It is important to see Dr. [**Last Name (STitle) **] within one week.
You have hemodialysis tomorrow. Please confirm this with [**Location (un) 4265**].
[**Last Name (un) **]: Dr. [**Last Name (STitle) **] wednesday, [**4-3**] at 1pm
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 2:30
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2115-8-5**] 1:45
|
[
"486",
"40391",
"2767",
"4280",
"V5867"
] |
Admission Date: [**2182-4-12**] Discharge Date: [**2182-5-1**]
Date of Birth: [**2115-5-15**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
1. Increased abdominal pain
2. Fevers
3. Rigors.
Major Surgical or Invasive Procedure:
[**2182-4-12**]: : Uncomplicated exchange of an occluded biliary catheter
for a 8.5 French Cook biliary catheter
[**2182-4-17**]: Cardiac Cath
[**2182-4-22**]: Uncomplicated upsizing of a pre-existing 8.5 French
biliary
catheter for a 10.2 French multipurpose drainage catheter.
[**2182-4-23**]: UGD
[**2182-4-25**]: Colonoscopy
History of Present Illness:
Mr. [**Known lastname 8430**] is a 66 year-old gentleman with duodenal carcinoma
causing biliary obstruction who underwent placement of a
percutaneous biliary drain for decompression on [**2182-3-27**].
Pathology revealed a poorly differentiated carcinoma, consistent
with pancreatic or biliary origin.) He was seen in Dr. [**Name (NI) 60612**]
clinic today for scheduled consulation for possible tumor
resection. He reported a [**5-14**] day history of increasing
abdominal
pain, fevers, and rigors. Due to a concern for developing
cholangitis, he was directly admitted from clinic for
resuscitation and further management.
Upon interviewing Mr. [**Known lastname 8430**] he reports feeling overall unwell.
His abdominal pain, fevers, and chills continue
Past Medical History:
Coronary artery disease and remote history of myocardial
infarction
Hyperlipidemia
Tobacco use
Anxiety
Social History:
Married and lives with wife in [**Name (NI) **]. Retired 18 years ago
from a granite quarry. Smokes 4 packs of cigarettes/week x
40-50
years. No EtOH.
Family History:
Father with duodenal ulcer, died of renal ca metastatic
to lungs. Mother with [**Name (NI) 1932**] disease. Uncles with bleeding
ulcers. One sister with cardiac disease; no other siblings. 2
sons alive and well.
Physical Exam:
On Discharge:
VS: 98.1, 93, 133/76, 18, 100 % RA
GEN: Anxious, pleasant
CV: RRR, no m/r/g
Lungs: CTAB. No wheezes, rales, or rhonchi.
Abd: Soft, LUQ with PTB drain, insertion site with dry dressing
and c/d/i
Extr: WWP, NO C/C/E
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout.
Pertinent Results:
[**4-17**] Cardiac Cath:
1. Selective coronary angiography demonstrated 2 vessel coronary
artery
disease. The LMCA was free of angiogrphically significant
disease. The
LAD was occluded in its mid segment. There were left to right
and right
to right collaterals to the LAD. The LCx gave rise to a large
obtuse
marginal proximally that was free of significant disease. The AV
groove
LCx collateralized the right giving rise to an RPL and R-PDA.
The RCA
was occluded proximally with right to right collaterals.
2. Limited resting hemodynamics revealed normal central aortic
pressure.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Normal central aortic pressures.
[**4-15**] ECHO
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated. There is moderate to severe global
left ventricular hypokinesis with relative preservation of
function of the inferolateral and anterolateral walls (LVEF =
30-35 %). No masses or thrombi are seen in the left ventricle.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
to moderate ([**2-10**]+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is high normal. There is no
pericardial effusion.
IMPRESSION: Mild left ventricular cavity dilation with global
systolic dysfunction. Mild-moderate mitral regurgitation.
Increased PCWP.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2178**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
[**4-12**] Replacement PTBD:
1. Obstruction of the distal portion of the pre-existing 8.5
French Cook
catheter. No flow was seen into the duodenum.
2. Post-procedure cholangiogram demonstrates flow into the
duodenum and
opacification of the intrahepatic ducts.
IMPRESSION: Uncomplicated exchange of an occluded biliary
catheter for a 8.5 French Cook biliary catheter
[**2182-4-22**]: Replacement PTBD:
IMPRESSION: Uncomplicated upsizing of a pre-existing 8.5 French
biliary catheter for a 10.2 French multipurpose drainage
catheter. The catheter was attached to a bag.
[**2182-4-23**] UGD:
Impression: A tiny clot was noted at the pylorus and suctioned.
No other blood or stigmata of recent bleeding noted otherwise in
the stomach.
There was again a compressing mass at the duodenal sweep and the
gastroscope could not be passed through.
No active bleeding noted in the visualized duodenum.
[**2182-4-25**] COLONOSCOPY:
Impression: No blood or bleeding was seen.
A tiny raised area was seen and thought to be a small polyp,
however upon further examination could not be found. This could
represent and fold or a small polyp.
Otherwise normal colonoscopy to cecum.
Brief Hospital Course:
The patient with biliary obstruction secondary to duodenal mass
was admitted to the General Surgical Service on [**2182-4-12**] with
symptoms of cholangitis. The patient currently scheduled for
elective Whipple resection on [**2182-5-16**]. The patient had PTBD
placed on [**2182-3-27**] and drain was found occluded during his
outpatient office follow up with Dr. [**Last Name (STitle) **]. On [**2182-4-12**], the
patient underwent drain replacement. After the procedure,
patient was noted to have hypotension/tachycardia, chest pain,
and elevated cardiac enzymes. The patient was transferred in ICU
and Cardiology was consulted.
CV: Initial EKG demonstrated sinus tachycardia with ST segment
depressions in high lateral leads concerning for possible
myocardial ischemia. Blood test was positive for Troponin leak.
The patient was treated as NSTEMI per Cardiology
recommendations, although this EKG may represent stable
angina/demand ischemia in the setting of SIRS response. The
patient was given ASA, B-blockers, and one unit of pRBC. Patient
was hypodynamically stable. On HD # 2, the patient was
transfused with 2 unit of RBC for Hct = 22.9, Hct improved to
30.4 post transfusion. On HD # 3, patient was transferred on the
floor. On [**2182-4-15**] (HD # 5), the patient underwent
echocardiography, which demonstrated global systolic dysfunction
with LVEF = 30-35%. On HD # 7, the patient underwent cardiac
catheterization, with demonstrated two vessel disease (LAD and
RCA) with good collaterals. Cardiology did not support coronary
artery intervention with stent or CABG prior scheduled surgery.
An echo or stress test can be done prior the Whipple procedure.
Patient will required to have cardiac anesthesist during planned
surgery. After cardiac catheterization, patient was continued on
ASA, Metoprolol and statin, ASA was discontinued on HD # 12
secondary to active rectal bleeding. The patient's cardiac
status was monitored with telemetry, the patient continue to
have asymptomatic runs of SVTs, cardiac enzymes continue to go
downward, repeat EKG was stable.
Cholangitis/ID: On admission the patient was found to have
leukocytosis with WBC max 19.4. Blood cultures were positive for
E-coli and bile culture was positive for multiple organisms.
Infectious Disease was consulted, the patient was started on
Vancomycin, Zosyn and Fluconazole as ID recommendations.
Finally, antibiotics regiment was simplified to Zosyn only, WBC
trended down, repeat blood/urine cultures were negative. Abx was
stopped on [**2182-4-27**]. The patient remained afebrile with WBC wnl.
PTBD drain was exchanged on HD # 1, and drained well with T-bili
down from 3.5 to 1.2 on HD # 7. The patient's PTBD was capped.
On HD # 9, the patient's T-bili went up to 2.8 and was continued
to rise. The patient was taken back to IR on HD # 11 and PTBD
was upsized to 10, T-bili trending down to normal. PTBD was
capped prior discharge, patient tolerated well, he will continue
on Ursodiol PO BID.
Anemia/GI bleeding/Hematology: The patient has HCT 23.7 on
admission, he received one unit of RBC on HD # 1, and two units
on HD # 2. HCT went up to 30 on HD # 4 and was grossly stable.
On HD # 11, the patient's HCT fell to 19.6, he received 2 units
of RBC, post transfusion HCT was 28.5. At the same day, the
patient underwent PTBD exchange. On HD # 12, HCT fell to 23.9,
he had BRBPR x2 and PTBD output was bloody. The patient was
transfused with 5 units total of RBC and underwent EGD, which
was grossly normal down to duodenal mass. The patient also
received Vitamin K for INR 1.6. On HD # 13, the patient
continued to have bloody stools (850 cc total), PTBD drainage
was bilious, the patient received 2 units of RBC for HCT = 26.4.
On POD # 14, the patient had one tarry stool, he underwent
colonoscopy, which was negative for any bleeding, and patient's
HCT was stable > 30. On HD # 15, the patient' HCT remained
stable, no transfusions were required. The patient's GI bleed
was thought to be caused by his duodenal mass secondary to PTBD
manipulation. The patient's HCT was 33.1 prior discharge.
Acute renal failure/GU: On HD # 9, patient's Cr was elevated to
2.3, and FeNa was 3%. The patient was started on IV fluids, all
medications were adjusted to renal doses. The patient's Cr
improved daily and downwarded to normal on HD # 14. The patient
continued to have normal renal output throughout
hospitalization.
GI: On admission the patient was made NPO with IV fluids, diet
was advanced to regular cardiac healthy diet with supplements
QAC. The patient complained about poor appetite and his PO
intake was noticed to be inadequate. He was made NPO for
procedures and secondary to acute GI bleed. On HD # 12, the
patient was started on TPN per Nutritionist recommendation. Diet
was advanced on HD # 15 to clears and on HD # 17 to regular
cardiac healthy diet. The patient reported poor appetite and TPN
was continued. TPN was cycled prior discharge. The patient was
discharged on regular diet with cycled TPN. Patient's intake and
output were closely monitored, and IV fluid was adjusted when
necessary. Electrolytes were routinely followed, and repleted
when necessary.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin in patient's TPN was adjusted accordingly.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; SC Heparin was
discontinued since GI bleeding was noticed. The patient was
encouraged to ambulate, Physical Therapy followed the patient
daily.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a small
amount of regular food and TPN, ambulating with assist, voiding
without assistance, and pain was well controlled. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
Xanax 0.5 qam, Toprol 50', fish oil (he recently stopped aspirin
and simvastatin 80')
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
3. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): SEE SLIDING SCALE.
4. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
8. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) **]
Discharge Diagnosis:
Poorly differentiated duodenal carcinoma
Cholangitis
PTBD Occlusion
Angina/demand ischemia
CHF
Two vessel CAD
Anemia
Rectal bleeding
Acute renal failure (resolved)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory -with assistance.
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 driving or
operating heavy machinery while taking pain medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
PTBD Care:
*[**Last Name (un) **] capped
*Dry dressing apply daily
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the drain
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash with a mild soap and warm water.
Gently pat the area dry.
PICC line care:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2182-5-17**] 9:45
Radiology, [**Hospital Ward Name **] 3 rd floor
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2182-5-17**] 10:45 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]
Completed by:[**2182-5-1**]
|
[
"41401",
"412",
"2724",
"2767",
"3051",
"99592",
"41071",
"5849"
] |
Admission Date: [**2199-4-24**] Discharge Date: [**2199-4-28**]
Date of Birth: [**2132-7-17**] Sex: M
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: The patient is a 66 year-old
male with a prior history of inferior myocardial infarction
who was referred for cardiac catheterization due to recent
fatigue and positive stress test. His cardiac
catheterization revealed three vessel disease and he was
referred to cardiac surgery. The decision to operate was
made. The patient came in for elective coronary artery
bypass graft on [**2199-4-24**].
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post IMI in [**2186**]. 2. Gout. 3. Depression. 4. Peripheral
vascular disease.
PAST SURGICAL HISTORY: 1. Surgery of left great toe.
ALLERGIES: No known drug allergies.
MEDICATIONS PRIOR TO ADMISSION: Aspirin 81 mg q.d., Effexor
150 q.d., Colchicine .6 mg b.i.d., Zestril 2.5 mg q.d.,
Lopressor 25 mg b.i.d., Lipitor 5 mg q.o.d., Allopurinol 100
mg b.i.d.
HOSPITAL COURSE: The patient underwent a coronary artery
bypass graft times three on [**2199-4-24**] with left internal
mammary coronary artery to left anterior descending coronary
artery, saphenous vein graft to obtuse marginal, saphenous
vein graft to posterior descending coronary artery. He
tolerated the procedure well and was transferred to the
Intensive Care Unit in stable condition. He was extubated on
postoperative day zero. He was stable hemodynamically and
was transferred to the floor on postoperative day one. His
subsequent stay on the floor was uncomplicated. His pacing
wires were discontinued on postoperative day three. By this
time he was ambulating well and his pain was under control
with po analgesics. He was ready for discharge home on
postoperative day four.
MEDICATIONS ON DISCHARGE: Lopresor 25 mg b.i.d., Lasix 20 mg
q.d. times one week, K-Ciel 20 milliequivalents q.d. times
one week, Colace 100 mg b.i.d., Zantac 150 mg b.i.d., enteric
coated aspirin 325 mg q.d., Allopurinol 100 mg b.i.d.,
Percocet one to two tablets q 4 to 6 hours prn. Lipitor 5 mg
q.o.d.
FOLLOW UP: Follow up with primary care physician in two
weeks and Dr. [**Last Name (STitle) **] in four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2199-5-9**] 20:52
T: [**2199-5-10**] 10:03
JOB#: [**Job Number 42511**]
|
[
"41401",
"4240",
"2720",
"V1582"
] |
Admission Date: [**2138-3-26**] Discharge Date: [**2110-2-24**]
Date of Birth: [**2076-12-15**] Sex: M
Service: MEDICAL ICU/[**Location (un) **]
Date of discharge to be determined by the next team taking
care of this patient.
CHIEF COMPLAINT: Hypotension, shortness of breath, emesis.
HISTORY OF PRESENT ILLNESS: This is a 61 year old male with
multiple medical problems who is a resident at [**Hospital3 537**],
who reportedly had a witnessed episode of emesis some time
during the night prior to admission. On the morning of
admission, the patient was found by staff to be tachypneic
with a respiratory rate in the 40s and oxygen saturation 78%
on three liters nasal cannula. The patient was brought to
the [**Hospital1 69**] Emergency Department
for further evaluation. Upon arrival, he was found to be
hypoxic with oxygen saturation at 80% on 100% nonrebreather.
The patient was then placed on nasal BiPAP with 10 liters of
oxygen. The patient denied any pain, cough, shortness of
breath, at that time. He was found to be febrile to 102.4
with an elevated white blood cell count, tachypneic and a
lactate of 4.5. The patient was subsequently started on MUST
protocol while in the Emergency Department. A right
subclavian was placed with mixed oxygen saturation of 50 to
61%. The patient was aggressively fluid resuscitated with
three liters of normal saline with CVP in the range of 3.0 to
5.0 and a SVP that was low to the 90s. Levophed was
initiated and the patient was transferred to the Medical
Intensive Care Unit for further management. The patient
reversed his code status when questioned by the Emergency
Department staff and requested to be intubated should he be
needed to intubated.
PAST MEDICAL HISTORY:
1. History of syphilis initially treated with Penicillin in
[**2103**], complicated by neurosyphilis treated with Penicillin
times two weeks in [**2137-12-26**]. History of lumbar puncture
with negative VDRL and positive FTA.
2 Cerebrovascular accident in [**2131**], and [**2132**], with three in
total.
3. Chronic aspiration, status post percutaneous endoscopic
gastrostomy tube.
4. Hypertension.
5. History of gastrointestinal bleed.
6. History of Methicillin resistant Staphylococcus aureus
pneumonia.
7. History of seizure disorder.
8. History of depression.
9. Osteoarthritis.
10. Gender identity disorder.
11. Hypercholesterolemia.
ALLERGIES: Percodan.
MEDICATIONS ON ADMISSION:
1. Zinc 220 mg p.o. once daily.
2. Subcutaneous Heparin 5000 units q12hours.
3. Baclofen 10 mg p.o. three times a day.
4. Vitamin 500 mg p.o. twice a day.
5. Colace 100 mg p.o. once daily.
6. Aspirin 325 mg p.o. once daily.
7. Atenolol 100 mg p.o. once daily.
8. Celexa 60 mg p.o. once daily.
9. Zantac 150 mg p.o. once daily.
10. Neurontin 300 mg p.o. twice a day to three times a day.
11. Percocet one tablet p.o. three times a day.
12. Dilantin 200 mg p.o. twice a day.
13. Jevity tube feeds.
14. Ativan p.r.n.
15. Ultram p.r.n.
16. Trazodone p.r.n.
17. Dulcolax p.r.n.
18. Chlorpromazine p.r.n.
SOCIAL HISTORY: The patient lives in [**Hospital3 537**] as a
resident. History of remote alcohol and tobacco use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 102.4, heart rate 86,
blood pressure 134/48, respiratory rate 46, breathing 83% on
nonrebreather and 93% on BiPAP with pressure support of 10
and PEEP of 5. Generally, this is an elderly chronically ill
appearing male in no apparent distress using accessory
muscles of respiration. Head, eyes, ears, nose and throat -
Extraocular movements are intact. Mucous membranes are dry.
Jugular venous pressure is approximately four to five
centimeters. Poor dentition. Heart - Distant heart sounds
bilaterally. Lungs - bronchial breath sounds at the left
base. Decreased breath sounds at the right base. The
abdomen is soft, percutaneous endoscopic gastrostomy tube
site without erythema, decreased bowel sounds. Extremities
contracted bilaterally with no edema, cool extremities, left
foot two to three centimeters shallow ulcer, no fluctuance or
pus.
LABORATORY DATA: Potassium 4.6, creatinine 0.8, INR 1.2,
lactate 4.5. White blood cell count 11.3, 40% polys, 41%
bands, hematocrit 37.3, platelet count 341,000, MCV 100.
Urinalysis showed moderate leukocytes, positive nitrites,
21-25 white blood cells.
Arterial blood gas on 100% nonrebreather 7.45/33/52. On
BiPAP 7.39/35/84.
HOSPITAL COURSE:
1. Septic shock - The patient likely presented with septic
shock and the patient was initially started on MUST protocol.
The likely source was aspiration pneumonia from episodes of
emesis and aspiration as a chronic risk plus/minus urine
which showed positive nitrites and moderate leukocytes. The
patient's other sources include skin from the percutaneous
endoscopic gastrostomy site which looked clean, sacral
decubitus ulcer which did not probe to bone, as well as a
left superficial ulcer in the left lower extremity, which did
not have any evidence of fluctuance or pus. The patient was
aggressively fluid hydrated with lactated ringer's to
maintain a SCVP greater than 10 and the patient did not
qualify for Zygres on this admission. The patient was
initially started on Levophed drip for improvement of his
hemodynamics to maintain a MAP greater than 65. Cortrosyn
stimulation test was performed which showed that the patient
had a cortisol in the 50 range, 58.2, which was not
consistent with adrenal insufficiency. Serial lactate levels
trended and the patient's lactate continued to trend down
with improvement of his anion gap and metabolic acidosis.
The patient was initially started on Vancomycin for history
of Methicillin resistant Staphylococcus aureus pneumonia and
Ceftriaxone and Clindamycin empirically for aspiration
pneumonia and consolidation on the left lower lobe. On
hospital day three, the patient had a repeat spike
temperature of 101 and was pancultured. Urine culture was
growing Staphylococcus aureus greater than 100,000 organisms
and the patient was continued on Vancomycin dosed by levels.
Aspiration pneumonia was continued empirically with coverage
by Ceftriaxone and Clindamycin. The patient had an
ultrasound of his chest which showed no fluid collection in
the lungs and therefore there was nothing to tap.
2. Hypoxic respiratory failure - Likely due to aspiration
pneumonia. The patient was placed on a ventilator on
admission to the Medical Intensive Care Unit after failure to
tolerate CPAP with worsening acidemia. The patient was
maintained on AC 500/22 and his FIO2 was weaned down. The
patient was sedated. An echocardiogram was performed to
assess ejection fraction which was essentially normal at 55%.
3. Neurology - The patient was minimally functional at
baseline. Calls to [**Hospital3 537**] revealed the patient was
wheelchair bound at baseline. The patient's Dilantin level
was checked and was low normal. Even adjusting for his low
albumin, the patient was subsequently restarted on Dilantin
bolus times one and change of his Dilantin to intravenous
while he was intubated. Baclofen was given p.r.n. for leg
pain.
4. FEN - The patient was restarted on tube feeds for
improvement of his nutritional status.
5. Endocrinology - The patient had cortisol levels that were
stable. The patient was maintained on insulin drip to
improve his glucose control.
6. Metabolic acidosis - Likely due to lactic acidosis which
had resolved with improvement of his hemodynamics.
7. Metabolic alkalosis - The patient was likely volume
contracted. Urine chloride was 33 and this had resolved with
improvement of his fluid status with lactated ringer's.
8. Renal - The patient's renal function was stable
throughout the hospital course. However, his FNA on
admission was 0.2%, likely prerenal which subsequently
resolved with improvement of his intravenous fluids.
9. Anemia - The patient initially presented with a
hematocrit drip. The patient was transfused two units of
packed red blood cells, however, since the patient was
intubated, there was an effort to try and identify patient
for consent. The patient prior to intubation had noted that
he had no immediate family and had no health care proxy and
therefore should have whatever medical procedures would be
necessary to his care. Attempts to contact his emergency
contact both at [**Hospital3 537**] revealed that the emergency
contact was a neighbor and that the patient had a sister who
had moved to [**Name (NI) 108**], whose telephone number was no longer
working. At this time, the patient does not have a health
care proxy.
10. Code - The patient reversed his code status on admission
and is now a full code.
11. Prophylaxis - The patient was maintained on subcutaneous
Heparin and Sucralfate during his hospitalization.
The remainder of the hospital course and discharge
information will be dictated by the next intern who will be
covering for this patient.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**]
Dictated By:[**Last Name (NamePattern1) 5227**]
MEDQUIST36
D: [**2138-3-29**] 20:27
T: [**2138-4-1**] 20:09
JOB#: [**Job Number 109135**]
|
[
"5070",
"78552",
"99592",
"51881",
"2762",
"2859"
] |
Admission Date: [**2186-3-10**] Discharge Date: [**2186-4-13**]
Date of Birth: [**2130-11-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 55 yo man w/ h/o end-stage sarcoid dx on home O2 (3L NC)
no longer on xplant list, on home O2, who p/w SOB, f/c x 5
days. Pt was in his USOH until 5 days ago when noted increased
SOB, dry cough. Called PCPs office on [**3-8**], who directed him to
go to ED, but pt waited as is having financial problems at home
and wanted to wait to work out some things before coming to ED.
Pt had self-titrated up O2 to 4L. Also states felt like he had a
fever o/n, but did not take temp. Today pt was seen at home by
OT who noted that he had decreased O2 sats to 85-90% on 4L O2.
OT called PCPs office who instructed them to call ambulance.
Pt initially presented to [**Hospital3 **] where
initial vitals noted to be T 98.8, HR 81, BP 132/68, RR 18, O2
91% 4L NC. Labs notable for slightly elevated WBC at 10.4. CXR
there demonstrated ?new infiltrate, although difficult to assess
given underlying lung dx. Pt was given rocephin 1gm x 1, azithro
500mg x 1, and transferred to [**Hospital1 18**].
In ED initial vitals T 97.4, HR 104, BP 115/82, RR 20, O2 91% 4L
NC. Pt admitted for further management.
Currently pt c/o continued SOB, cough, no other complaints at
this time.
Past Medical History:
1. Hepatitis C, diagnosed as part of the lung transplant workup
at the [**Hospital1 756**]. He is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in GI. He
is hepatitis B core surface antibody positive and surface
antigen
negative. In addition, he has hepatitis C antibody plus type 2b
with a viral load in [**8-/2185**], of 5.5 million. He had grade 2
fibrosis on [**2184-4-28**]. He is not thought to be a candidate
currently for interferon treatment given his sarcoidosis. He has
transaminitis.
2. Sarcoidosis. He is followed by Dr. [**Last Name (STitle) 2168**]. The patient has
been obtaining PFTs from Dr. [**Last Name (STitle) **], and he is currently on
azathioprine and prednisone with prophylaxis Bactrim.
3. Sleep apnea.
4. Erectile dysfunction.
5. Emotional lability and anxiety.
6. Status post mandible fracture [**8-20**].
7. Status post multiple rib and clavicle fractures over the past
year secondary to fall.
8. Spinal stenosis: diagnosed on MRI and is followed by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 363**], [**First Name3 (LF) **] orthopedic physician at the [**Hospital1 18**]. The diagnosis was
established as part of a workup for progressive lower leg
weakness, which led to multiple falls and currently an inability
to ambulate.
9. Shingles in [**12/2184**] on the right side of the face with
residual neuropathic pain.
Social History:
Lives in an apartment in [**Location (un) 1459**] with his 27 yo daughter who
is s/p traumatic brain injury in a motor vehicle accident. Has
another daughter from whom he is estranged. Recently divorced
from his wife of 33 years who he says did "not want to take care
of him." Patient is a former food salesman, selling restaurant
supplies to pizzerias. Has been unemployed for about a year, no
longer on unemployment. Recently obtained some disability
benefits. Reports a 10 pack year smoking history, but quit 20
years ago. Reports no history of ethanol use or IV drug use. Pt
had previous admission in which he was on high doses of
methadone and benzodiazepenes that were verified by PCP to be
prescribed by an outpatient physician to treat his pain from
spinal stenosis; pt believed to withdraw from both on previous
admissions.
Family History:
Non contributory of pulmonary disease.
Physical Exam:
Admission
Vitals - T 97.9, HR 97, BP 121/70, RR 25, O2 86% --> 94% 4L NC
Gen - awake, alert, eating [**Location (un) 6002**], tachypnic slightly,
speaking in full sentences
CVS - RRR no noted m/r/g
Lungs - mild decreased BS diffusely but overall fairly good air
movement w/ no noted crackles, + mild wheezing
Abd - soft, NT/ND
Ext - trace LE edema b/l
.
Discharge
Vitals - T 97.9, HR 97, BP 126/86, RR 18, O2 98%6L with facemask
mist supplementation
Gen - awake, alert, comfortable, speaking in full sentences
CVS - RRR no noted m/r/g
Lungs - mild decreased BS diffusely but overall fairly good air
movement w/ no noted crackles, + mild expiratory wheezes at
bases, no increased work of breathing
Abd - soft, NT/ND
Ext - trace LE edema b/l, + mild right forearm edema
Pertinent Results:
CXR [**2186-3-11**]:Extensive pulmonary fibrosis and architectural
distortion, presumably due to the provided history of sarcoid
although basilar predominance is atypical. No findings to
suggest an acute superimposed pneumonia, but subtle infection
could be easily obscured by the chronic lung disease.
.
CXR [**2186-4-6**]:
Today's study demonstrates fracture displacement of the right
seventh rib laterally, other lower fractures were demonstrated
along the lateral chest wall on the 9:27 a.m. film. Severe
pulmonary fibrosis and marked emphysema are longstanding. There
is no evidence of acute pulmonary changes though subtle findings
would be missed. No appreciable pleural effusion is seen. Heart
size is normal. No pneumothorax.
.
CT Chest [**2186-3-14**]
1. No evidence of pneumonia or other acute cardiopulmonary
process.
2. Chronic severe pulmonary fibrosis, could be end- stage
sarcoidosis.
Chronic pulmonary hypertension.
3. Previous right upper lobe infection resolved.
4. Possible small right upper lobe mycetoma.
5. New left lower lobe 3.5 mm lung nodule warrants [**5-25**] month CT
followup.
.
CT abd:
1. Bilateral rectus sheath hematomas as described above. Small
amount of blood in the fat-containing right inguinal hernia.
2. No evidence of retroperitoneal hematoma.
3. Changes in the lung bases, incompletely evaluated, are
consistent with the patient's history of sarcoid.
4. Healing bilateral rib fractures.
5. Abdominal aortic ectasia as above up to 2.8 cm.
6. Nonobstructing left nephrolithiasis.
.
CT Chest [**2186-4-6**]:
1. Small PE of segmental/subsegmental right upper lobe branch.
This was communicated by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 24949**] with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3766**] by telephone in the AM on [**2186-4-10**].
2. New minimally displaced fracture of the lateral right ninth
rib. Multiple additional bilateral healing rib fractures.
3. Healing left distal clavicle fracture.
3. Resolution of right upper lobe pneumonia.
4. Chronic severe pulmonary fibrosis in the setting of
sarcoidosis.
.
LE U/S:No evidence of DVT in either extremity.
.
CBC
[**2186-3-11**] 05:15AM BLOOD WBC-9.2 RBC-3.74* Hgb-13.2* Hct-39.3*
MCV-105* MCH-35.4* MCHC-33.6 RDW-15.3 Plt Ct-259
[**2186-3-13**] 04:40AM BLOOD WBC-10.6 RBC-3.70* Hgb-13.0* Hct-39.3*
MCV-106* MCH-35.3* MCHC-33.2 RDW-15.9* Plt Ct-294
[**2186-3-14**] 04:40AM BLOOD WBC-12.0* RBC-3.53* Hgb-12.4* Hct-36.9*
MCV-105* MCH-35.1* MCHC-33.6 RDW-15.4 Plt Ct-269
[**2186-3-19**] 05:11AM BLOOD WBC-10.1 RBC-3.72* Hgb-13.1* Hct-39.9*
MCV-107* MCH-35.1* MCHC-32.7 RDW-16.1* Plt Ct-232
[**2186-3-21**] 04:40AM BLOOD WBC-11.3* RBC-3.71* Hgb-13.1* Hct-39.9*
MCV-108* MCH-35.4* MCHC-32.9 RDW-16.2* Plt Ct-298
[**2186-3-23**] 07:30AM BLOOD WBC-11.0 RBC-3.56* Hgb-12.4* Hct-38.6*
MCV-108* MCH-34.9* MCHC-32.3 RDW-16.2* Plt Ct-297
[**2186-3-25**] 06:22AM BLOOD WBC-10.8 RBC-3.40* Hgb-12.0* Hct-36.4*
MCV-107* MCH-35.4* MCHC-33.1 RDW-16.3* Plt Ct-282
[**2186-3-28**] 03:58PM BLOOD Hct-32.0*
[**2186-3-31**] 07:55AM BLOOD WBC-10.6 RBC-2.86* Hgb-10.0* Hct-31.1*
MCV-109* MCH-35.1* MCHC-32.2 RDW-16.9* Plt Ct-361
[**2186-4-2**] 06:03AM BLOOD WBC-11.1* RBC-2.91* Hgb-10.3* Hct-32.3*
MCV-111* MCH-35.2* MCHC-31.8 RDW-17.1* Plt Ct-320
[**2186-4-5**] 05:54AM BLOOD WBC-15.2* RBC-3.26* Hgb-11.6* Hct-36.2*
MCV-111* MCH-35.5* MCHC-32.0 RDW-16.5* Plt Ct-367
[**2186-4-9**] 05:42AM BLOOD WBC-9.6 RBC-3.10* Hgb-11.1* Hct-33.9*
MCV-109* MCH-35.8* MCHC-32.8 RDW-16.2* Plt Ct-259
[**2186-4-10**] 04:08AM BLOOD WBC-8.6 RBC-3.18* Hgb-11.2* Hct-34.7*
MCV-109* MCH-35.1* MCHC-32.1 RDW-16.3* Plt Ct-277
[**2186-4-11**] 05:35AM BLOOD WBC-7.7 RBC-3.18* Hgb-11.2* Hct-34.7*
MCV-109* MCH-35.3* MCHC-32.4 RDW-16.3* Plt Ct-290
.
Chem 7
[**2186-3-11**] 05:15AM BLOOD Glucose-243* UreaN-16 Creat-0.5 Na-138
K-4.9 Cl-101 HCO3-28 AnGap-14
[**2186-3-13**] 04:40AM BLOOD Glucose-222* UreaN-20 Creat-0.5 Na-141
K-3.9 Cl-105 HCO3-27 AnGap-13
[**2186-3-15**] 05:31AM BLOOD Glucose-125* UreaN-18 Creat-0.5 Na-143
K-3.9 Cl-104 HCO3-29 AnGap-14
[**2186-3-19**] 05:11AM BLOOD Glucose-154* UreaN-27* Creat-0.5 Na-144
K-4.3 Cl-105 HCO3-30 AnGap-13
[**2186-3-23**] 07:30AM BLOOD Glucose-103 UreaN-23* Creat-0.6 Na-140
K-4.3 Cl-100 HCO3-32 AnGap-12
[**2186-3-26**] 05:39AM BLOOD Glucose-142* UreaN-29* Creat-0.6 Na-143
K-4.6 Cl-105 HCO3-25 AnGap-18
[**2186-3-28**] 06:42AM BLOOD Glucose-128* UreaN-23* Creat-0.4* Na-143
K-4.2 Cl-105 HCO3-34* AnGap-8
[**2186-3-30**] 05:05AM BLOOD Glucose-120* UreaN-22* Creat-0.5 Na-140
K-4.6 Cl-101 HCO3-32 AnGap-12
[**2186-4-1**] 06:06AM BLOOD Glucose-98 UreaN-17 Creat-0.5 Na-142
K-4.2 Cl-104 HCO3-36* AnGap-6*
[**2186-4-3**] 05:17AM BLOOD Glucose-186* UreaN-25* Creat-0.5 Na-143
K-4.2 Cl-104 HCO3-35* AnGap-8
[**2186-4-9**] 05:42AM BLOOD Glucose-139* UreaN-24* Creat-0.6 Na-144
K-3.9 Cl-102 HCO3-36* AnGap-10
[**2186-4-10**] 04:08AM BLOOD Glucose-139* UreaN-20 Creat-0.5 Na-145
K-3.8 Cl-106 HCO3-35* AnGap-8
[**2186-4-11**] 05:35AM BLOOD Glucose-111* UreaN-20 Creat-0.5 Na-147*
K-3.9 Cl-106 HCO3-36* AnGap-9
.
MISC
[**2186-3-11**] 05:15AM BLOOD ALT-131* AST-140* LD(LDH)-342*
[**2186-3-19**] 05:11AM BLOOD ALT-96* AST-113* AlkPhos-104 TotBili-0.5
[**2186-4-8**] 03:52AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2186-4-8**] 11:50AM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2186-4-8**] 05:55PM BLOOD Type-ART pO2-79* pCO2-54* pH-7.44
calTCO2-38* Base XS-10
[**2186-4-8**] 05:55PM BLOOD O2 Sat-93
Brief Hospital Course:
#SHORTNESS OF BREATH / VIRAL BRONCHITIS / SARCOIDOSIS / ANXIETY
Mr. [**Known lastname 52653**] was admitted with worsening SOB and lower oxygen
saturations. This was not felt to be a flare of sarcoidosis but
more likely a viral infection on top of severe underlying lung
disease caused by sarcoid. A pulmonary consultation was
obtained. Prednisone was increased to 60mg PO daily in addition
to his azathioprine 150mg once daily. His oxygen flow was
increased to four liters, and later to 5-6 liters. He briefly
went to the MICU on [**2186-4-7**] for worsening tachypnea; he remained
on his baseline 6L NC with shovel mask mist support. After
returning to the floor and again becoming tachypneic, he
underwent CTA which showed as small subsegmental PE. LENI's were
negative for DVT. As the patient had had recent bleeding with
rectus sheath hematomas, anticoagulation was not started.His
outpt pulmonologist was made aware and agreed with holding off
on anticoagulation. At discharge, he was restarted on lower dose
sc heparin 5000 [**Hospital1 **] (down from TID). He will be followed
closely as an outpt with Dr. [**Last Name (STitle) **]. At discharge he was 97%
on 6L NC and shovel mask mist support, slightly tachypnic. Per
Dr.[**Last Name (STitle) 18309**], transtracheal oxygen catheter has been discussed to
improve oxygen delivery. He was evaluated by throracic surgery
during his inpt stay but a decision was defered as the surgeon
was out of town. The cardiothoracic surgery clinic will call the
patient with an appointment to follow up in clinic for
evaluation.
.
#PSEUDOMONAS PNEUMONIA
He stabilized after initial presentation but intermittently
became tachypneic from his viral bronchitis, but later developed
much more productive cough with phlegm. Sputum culture was
obtained which was notable for multidrug-resistant pseudomonas.
CT scan showed interval developement of new RUL consolidation.
He was treated with meropenem for 14 days. Subsequent CT showed
interval resolution.
.
#SEVERE ANXIETY
He has severe anxiety related to advanced illness and is quite
fearful of death, and this exacerbated respiratory symptoms. A
palliative care consultation was obtained and the patient wsa
tried on sublingual morphine with an increase in his anxiolytic
medications. He personally was not yet ready for hospice. In
terms of psychopharmacology, the patient was started on
risperidone 1mg PO BID, and his duloxetine was increased to 90mg
PO daily. SL Morphine aided in comfort.
.
#RIB FRACTURES / OSTEOPOROSIS:
THe patient had several old rib fractures, but also developed a
new acute rib fracture during this admission. This is due to
chronic steroid use and coughing. A vitamin D level was normal
in [**11-19**]. A repeat Vit D level is pending. This value should be
followed up on and Vit D supplements started if low. The patient
may also need bisphosphonates although the long-term benefits
are doubtful given his poor prognosis.
.
#RECTUS SHEALTH HEMATOMA
The patient developed a moderate sized rectus shealth hematoma
during this admission with 8 point hematocrit drop. This was
felt to be in part to coughing while on subcutaneous heparin
injections. Heparin sc was discontinued. His HCT stabilized
without intervention. Heparin at a lower dose of 5000 [**Hospital1 **] was
restarted. If the patient has any sign of bleeding or worsening
abd bruising, discontinue heparin and please use pneumoboots.
.
#FALL
The patient fell on [**2186-4-6**] while toileting. He did not hit his
head and had no LOC.
New rib fracture and rectus sheath hematoma were not attributed
to this fall.
.
#SPINAL STENOSIS
The patient was continued on long and short acting morphine for
pain control.
His MS contin was increased to 45/15/45 mg three times per day
respectively.
He had sublingual morphine and percocet on PRN basis.
.
#PAIN MEDICATION ISSUES
The patient was seen by nursing to be saving pain medication for
his daughter. [**Name (NI) **] was directly observed taking all medications
subsequently. There were no subsequent concerns regarding pain
medication.
.
# MENTAL STATUS
The patient is typically fully oriented, though he had frequent
periods where he was unsure of surroundings. He typically became
quite paranoid at night and felt that most night nurses were
playing tricks on him. He was started on risperidone 1mg PO BID
with PRN haldol for agitation.
Medications on Admission:
Albuterol PRN , Azathioprine 150mg daily Klonipin 0.5mg TID PRN
Cymbalta 60mg daily Advair 500/50 INH [**Hospital1 **] Remeron 15mg qhs
Morphine SR 30mg TID Omeprazole 20mg daily Percocet q6hr PRN
Prednisone 40mg daily Simvastatin 20mg daily Spiriva 18mcg INH
daily Trazadone 50mg qhs PRN ASA 325mg daily colace
senna thiamine 100mg daily tylenol PRN
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours).
2. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMWF ().
14. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
16. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
18. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO q 1:00pm as needed.
20. Morphine 15 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO QAM (once a day (in the morning)).
21. Morphine 15 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO QPM (once a day (in the evening)).
22. Morphine Concentrate 20 mg/mL Solution Sig: 0.5-0.75 mL PO
Q3H (every 3 hours) as needed.
23. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q3H PRN ().
24. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
25. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
26. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
27. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) as needed.
28. Insulin
12 units NPH qAM, 6 units NPH qPM
Regular Insulin Sliding scale coverage (see attached scale)
29. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
30. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal QID (4 times a day) as needed.
31. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary:
- Acute exacerbation of COPD
- Hospital acquired pneumonia
- Rectus sheath hematoma
- End stage pulmonary sarcoid
Secondary:
- Chronic immunosuppression
- Obstructive sleep apnea
- Left III nerve palsy
- Anxiety; depression; paranoia
- Traumatic mandibular, rib, clavicle fractures
- Spinal stenosis; frequent falls
- Chronic pain
- Zoster
- Hepatitis C
Discharge Condition:
Stable. On 6L NC. afebrile.
Discharge Instructions:
You were admitted with shortness of breath and thought to have a
viral bronchitis on top of your sarcoidosis. You had a new
pneumonia and were treated with IV antibiotics: 14 day course of
meropenem completed. You were continued on a higher dose of
predisone as well as your current dose of azathioprine.
.
You had a large abdominal (rectus sheath) hematoma that will
improve over time.
.
Your medications were changed.
Your prednisone was increased as above.
Your pain medications have changed; please review your NEW
medication list and adjust your home meds as needed.
.
If you develop worsening shortness of breath, low oxygen
saturations on your current level of home oxygen, fevers or
chills, please return to the hospital.
Followup Instructions:
New left lower lobe 3.5 mm lung nodule warrants [**5-25**] month CT
followup.
.
Please make an appointment with Dr. [**Last Name (STitle) **], your outpt
psychiatrist ([**Telephone/Fax (1) 52654**]) to be seen in [**12-14**] weeks.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2186-5-1**] 2:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2186-5-1**] 1:00
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2186-5-1**] 1:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"2851",
"486",
"2762",
"32723",
"4168"
] |
Admission Date: [**2176-3-10**] Discharge Date: [**2176-3-13**]
Date of Birth: [**2120-4-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
instent thrombosis
Major Surgical or Invasive Procedure:
Cardiac Cath
History of Present Illness:
55yo male with a history of coronary artery disease and
rheumatoid arthritis was admitted from the cath lab s/p STEMI
with instent thrombosis.
.
Patient initially presented to the Emergency Department on
[**2176-3-4**] with left knee pain. He was treated with pain medication
and sent home with percocet for pain control. His pain improved
for the first 24 hours after discharge from the ED. However over
the next 3-4 days, his knee pain again worsened and on the
morning of admission, he developed bilateral knee pain
necessitating an ED visit. He then presented to the ED for
evaluation of knee pain. He describes his knee pain as localized
in the bottom of his knees and behind his kenes with associated
swelling. His initial vital signs upon arrival to the ED was
temp 97.9, BP 143/74, HR 128, RR 20, and O2 sat 98% on room air.
However, while in the waiting room of the Emergency Department,
he developed left-sided chest pressure radiating to his left
arm. He had an ECG performed which demonstrated STE in II, III,
and avF with STD in 1, avL, V1-V3, suggesting posterior-inferior
infarction. He was taken immediately to the cath lab where he
had 100% proximal stent thrombosis in the RCA. He had
thrombectomy performed wtih export of the thrombus, followed by
IVUS and POBA to RCA. His catheterization was complicated by
brief episodes of afib with RVR. He was then sent to the CCU for
further monitoring.
.
Upon arrival to the floor, he reports feeling generally well. He
denies chest pain, shortness of breath, light-headedness,
dizziness, lower extremity swelling, nausea, or vomiting. His
bilateral knee pain is somewhat improved with the fentanyl and
versed he received during his cardiac catheterization and he is
pain free currently. He reports taking his medications
regularly, including his aspirin and plavix, and does not
remember missing any doses. Medication changes include the
following:
- lipitor: discontinuing his statin approximately 2 weeks ago as
they were thought to be contributing to his joint pain
- methotrexate: he was recently restarted on his methotrexate
20mg on [**2176-3-1**] to better control his rheumatoid arthritis
.
Of note, he was admitted to a hospital in [**State 108**] in [**12-22**] for a
heart attack at which time he had two stents placed. His
hospital course was complicated by development of a staph
infection for which he received 8 weeks of IV antibiotic therapy
that he completed roughly two weeks ago.
.
On review of systems, 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. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. Cardiac review of systems is
notable for absence of dyspnea on exertion, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
PMH
1. Coronary Artery Disease s/p RCA stents in ~[**2170**] and [**12-22**]
2. Hypertension
3. Hyperlipidemia
4. Gastric Ulcer
5. Ruptured [**Hospital Ward Name 4675**] Cyst
6. Degenerative tears of the medial meniscus of the right knee,
patellofemoral disease.
7. Gastric ulcer.
PSH
1. Left knee arthroscopy 20 years ago to repair a ligament.
Social History:
Social history is significant for the absence of current tobacco
use. Pt quit smoking on [**2176-1-10**]. There is no history of alcohol
abuse. There is no family history of premature coronary artery
disease or sudden death. He works fulltime selling medical
insurance to large companies. He lives in [**Location **], [**Location (un) 3844**]
with his wife and 17yo step son. [**Name (NI) **] has three other children in
their 20s.
Family History:
- Mother - died at age [**Age over 90 **] with rheumatoid arthritis.
- Father - died with nonspecified cancer.
- Three sisters alive and well.
- Two brothers, one of them with knee problems. Two children
alive and well.
Physical Exam:
VS - T 99 / HR 106 / BP 145/98 / RR 12 / Pulse ox 99% on 2L
Gen: WDWN middle aged male 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 [**5-20**] 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. Blood oozing through the
pressure dressing. Left knee is warm, swelling with small
effusions, no erythema, no tenderness; Right knee with swelling
and small effusions, no erythema, no warmth, no tenderness
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Dopplerable DP / PT pulses bilaterally and symmetric.
Pertinent Results:
[**2176-3-10**] 12:35PM GLUCOSE-108* UREA N-18 CREAT-1.0 SODIUM-134
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-25 ANION GAP-19
[**2176-3-10**] 12:35PM estGFR-Using this
[**2176-3-10**] 12:35PM CK(CPK)-18*
[**2176-3-10**] 12:35PM cTropnT-<0.01
[**2176-3-10**] 12:35PM CK-MB-NotDone
[**2176-3-10**] 12:35PM WBC-16.6* RBC-4.54* HGB-13.7* HCT-38.9*
MCV-86# MCH-30.1 MCHC-35.1* RDW-14.4
[**2176-3-10**] 12:35PM PLT COUNT-531*#
[**2176-3-10**] 12:35PM PT-15.4* PTT-25.0 INR(PT)-1.4*
.
[**2176-3-10**] - 12:35pm
Na 134 / K 4.3 / Cl 94 / CO2 25 / BUN 18 / Cr 1 / BG 108
CK 18 / MB not done / Trop T < .01
WBC 16.6 / Hct 38.9 / Plt 531
INR 1.4 / PTT 25
.
STUDIES:
- Cardiac Catheterization - [**2176-3-10**]
--> RCA: 100% proximal stent thrombosis
--> LAD: 30% mid stenosis
--> LCx: no significant disease
- ECG - [**2176-3-10**] - NSR at ~60 bpm, normal axis, 2-3mm STE in II,
III, avF with 2-3mm STD in I, avL, V1-V3
- Portable CXR - [**2176-3-10**] - formal read pending; poor lung
volumes, enlarged heart but slightly difficult to assess on
portable AP film, no infiltrates, clear diaphragmatic borders
- Echo - not done
- Stress Tests - never done
.
Brief Hospital Course:
STUDIES:
TTE [**2176-3-11**]:
The left atrium is dilated. A left-to-right shunt across the
interatrial septum is seen at rest. A small secundum atrial
septal defect is present. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with mild hypokinesis of the basal to mid
inferior and inferolateral segments. There is no ventricular
septal defect. The right ventricular cavity is mildly dilated
with borderline normal free wall function. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
IMPRESSION: Mild focal LV systolic dysfunction and right
ventricular dilatation and dysfunction consistent with RCA
ischemia/infarction. No significant valvular abnormality seen.
There is a small secundum ASD seen at rest (image #86). Agitated
saline is seen to cross the inter-atrial septum on release of
the Valsalva maneuver (image #89).
1. Coronary Artery Disease
Patient developed chest pain in the ED waiting room with ECG
changes suggestive of a STEMI in the posterior-inferior
distribution. He was found to have an instent thrombosis of
stent in the RCA. Patient has remained hemodynamically stable
with this event and is currently chest pain free. Unclear what
may have precipitated this event given that the patient reports
taking his plavix and aspirin regularly. Possible explanations
include recent statin discontinuation in the setting of recent
stent placement or inflammatory / procoagulable state in the
setting of RA flare. Since patient failed aspirin and plavix
therapy we continued aspirin and, for additional platelet
inhibition, increased plavix to 150mg daily and added cilostazol
100mg PO bid. He was maintained on integrillin for 18hours
post-cath. Statin was re-started and beta blocker was increased
given tachycardia post-cath. He was also re-started on his ace
inhibitor. TTE showed mildly depressed EF as well as an ASD
(secundum) defect. He will follow up with cardiology clinic here
in a few weeks.
2. Knee Pain
Patient's knee pain appeared most likely related to his
rheumatoid arthritis. No previous history of gout or pseudogout.
Bilateral septic arthritis would also be very atypical.
Rheumatology was consulted and increased his prednisone to 20mg
daily and restarted him on his methotrexate (20mg weekly). He
was continued on folate. Once BPs were stable he was given
morphine for pain control as well as round-the-clock tylenol.
3. Atrial fibrillation
Patient had short episodes of atrial fibrillation in the cath
lab. Afterward remained in sinus, although at times tachycardic
to 100s. As BPs were stable, increased beta blocker dose for
better control.
4. Pump: patient had moderately depressed LV systolic function
on TTE after his STEMI. He remained euvolemic throughout his
hospital course. He was continued on ACE-I, beta blocker,
statin, asa as above.
#. PPx: PPI, fall precautions, bowel regimen prn, heparin SC in
the AM
#. Code: FULL CODE
#. Communication: [**First Name5 (NamePattern1) **] [**Known lastname 74463**] [**Telephone/Fax (1) 74464**], [**Telephone/Fax (1) 74465**]
Medications on Admission:
1. Plavix 75mg PO daily
2. Enalapril 2.5mg PO daily
3. Aspirin 325mg PO daily
4. Metoprolol Tartrate 12.5mg PO bid
5. Methotrexate 20mg PO q weekly
6. Folate 1mg PO daily
7. Omeprazole 20mg PO daily
8. Prednisone 10mg PO daily
9. Zyrtec
10. Oxycodone 5-325mg q4-5hour prn
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO bid ().
Disp:*60 Tablet(s)* Refills:*2*
3. Enalapril Maleate 5 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
11. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
13. Methotrexate Sodium 2.5 mg Tablet Sig: Eight (8) Tablet PO
once a week.
Discharge Disposition:
Home
Discharge Diagnosis:
STEMI
ASD-secundum type
Rheumatoid arthritis flare
History of Congestive Heart Failure
Discharge Condition:
The patient was afebrile, hemodynamically stable, and chest pain
free prior to discharge.
Discharge Instructions:
You were admitted to the hospital with a rheumatoid arthritis
flare and a heart attack. For your heart attack you received
medications and a clot was removed from one of the stents in
your heart. For your arthritis your rheumatologist saw you and
recommended re-starting on methotrexate and given extra doses of
prednisone.
You had an ultrasound of your heart that showed a small hole
between the top two [**Doctor Last Name 1754**] of your heart. This is usually
something you are born with and should not cause you any health
problems.
A vitamin D level was sent to check to see if you have a
deficiency. Dr. [**Last Name (STitle) **] can check the result at your next appt.
.
MEDICATION CHANGES:
START: Cilostazol - to keep your stents open by making platelets
less sticky. You should take this EVERY DAY
CHANGE: Plavix to 150mg daily - to keep your stents open. You
should take this medication EVERY DAY
CHANGE: Prednisone to 20mg daily- for your rheumatoid arthritis
flare
CHANGE: Calcium and Vitamin D, to prevent thinning of the bones
because of prednisone. To be taken twice daily.
CHANGE: discontinue Metoprolol and start Atenolol, a beta
blocker that you only take once a day.
.
Please call your PCP or come back to the hospital if you have
fainting or near-fainting, dizziness, chest pain, jaw pain, arm
pain, shortness of breath, nausea, abdominal pain, vomiting,
blood in your stools or black tarry stools, leg swelling, weight
gain of more than 3lbs in 1 day, rash, or any other concerning
symptoms.
.
Please weigh yourwself every day in the am before breakfast.
Call Dr. [**Last Name (STitle) 171**] if you notice more than 3 pounds weight gain in
1 day or 6 pounds in 3 days. Please also call Dr. [**Last Name (STitle) 171**] if you
notice trouble breathing with activity, trouble lying flat to
sleep, swelling in your legs or feet.
Followup Instructions:
Rheumatology:
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time: [**3-22**]
at 12:00pm.
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2176-4-30**]
2:30
.
Orthopedics:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 5500**], M.D. Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2176-3-19**] 10:15
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2176-3-19**] 9:55
Cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2176-4-3**]
10:20
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Phone: [**Telephone/Fax (1) 250**] Date/Time: Office will call
you with an appt.
Completed by:[**2176-3-13**]
|
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"412",
"4019",
"2724"
] |
Admission Date: [**2107-7-1**] Discharge Date: [**2107-7-4**]
Date of Birth: [**2052-8-2**] Sex: F
Service: MEDICINE
Allergies:
Latex / Lisinopril
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Chest pain/pressure/nausea
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2107-7-1**] with bare metal stent to mid left
anterior descending artery and thrombectomy to proximal left
anterior descending artery.
History of Present Illness:
54yo female with h/o CAD s/p PCI with stenting of first diagonal
and proximal LAD in [**10/2102**], HTN, and hyperlipidemia who
presents now after emergent cardiac cath for STEMI with stent
thrombosis of LAD stent.
Patient had outpatient surgery earlier today for nasal polyp
removal. Had been holding aspirin about 2 weeks prior to
procedure. On driving home, developed nausea and bilateral arm
pain. Pain radiated to her left jaw, and she then developed [**6-18**]
substernal chest pain as well as SOB. Her husband pulled the
car over, called 911, and the patient was brought to [**Hospital1 18**] ED
via ambulance. In ambulance patient received aspirin and SL
nitro without improvement in symptoms.
.
Initial VS: HR 50, BP 140/80. On arrival to ED VS were 47 144/78
18 and 100% on non-rebreather. Patient was fatigued but alert
and oriented x3. ECG revealed ST elevations in I, AVL, V1-V3,
V4-6. Code STEMI called. Guaiac negative. Patient was started on
heparin bolus and gtt, integrillin. She was bradycardic and had
pacer pads placed on chest, but did not require pacing. She was
brought emergently to the cath lab.
In cath lab, was found to have stent thrombosis in proximal LAD
stent. Large clot was removed via aspiration thrombectomy, and
stent was dilated by balloon angioplasty. She also had a BMS
placed in the mid-LAD. While in the cath lab, she was on a
bivalirudin drip, was continued on integrillin, and also was
loaded with 60mg Prasugrel. She tolerated the procedure well
and was transferred to the CCU for further management.
.
On arrival to CCU, VS: 95.9 72 128/71 14 100% on oxygen face
mask 6L. Patient was chest pain free and denied any
lightheadedness, SOB, nausea/vomiting, abdominal pain, pain at
right groin site, or leg pain. She c/o mild headache which she
felt was secondary to her flat position in bed.
.
She has h/o CAD and underwent PCI with stenting of first
diagonal and proximal LAD (DES) in 11/[**2101**]. She was on Plavix
following the procedure, but has been off Plavix now for
approximately two years. She has not had any cardiac
interventions since that time, but did undergo a stress test
about 2 weeks ago prior to her nasal surgery which by patient's
report was unremarkable. SHe has been off ASA for the last two
weeks prior to the surgery today.
Prior to today, she has not had any recent episodes of CP at
rest or on exertion. She has had some SOB, secondary to her
nasal polys.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias,
cough, or hemoptysis. She denies any 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 dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. Positive for recent chest
pain, SOB, and nausea as above.
Past Medical History:
CAD, s/p PCI with stenting of first diagonal and proximal LAD
[**10/2102**]
HTN
Hyperlipidemia
Asthma
Nasal polys
GERD
h/o Spinal Fusion
h/o Herniated disc in neck
Carpal Tunnel, bilateral
s/p hysterectomy
s/p knee surgery
CARDIAC RISK FACTORS: Hyperlipidemia, Hypertension. No history
of diabetes.
CARDIAC HISTORY: PCI [**10/2102**] with stenting of first diagonal and
proximal LAD
Social History:
Married. Works for hospice program. Reports she is generally
active with walking, dancing. Remote smoking history, quit 30
years ago. Infrequent alcohol use. No illicit drug use.
Family History:
Positive family h/o premature CAD. Father with DM Type 2, CAD -
First MI at age 35, died at 52. Mother had hyperlipidemia -
cholesterol level >400, CAD - died at age 60, went in for
planned angioplasty and had MI during the procedure, died 3
months later.
Physical Exam:
VS: T=95.9 BP=128/71 HR=72 RR=14 O2 sat=100% on oxygen face mask
GENERAL: WDWN female. Alert, oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink.
NECK: Supple.
THYROID: no goitre, euthyroid
CARDIAC: RRR. Normal S1, S2. No R/M/G appreciated. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Warm, well-perfused. No edema.
SKIN: No stasis dermatitis or rashes noted.
PULSES: Radial, PT and DP pulses 2+ bilaterally.
Pertinent Results:
Admission Labs
[**2107-7-1**] 08:21PM SODIUM-140 POTASSIUM-4.3 CHLORIDE-107
[**2107-7-1**] 08:21PM CK(CPK)-5776*
[**2107-7-1**] 08:21PM CK-MB-417* MB INDX-7.2* cTropnT-14.86*
[**2107-7-1**] 08:21PM WBC-16.6* RBC-4.20 HGB-10.9* HCT-32.7*
MCV-78* MCH-26.0* MCHC-33.5 RDW-15.0
[**2107-7-1**] 08:21PM PLT COUNT-208
.
Discharge Labs
[**2107-7-4**] 07:30AM BLOOD WBC-8.5 RBC-3.67* Hgb-9.4* Hct-28.5*
MCV-78* MCH-25.5* MCHC-32.9 RDW-15.3 Plt Ct-221
[**2107-7-4**] 07:30AM BLOOD Plt Ct-221
[**2107-7-4**] 07:30AM BLOOD Glucose-112* UreaN-15 Creat-0.7 Na-141
K-4.3 Cl-107 HCO3-29 AnGap-9
[**2107-7-4**] 07:30AM BLOOD ALT-49* AST-82* CK(CPK)-340* AlkPhos-48
TotBili-0.5
[**2107-7-4**] 07:30AM BLOOD CK-MB-5 cTropnT-3.98*
[**2107-7-3**] 04:59AM BLOOD CK-MB-23* MB Indx-3.0 cTropnT-4.84*
[**2107-7-2**] 05:54AM BLOOD CK-MB-236* MB Indx-7.8* cTropnT-8.68*
[**2107-7-1**] 08:21PM BLOOD CK-MB-417* MB Indx-7.2* cTropnT-14.86*
[**2107-7-4**] 07:30AM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.8 Mg-2.0
[**2107-7-2**] 05:54AM BLOOD %HbA1c-6.4* eAG-137*
.
Micro-None pending
.
Reports
Cardiac Catherization [**2107-7-1**]:
COMMENTS:
1. Coronary angiogrpahy in this right dominant system
demonstrated acute
thrombotic occlusion of the proximal LAD stent. The LMCA had no
angiographically apparent disease. The mid LAD had 70-80%
stenosis after
the diagonal branch which had a patent stent. The LCx had 50%
stenosis
in the mid vessel. The RCA had 60-70% mid to distal stenosis
with TIMI 3
flow.
2. Limited resting hemodynamics revealed mild systemic arterial
systolic
hypertension with SBP 154 mmHg. Following reperfusion the
patient
transiently developed an accelerated idioventricular rhythm
without
hemodynamic compromise and then reverted to sinus rhythm.
FINAL DIAGNOSIS:
1. Very late stent thrombosis of the proximal LAD.
2. Mild systemic arterial systolic hypertension.
3. Transient reperfusion-related accelerated idioventricular
rhythm.
.
[**2107-7-1**] EKG
Sinus bradycardia. ST segment elevation in leads I, aVL and
V1-V6 consistent with myocardial injury/acute myocardial
infarction. Downsloping ST segments in the inferior leads with T
wave inversion could be reciprocal changes. Compared to the
previous tracing of [**2102-10-31**] the ST segment changes are new and
ventricular rate is slower.
.
[**2107-7-2**] ECHO
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is moderate to severe regional
left ventricular systolic dysfunction with akinesis of the mid
to distal anterior septum, anterior wall and lateral wall. The
apex is dyskinetic. No masses or thrombi are seen in the left
ventricle. A left ventricular mass/thrombus cannot be excluded.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. 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. The pulmonary artery systolic pressure could not be
determined. There is a small pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Extensive regional LV systolic dysfunction
consistent with proximal to mid LAD infarction. No significant
valvular abnormality seen.
.
[**2107-7-3**] EKG
Sinus rhythm. Q waves in leads V1-V2 with a small R wave. ST
segment
elevation in lead V2 with biphasic T waves in leads V1-V3. These
changes could be consistent with evolving changes of an
myocardial infarction. T wave inversion in leads I and aVL also
suggest ischemia. Compared to tracing #2 T wave inversion is new
in lead I and biphasic T wave is new in lead V3. TRACING #3
Brief Hospital Course:
54yo female with h/o CAD, HTN, and hyperlipidemia admitted s/p
emergent cardiac cath for anterolateral STEMI which revealed
in-stent thrombosis in proximal LAD stent likely secondary to
recent discontinuation of aspirin. Patient had aspiration
thrombectomy and placement of BMS to mid-LAD.
.
# CAD: s/p emergent cardiac cath for STEMI which revealed
in-stent thrombosis in proximal LAD stent, thought to be
secondary to patient's discontinuation of aspirin. Patient
underwent aspiration thrombectomy and BMS to mid-LAD. She was
loaded with Prasugrel in cath lab and continued on integrillin
gtt. Patient tolerated procedure well, and was chest pain free
and hemodynamically stable on transfer to the CCU. We continued
ASA 325mg daily, integrillin gtt for 18 hours total, started
Prasugrel 10mg daily, and continued rosuvastatin 40mg daily.
Initially her beta blocker was held given bradycardia on
presentation, but she was restarted on metoprolol tartrate (home
dose) 25mg PO BID the following day. She was also started on
Valsartan given h/o ACE inhibitor allergy. Echo obtained
post-cath on [**2107-7-2**] revealed
extensive regional LV systolic dysfunction (LVEF 30-35%)
consistent with proximal-to-mid LAD infarction, and no
significant valvular abnormalities. Given relative apical
hypokinesis seen on echo, she was started on warfarin for
thrombus prevention. She remained hemodynamically stable, and
in sinus rhythm with rate 60s-70s on telemetry. Her SBPs were
90s-110s, and she was asymptomatic with SBPs in the 90s.
However, her metoprolol dose was adjusted given lower BP. Her
HCTZ was stopped, and she will be discharged on Metoprolol
Succinate 25 mg daily, Valsartan 20mg [**Hospital1 **], ASA, Prasugrel, and
Coumadin. She will follow-up with her outpatient cardiologist
and PCP.
SHE SHOULD NEVER STOP ASPIRIN AND SHOULD CONTINUE PRASUGREL
UNTIL ASKED TO STOP BY HER CARDIOLOGIST, DR [**Last Name (STitle) **]
# Hyperlipidemia - She was continued on rosuvastatin, Zetia.
.
#) Asthma - She was continued on Singulair and will resume all
other asthma medications on discharge.
.
# s/p Nasal polypectomy [**2107-7-1**]: ENT followed patient during
admission. Nasal packing remains in place, and will be removed
on POD #7. Care should be taken given that the patient is on
aspirin, prasugrel and coumadin. Until packing removed, patient
on Keflex 500mg PO QID. Also on Tylenol, Oxycodone prn pain.
Medications on Admission:
Symbicort Inhaler 160 mcg-4.5 mcg/Actuation 2 INH [**Hospital1 **]
Zetia 10mg PO daily
Crestor 40mg PO daily
Nasonex Nasal Spray 2 sprays [**Hospital1 **]
Metoprolol 25mg PO BID
Hydrochlorothiazide 12.5mg PO daily
ASA 325mg PO daily (stopped 2 weeks ago prior to surgery)
Nexium 40mg PO daily
Zyrtec PO daily
Albuterol prn SOB
Singulair 10mg PO QPM
Nitroglycerin SL 0.3mg prn chest pain (has never needed to take)
Oxycodone 5mg 1-2 tabs PO Q4-6hrs prn pain (started [**2107-7-1**])
Keflex 500mg PO QID (started [**2107-7-1**])
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for STEMI and DES.
Disp:*30 Tablet(s)* Refills:*11*
3. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
Disp:*20 Capsule(s)* Refills:*0*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Outpatient Lab Work
Please check INR, hct and Chem-7 on Wednesday [**7-7**] at Dr. [**Name (NI) 38327**] office in [**Location (un) **].
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: take
in the morning.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for acid
reflux .
11. Valsartan 40 mg Tablet Sig: 0.5 Tablet PO at bedtime.
Disp:*15 Tablet(s)* Refills:*2*
12. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation twice a day.
13. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
15. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
16. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
17. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Acute Systolic Dysfunction
S/P nasal polyp removal surgery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack because your stent in the first part of
the left anterior descending artery was clotted off. A
thrombectomy was done to clear that stent and a bare metal stent
was placed in the mid part of that artery. We started you on
Prasugrel, this is similar to Plavix but we hope will keep the
stents open better. You will need to take this medicine every
day for at least one year and probably indefinitely. Do not miss
any doses or stop taking aspirin or Prasugrel unless Dr. [**Last Name (STitle) 7047**]
tells you to. Your heart function was weak after the heart
attack and you were started on coumadin to prevent blood clots.
We hope you will able to stop taking coumadin in a few months
once your heart function is stronger. You will need to take this
medicine every day and frequent blood tests for the drug level
will help us determine the correct dose. Dr. [**Last Name (STitle) 7047**] will tell
you how much coumadin to take every day.
.
Other medicine changes:
1.change Metoprolol Tartrate to Metoprolol Succinate 25 mg daily
2. Stop taking Hydrochlorothiazide
3. Start taking Prasugrel to keep the stents open
4. Start taking Valsartan 20 mg twice daily
5. Start taking coumadin to prevent blood clots
6. Continue taking a full aspirin daily with the Prasugrel.
7. Take nitroglycerin as directed for chest pain. Call 911 if
you have any chest pain at all that is similar to your chest
pain before admission.
.
Please get some blood work on [**7-6**] with results to Dr. [**Last Name (STitle) 7047**].
You can have this done at the [**Location (un) **] office.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 7047**] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Name: [**Doctor First Name **] [**Last Name (NamePattern4) 65417**],MD
Department: Internal Medicine
When: Friday [**7-8**] at 11:45am.
Location: [**Hospital **] MEDICAL ASSOCIATES, INC
Address: [**Street Address(2) 9646**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 3183**]
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **],MD
Department: Cardiology
When: Thursday [**7-28**] at 12:40pm
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) 8720**]
Address: 15 [**Doctor Last Name 8721**] BROTHERS WAY,[**Apartment Address(1) 8722**], [**Location 8723**],[**Numeric Identifier 18655**]
Phone: [**Telephone/Fax (1) 8725**]
|
[
"9971",
"4280",
"41401",
"V4582",
"4019",
"49390",
"2724",
"53081"
] |
Admission Date: [**2195-8-21**] Discharge Date: [**2195-8-25**]
Date of Birth: [**2123-12-18**] Sex: M
Service: CCU-MEDICINE
ADMISSION DIAGNOSIS: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 71 year old
male with a history of hypertension, diabetes mellitus, and
neurogenic bladder, who presented with light-headedness. The
patient was in an outside hospital for urinary tract
infection for which he had been prescribed Ciprofloxacin.
Yesterday after dinner, the patient had an episode of
light-headedness after rising from his chair. The patient
sat down and symptoms resolved within minutes. No chest
pain, shortness of breath, palpitations, positive for
diaphoresis. One hour after dinner, the patient stood up
from couch and felt light-headedness. Again, positive for
diaphoresis, however, no chest pain, shortness of breath,
palpitations. His symptoms persisted for about one half hour
and the patient called 911. The patient's blood pressure
prior to EMT arrival was systolic around 80s, pulse around
40s. In the Emergency Department, the patient was found with
an ectopic atrial rhythm around 40s with systolic blood
pressure of 116. He states Atropine was given.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Type 2 diabetes mellitus.
3. Neurogenic bladder.
4. Chronic renal insufficiency.
5. Status post cholecystectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Verapamil 240 mg twice a day.
2. Furosemide 40 mg once daily.
3. Valsartan 80 mg once daily.
4. Labetalol 200 mg twice a day.
5. Insulin NPH 20 units twice a day.
6. Tamsulosin 0.4 mg once daily.
7. Bethanechol 25 mg four times a day which was a new drug
for him.
8. Nitrofurantoin 50 mg twice a day.
9. Ciprofloxacin 250 mg times five days.
SOCIAL HISTORY: The patient lives with wife. [**Name (NI) **] tobacco, no
alcohol and no intravenous drug abuse.
FAMILY HISTORY: No history of coronary artery disease or
diabetes mellitus.
PHYSICAL EXAMINATION: Vital signs revealed heart rate 54,
sinus, blood pressure 161/79, respiratory rate 20, oxygen
saturation 96% on four liters nasal cannula. In general, the
patient is pleasant elderly male in no apparent distress,
awake, alert and oriented times three. Head, eyes, ears,
nose and throat is normocephalic and atraumatic. The pupils
are equal, round, and reactive to light and accommodation.
Anicteric. The oropharynx is clear. Neck is supple with no
masses, no jugular venous distention. Carotids are 2+
bilaterally without bruits. Cardiovascular reveals
bradycardia but regular, no murmurs, rubs or gallops. Lungs
are clear to auscultation bilaterally. Abdomen is soft,
nontender, nondistended, positive bowel sounds. Extremities
- 1+ pitting edema bilaterally.
LABORATORY DATA: On admission, CK was 158, CK MB 4.0,
troponin I less than 0.01. Chem7 and complete blood count
were stable.
Electrocardiogram showed junctional bradycardia at a heart
rate of 45 beats per minute. Chest x-ray showed widened
mediastinum likely secondary to tortuous aorta.
HOSPITAL COURSE:
1. Cardiovascular - Symptomatic bradycardia. The patient's
beta blocker, calcium channel blocker and Bethanechol were
held on admission. Additionally, electrophysiology was
consulted for his bradycardia and diagnosed with junctional
bradycardia with VA conduction and most likely cause of his
junctional bradycardia was AV nodal disease with His-Purkinje
system disease. At that time, temporary pacer was placed in
the patient and after 48 hours, the patient was still pacer
dependent. At that time, a permanent pacemaker was placed
secondary to third degree AV block. Additionally, the
patient's blood pressure medications were titrated
accordingly. Finally, the patient was instructed to
discontinue his Bethanechol.
The patient tolerated his pacemaker placement with no
problems and was discharged with electrophysiology follow-up
in addition to medications being Valsartan 80 mg a day,
Labetalol 200 mg three times a day, Verapamil 240 mg twice a
day, Hydralazine 10 mg q6hours and Hydrochlorothiazide 25 mg
a day.
2. Urinary tract infection - The patient completed a seven
day course of Ciprofloxacin.
3. Diabetes mellitus - The patient's diabetes mellitus was
controlled with four times a day fingerstick and NPH insulin.
No changes were made to this regimen.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home.
DISCHARGE DIAGNOSES:
1. AV nodal disease.
2. Permanent pacemaker implantation.
MEDICATIONS ON DISCHARGE:
1. Valsartan 80 mg once daily.
2. Tamsulosin 0.4 mg p.o. q.h.s.
3. Docusate 100 mg twice a day p.r.n. constipation.
4. Labetalol 200 mg p.o. three times a day.
5. Verapamil 240 mg p.o. q12hours.
6. Hydralazine 10 mg p.o. q6hours.
7. Hydrochlorothiazide 25 mg p.o. once daily.
8. Cephalexin 500 mg p.o. q6hours times one day.
9. NPH 20 units in the a.m. and 20 units in the p.m.
FOLLOW-UP PLANS: The patient is to follow-up with primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 35256**], for a follow-up appointment in
one to two weeks.
The patient also has an electrophysiology follow-up with Dr.
[**Last Name (STitle) 50355**] on [**2195-9-1**], at 10:00 a.m.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 23649**]
Dictated By:[**Last Name (NamePattern4) 50356**]
MEDQUIST36
D: [**2195-8-26**] 16:53
T: [**2195-8-26**] 18:08
JOB#: [**Job Number 50357**]
|
[
"5990",
"42789",
"4019",
"25000"
] |
Admission Date: [**2162-12-16**] Discharge Date: [**2162-12-21**]
Date of Birth: [**2109-2-5**] Sex: M
Service: MEDICINE
Allergies:
Lactose / Latex / Nafcillin / rifampin / adhesive tape
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
jaundice, abdominal pain
Major Surgical or Invasive Procedure:
1. Esophagogastroduodenoscopy
History of Present Illness:
53M with h/o Hep B, Hep C and EtOH cirrhosis c/b variceal bleed
and ascites, recent MSSA infected hip joint/prothesis s/p
removal on doxycycline, AIN secondary to nafcillin, admitted to
OSH [**2162-12-10**] for evaluation of jaundice and abdominal pain, who
has developed probable HRS and is transferred to [**Hospital1 18**] now for
further evaluation and treatment of decompensated cirrhosis and
HRS. Patient had 1.5-2 week period of N/V (denies hematemesis)
and decreased PO intake. At onset of these symptoms also had
large, dark tarry stool (per his report). Did not have any
fevers, diaphoresis, or chest pain, but was having chills.
Reported >10 pound weight loss over past few months. Abstinent
from EtOH x2 months. Limited history of abdominal pain. Vomiting
resolved, but he saw his PCP several days later as he had run
out of oxycodone. PCP was concerned about jaundice, and sent him
to OSH.
.
At the OSH, was initial concern for cholecystitis given
leukocytosis, elevated LFTs, and RUQ pain. Also of note,
patient's SBP dropped from the 120s to 90s initially, though
responded to IVF administration. He was started empirically on
Zosyn. Diagnotic paracentesis was negative for SBP. The patient
was seen by Surgery, who felt his exam was unremarkable. Also
felt pt would not be surgical candidate given his
co-morbidities. RUQ showed cirrhosis, ascites, and
cholelithiasis w/mild gallbladder wall thickening, but no e/o
acute cholecystitis. CT abd/pelvis also showed cholelithiasis
and a distended gallbladder. A HIDA scan was performed, and was
c/w hepatic dysfunction but did not show e/o acute
cholecystitis. MRCP demonstrated cholelithiasis and bile sludge,
mild common bile duct dilation, suggestion of mild long
segmental circumferential thickening of common hepatic duct
which could represent cholangitis, and no choledocolithiasis.
Patient was continued on antibiotics, though was switched from
Zosyn to cipro/Flagyl (has h/o AIN with nafcillin, and was
concern for possible reaction to Zosyn). Blood cultures were
negative. WBC trended down, but is still elevated at 12.9.
.
During his hopsital course, his albumin dropped to 1.2 despite
nutrition consult and supplementation. His Cr was elevated on
admission, transiently improved with IVF, but then began
trending up to as high as 2.43 on morning of transfer. Cr was
1.14 on [**2162-10-19**]. Trend during this admission: 2.21 ([**12-10**]), 1.82
([**12-11**]), 1.79 ([**12-12**]), 2.02 ([**12-13**]), 2.14 ([**12-14**]), 2.16 ([**12-15**]), 2.43
([**12-16**]). Urine output significantly dropped as well. Nephrolology
consulted, and was concerned for HRS. It is unclear how much
albumin the patient received, but he was started on trial of
midodrine/octreotide without improvement. Also of note, on day
of transfer, patient was noted to become more encephalopathic.
Ammonia level checked and was 77.
.
Currently, patient reports feeling cold. Reports hip pain and
mild persistent abdominal pain. Denies any nausea at present,
though does report episode of non-bloody, non-bilious emesis and
loose stool within past day.
Past Medical History:
Hepatitis B
EtOH/HCV cirrhosis, c/b variceal bleeding, ascites (last para
[**7-/2162**])
Osteomyelitis R sacroiliac joint [**2160**]
GERD
Chronic pain
DM2
MSSA infection prosthetic hip joint
s/p L total hip arthroplasty [**2162-4-23**] c/b MSSA infection
w/subsequent prothesis removal and spacer placement
AIN [**1-6**] nafcillin
BCC on nose
h/o splenectomy
Social History:
Lives alone. Has worked as plumber. Currently smokes ~4
cigarettes/day, >20 year smoking history. Quit EtOH 9 weeks ago,
previously drank >9-12 beers/day. History of marijauna use and
cocaine use, last cocaine use several weeks ago. Denies h/o
IVDU.
Family History:
Father - [**Name (NI) 91988**], EtOH abuse. Mother - skin cancer,
[**Name (NI) 2481**]. Denies family hx liver or kidney disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 97.9F, BP 98/58, HR 61, R 18, O2-sat 99% RA, Wgt 81.2
kg
GENERAL: patient with jaundice, temporal wasting, slightly
drowsy but responds quickly to voice and answers questions
fairly appropriately once awake (occasionally requires
redirection), NAD
HEENT: NC/AT, PERRL, EOMI, + scleral icterus, slightly dry MM
NECK: supple, no cervical LAD, no JVD
LUNGS: decreased breath sounds at bases, no
wheezing/rales/rhonchi, good air movement, respirations
unlabored, no accessory muscle use
HEART: RRR, nl S1-S2, no r/m/g
ABDOMEN: normoactive bowel sounds, soft but distended, tender to
palpation in RUQ without guarding or rebound tenderness,
reducible umbilical hernia, guiac positive (light brown stool)
EXTREMITIES: warm, well-perfused, [**1-7**]+ edema, 2+ peripheral
pulses
SKIN: jaundice, prior surgical scar on abdomen, well-healed
incision on left hip w/o surrounding erythema
NEURO: drowsy but arousable, oriented to person/hospital setting
and city/month and year, CNs II-XII grossly intact, muscle
strength 5/5 throughout, + asterixis
Pertinent Results:
OSH LABS [**2162-12-16**]:
Na 138, K 3.8, Cl 111, CO2 21, BUN 22, Cr 2.4
AST 272, ALT 69, AP 173, Tbili 4.4 (down from 5.2 on [**12-10**]), Dbili
2.5
INR 2.4
WBC 12.9, HGB 7.9, Hct 23.6, Plt 124
Alb 1.2, Total protein 6.3
Ammonia 77
.
OTHER OSH LABS:
Urine Na <3, Urine K 32, Urine Cl <4
UA 1+ urobiln, neg leuk, neg nitr, neg bld, 2 WBC, 1 RBC, 1 eos
.
OSH MICROBIOLOGY:
Urine culture [**12-13**] negative
Blood cultures 1/7 negative
Peritoneal fluid culture negative
.
Admission Labs:
[**2162-12-17**] 05:53AM BLOOD WBC-12.2* RBC-2.49* Hgb-7.6* Hct-24.0*
MCV-96 MCH-30.4 MCHC-31.5 RDW-19.1* Plt Ct-127*
[**2162-12-17**] 05:53AM BLOOD Neuts-59.9 Lymphs-18.3 Monos-17.2*
Eos-3.9 Baso-0.8
[**2162-12-17**] 05:53AM BLOOD PT-35.4* PTT-74.8* INR(PT)-3.4*
[**2162-12-17**] 05:53AM BLOOD Glucose-98 UreaN-27* Creat-2.8* Na-137
K-3.6 Cl-107 HCO3-21* AnGap-13
[**2162-12-17**] 05:53AM BLOOD ALT-60* AST-229* AlkPhos-159*
TotBili-5.3* DirBili-3.5* IndBili-1.8
[**2162-12-17**] 05:53AM BLOOD Albumin-2.4* Calcium-7.9* Phos-3.5
Mg-1.4*
.
Ascites fluid:
[**2162-12-18**] 07:34PM ASCITES WBC-28* RBC-56* Polys-14* Lymphs-27*
Monos-6* Macroph-53*
[**2162-12-18**] 07:34PM ASCITES TotPro-1.0 Albumin-LESS THAN
.
Discharge Labs:
.
Microbiology:
[**2162-12-16**] 9:17 pm SWAB Source: Rectal swab.
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Preliminary):
ENTEROCOCCUS SP..
[**2162-12-18**] 4:22 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Pending):
[**2162-12-18**] 7:34 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2162-12-19**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
.
OSH STUDIES:
[**2162-12-15**] MRI for eval of cholangitis:
1. Hepatic cirrhosis with no suspicious focal lesion
2. Cholelithiasis and bile sludge
3. Mild common bile duct dilitation. There is suggestion of mild
long segmental circumferential thickening of the common hepatic
duct which could represent cholangitis. No choledocholithiasis.
4. Large volume ascites.
5. Moderate bilateral pleural effusions.
.
[**2162-12-11**] HIDA scan:
1. Findings consistent with hepatic dysfunction
2. No evidence of acute cholecystitis
.
[**2162-12-11**] CT abd/pelvis
1. Thickening of the distal esophagus. A barium swalllow or
endoscopic correlation may be helpful for further evaluation.
2. Small biltateral pleural effusions and bibasilar
consolidation.
3. Findings compatible with hepatic cirrhosis with large amount
of ascites, as described
4. Cholelithiasis and distended gallbladder. When read in
conjunction with the US examination this may be the source of
the patient's sepsis
5. Nonobstructing bilateral renal calculi
6. Retrperitoneal adenopathy
.
[**2162-12-10**] RUQ US
1. Findings suggesting hepatic cirrhosis
2. Cholelithiasis with mild gallbladder wall thickening. No e/o
acute cholecystitis
3. Mild increase in ascites
.
Imaging:
CXR ([**12-16**]):
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs: It is unclear whether the right PIC line ends in
the upper SVC or extends into the upper right atrium. Recommend
repeating the current examination using conventional technique,
particularly to make sure there is no retained fragment from
previous line placement. Small left pleural effusion is present;
the lateral view would be very helpful to exclude left lower
lobe pneumonia. Heart size normal. No pneumothorax.
.
CXR ([**12-16**]):
HISTORY: Evaluate PICC lines.
A PIC line ends in the right atrium approximately 2 cm below the
estimated location of the superior cavoatrial junction. In
addition of small pleural effusions, there is a moderate-sized
consolidation in the left lower lobe, pneumonia until proved
otherwise. Heart size is normal.
.
XR left hip ([**12-16**]): pending
.
Renal ultrasound ([**12-16**]):
no hydronephrosis
symmetric normal sized kidneys (R 10.7 cm, L 10.9 cm)
bladder difficult to visualize and incompletely distended
Large-volume ascites.
.
CXR ([**12-21**]):
PA and lateral upright chest radiographs were reviewed in
comparison to [**2162-12-20**] and [**2162-12-17**]. There is
substantial improvement since the most recent prior radiograph
in the extent of pulmonary edema bilaterally, but in particular
on the left. Still present nodular opacities are concerning for
multifocal infectious process/hemorrhage, in particular given
the presence of consolidation seen on [**2162-12-17**]
radiograph. Still present bilateral pleural effusions are
moderate. Right PICC line tip is at the level of mid SVC.
Brief Hospital Course:
53M with h/o Hep B, Hep C and EtOH cirrhosis c/b variceal bleed
s/p banding, ascites, recent MSSA infected hip joint/prothesis
s/p removal on doxycycline, AIN secondary to nafcillin, now with
decompensated cirrhosis and probably HRS.
.
# UGIB: Patient had episode of hematemesis on [**12-17**] leading to
ICU transfer, thought to be from esophageal band ulcers vs
varices. An emergent EGD was performed [**12-17**] with no
intervention, although it showed four cords of grade 2
esophageal varices and esophageal ulcers, as well as multiple
locations with stigmata of recent bleeding. No intervention was
performed given multiple potential sources. He remained
hemodynamically stable, and Hct has remained stable. He was
treated with a PPI, octreotide gtt, sucralfate, ceftriaxone.
Nadolol was held for GIB [**12-18**], restarted when HCT stable. He had
a triple lumen PICC from OSH for access, per report is very
difficult access otherwise. PICC line 2 cm past cavoatrial
junction though not having ectopy. On the morning of [**12-21**], the
patient experienced recurrent hematemesis and shortly thereafter
BRBPR. He was scheduled for endoscopy and possible flexible
sigmoidoscopy to investigate the source of bleeding. He was
transferred to the ICU to perform these procedures. Prior to
endoscopy, the patient experienced massive upper and lower GI
bleeding. Efforts at resuscitation were fruitless and the
patient died shortly thereafter.
.
# [**Last Name (un) **]: Cr on admission 2.8, up from baseline 1.1 and increased
since beginning of recent hospitalization. Refractory to IVF,
UOP now very low. Workup at OSH ruled out AIN, obstruction,
pre-renal. Most likely HRS. Trigger may be infectious,
although OSH paracentesis negative for SBP, UA normal, no
clinical evidence of infection. One potential source is the
left hip, a site of previous osteomyelitis. Trigger appears to
be GIB though infection possible. Does have elevated WBC count
though CXR, UA, paracentesis neg for infections. Infection of L
hip spacer, or osteomyelitis possible. Renal US showed no
obstruction. The patient was treated with albumin, octreotide,
and midodrine. His diuretics were held.
.
# EtOH/HCV cirrhosis: Decompensated with ascites, possible HRS,
and possible developing encephalopathy. Patient also with recent
h/o variceal bleed. MELD 36 to 43 during admission. No evidence
of cholangitis as a source, although mild common bile duct
dilitation may indicate brewing infection. His home regimen of
nadolol and lactulose was continued. Cipro and Flagyl were
continued as empiric treatment for possible cholangitis until
[**12-19**], at which time this was switched to Ceftriaxone.
.
# MSSA infection prosthetic hip joint w/subsequent prothesis
removal and spacer placement: Possible etiology of leukocytosis.
Doxycycline suppressive therapy continued for several days,
then discontinued for concern of exacerbating liver dysfunction.
Repeat XR of hip did not reveal signs of recurrent infection.
.
# Possible RLL PNA: Per CXR, the patient may have a RLL
consolidation. Afebrile, no cough or other lung findings. [**Month (only) 116**]
be atelectasis.
.
Inactive issues:
# h/o EtOH abuse: Patient reported abstinence x9 weeks. Not
currently transplant candidate. Continue folic acid 1mg daily
# DM2: Held outpatient metformin. On ISS.
# GERD: Continued home pantoprazole.
# Chronic pain: Held oxycodone for now in setting of possible
worsening encephalopathy.
.
# CODE: Full
# CONTACT: [**Name (NI) **], Sister [**Name (NI) **] [**Name (NI) 91989**] [**Telephone/Fax (3) 91990**]
Medications on Admission:
Doxycycline 100mg Q12H
Folic acid 1mg daily
Lactulose 20gm TID prn constipation
Lasix 40mg QAM
Metformin 500mg daily
Nadolol 20mg daily
Oxycodone 5mg TID prn pain
Protonix 40mg daily
Sodium bicarbonate 650mg TID
Spironolactone 50mg [**Hospital1 **]
Discharge Disposition:
Expired
Discharge Diagnosis:
End-stage liver failure
hepatorenal syndrome
esophageal ulcers
Discharge Condition:
The patient expired.
|
[
"5849",
"25000",
"53081",
"3051"
] |
Admission Date: [**2150-1-15**] Discharge Date:
Date of Birth: [**2150-1-15**] Sex: M
Service: NB
DATE OF ADMISSION: [**2150-1-15**].
DATE OF DISCHARGE: Estimate is [**2150-1-23**]. This is
an interim date.
HISTORY: This dictation covers dates from [**1-15**] to
[**1-19**]. This is baby boy [**Name (NI) **], twin B. He is the 35-
[**4-22**] week twin gestation, diamniotic/dichorionic twins born on
[**2150-1-15**] to a 41-year-old G-3, P-2 mother with a
prenatal screen of blood type O positive antibody negative,
RPR nonreactive, rubella immune, hepatitis B negative, HIV
negative, GBS negative, PPD positive in [**2136**], with a negative
chest x-ray and six months of treatment. This mother was
transferred from [**Hospital3 1196**] for management of
her pre-term twins. The pregnancy was from donor eggs,
complicated by discordant growth, that occurred late in
gestation with this twin being a normal size. Labor was
uncomplicated. There was no maternal fever, rupture of
membrane was at the time of delivery. The infant was born
via induced vaginal delivery, Apgar scores were 8 and 9.
Other family history most significant for Ms. [**Known lastname **] suffers
from pre-term ovarian failure at age 30. All of her children
are from donor eggs and they are all from the same donor.
SOCIAL HISTORY: Mom is married to [**First Name8 (NamePattern2) 122**] [**Known lastname **] and she denied
alcohol, tobacco and drug abuse. The infant was admitted to
the NICU for prematurity. His birthweight was 2.610 kg,
which is 5 lb 12 oz, that is the 25th to 50th percentile.
Length was 48 cm, 15-75th percentile and head circumference
of 33 cm, which is the 50th percentile.
CURRENT PHYSICAL EXAMINATION: This is a generally well
appearing infant male in no apparent distress. His skin is
pink and intact with a Mongolian spot on his buttock. HEENT:
The infant is normocephalic, atraumatic, anterior fontanelles
are open and flat. Palates are intact. Red reflex is
present bilaterally. Pupils are equal and reactive to light.
Lungs are clear bilaterally. Cardiovascular: Regular rhythm
and rate, no murmur. Femoral pulses 2+ bilaterally. Abdomen
is soft, active bowel sounds, no masses or distention. GU:
Normal male, external testes bilaterally descended. Hips are
stable. Clavicles are intact. Neuro: Good tone, normal
suck, normal gag. Extremities: Warm and well perfused, with
brisk cap refill.
SUMMARY OF HOSPITAL COURSE BY SYSTEM: The infant was
admitted to the NICU on room air and has continued on room
air. He is having issues with drifting desaturations to the
80s, as well as more significant desaturations to the 60s,
while sucking on his pacifier and while taking bottles, so he
is currently on a spell count for occasional bradys and
desaturations. Today, is day 0 of 3 and is [**1-18**].
Cardiovascular: The infant's heart rate have been 130s to
140s with MAPs in the 40s. He has had no treatments for
cardiovascular issues; no echoes, no ECGs. Fluids,
electrolytes and nutrition: The baby was admitted to the
NICU p.o., ad lib, with stable blood sugars. He has
continued to either breast feed or take bottles. He started
on premature Enfamil and switched over to regular Enfamil on
[**1-17**]. He is currently taking a minimum of 100
cc/kg/day. GI: No issues. He had a bilirubin sent on the
[**1-18**] that was 6.9/0.3. He has never required
phototherapy. Hematology: There were no septic risk
factors, so the infant did not have a CBC, diff or blood
culture upon arrival to the NICU and has not required one
since arriving. Blood type is unknown. Infectious disease:
Again, no blood cultures were drawn and no antibiotics had
been given. Neurology: The infant is neurologically
appropriate, has not received any head ultrasounds or scans.
Sensory: Audiology hearing screen passed on [**1-25**].
Ophthalmology: This infant does not fall into the
category that requires ROP screening. Psychosocial: [**Hospital1 18**]
social work is involved with the family. The contact social
worker can be reached at [**Telephone/Fax (1) 8717**]. No follow-up is
planned.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], MD [**First Name8 (NamePattern2) **] [**Last Name (Titles) 2274**] [**University/College **].
The phone number is [**Telephone/Fax (1) 45369**]. To be seen on [**1-29**].
FEEDS AT DISCHARGE: Will be breast milk and/or Enfamil 20
cal.
MEDICATIONS: The infant is not currently receiving any
medication. Iron and vitamin D supplementation. Iron
supplementation is recommended for pre-term and low birth
weight infants until 12 months corrected age. While infant
fed predominantly breast milk, should receive vitamin D
supplementation at 200 International units daily until 12
months corrected age. This may be provided as a multivitamin
preparation.
CAR SEAT POSITION SCREENING: Has yet to be performed.
STATE NEWBORN SCREEN: Was sent on day of life 3, that would
be [**2150-1-18**]. Those results are pending.
IMMUNIZATIONS: The parents have deferred on hepatitis B,
referring that their children receive it from their primary
pediatrician.
Immunizations recommended: Synergist RSV prophylaxis should
be considered from [**Month (only) **] to [**Month (only) 958**] for infants who meet any
of the following four criteria: 1. Born at less than equal
to 32 weeks. 2. Born between 32 and 35-0/7 weeks with 2 of
the following; daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormality or
school age sibling. 3. Chronic lung disease. 4.
Hemodynamically significant congenital heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach six months of age. Before
this age and for the first 24 months of the child's life,
immunizations against influenza is recommended for household
contacts and out of home caregivers. This infant has not
received rotavirus vaccine. The American Academy of
Pediatrics recommends initial vaccination of pre-term infants
at or following discharge from the hospital if they are
clinically stable and at least six weeks, but fewer than 12
weeks of age. Follow-up appointment scheduled or
recommended. It is recommended that the infant follow-up
with his primary pediatrician within 48 hours of discharge
from the NICU.
DISCHARGE DIAGNOSIS:
1. Near term prematurity at 35-5/7 weeks, twin gestation
and immature feeding patterns.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
MEDQUIST36
D: [**2150-1-26**] 15:44:27
T: [**2150-1-19**] 16:30:31
Job#: [**Job Number 76703**]
|
[
"V053"
] |
Admission Date: [**2121-8-14**] Discharge Date: [**2121-8-18**]
Date of Birth: [**2065-3-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
crushing SSCP
Major Surgical or Invasive Procedure:
cardiac catheterization on [**2121-8-14**], no intervention
History of Present Illness:
Pt is a 56 y/o woman PMH significant for CAD (cath [**6-1**]: D1 with
50% stenosis, RPL 50% stenosis, LM, LCX, LAD, RCA without
stenosis, No PCI), DM2, HTN and CRI with b/l Cr 1.3, referred to
ED from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] clinic for new [**8-6**] crushing
SSCP at 11:30am [**2121-8-14**]. Pt had been off her clonidine patch
since Friday (ran out). Pt was cath'd [**6-1**] with no intervention
with miscellaneous chest pains in the past, never this severe.
EKG shows LBBB new since last EKG [**2121-6-24**]. In the ED, she was
given IV Heparin, integrillin, ASA 325, plavix 300, IV NG,
lopressor 5mg IV. Pt reports pain was persistent, +SOB,
dizziness, and on transport to ER, developed pain down right
arm, diaphoresis, nausea and vomiting. After she received
nitroglycerin SL, her pain decr to [**7-6**] dull pain. Her pain
completely resolved when she was wheeled to cath, and has not
had CP since. On exam, her BP was 180/100 with HR in 80s. She
was taken to cath. In the cath lab, no stents, admitted to CCU
for IV meds for BP control, transferred on nitro gtt and nipride
gtt.
After cath, she was in the MICU when she developed [**10-6**] low
back pain, localized to lower back and HA, tx with Tylenol and
morphine 1mg X3, which resolved her pain. A Hct was checked,
31.5 from 35.8 earlier. An Abd CT was ordered, showing a
pericardial effusion, with coronary calcifications and spleen
granulomas, with no retroperitoneal hemorrhage. A pulsus was
checked, 8mmHg.
.
ROS: Stable 7 pillow orthopnea, becomes SOB and fatigued
walking 1 flight of stairs.
Past Medical History:
1) Hypertension
2) Hyperlipidemia
3) Type II DM
4) Morbid obesity
5) s/p hysterectomy [**2085**]
6) mild transaminitis (?NASH)
7) Atypical chest pain
- [**2121-2-14**] PMIBI: No anginal symptoms or ischemic EKG changes.
Normal myocardial perfusion in a setting of soft tissue
attenuation.
- [**1-1**] TTE: Moderate symmetric LVH, LVEF 50%, trivial MR, mild
PA sys HTN, trivial/physiologic pericardial effusion.
8) h/o pericardial effusion after recent URI
Social History:
Lives with daughter in [**Location (un) 686**]
PreSchool Teacher
Denies ETOH, tobacco use
Family History:
Mother and father deceased [**1-29**] brain tumors.
Physical Exam:
Vitals: BP: 142/80, P: 82, RR: 28, Oxygen sat: 98% 2L NC
General: 56 y/o AAF NAD, WNWD, AOX3
HEENT: PERRL, MMM, Oropharynx clear without lesions
Neck: Difficult to assess JVD, fatty neck
Lungs: CTAB anteriorly
CV: RRR S1 and S2 audible
Abd: Soft, NT, ND, NABS, No masses.
Right Groin: Slight oozing, small 1cm hematoma felt on deep
palpation, no bruit
Peripheral vascular: 2+ symmetric dorsalis pedis and posterior
tibial pulses, warm extremities, pulse is regularly regular
Skin: Nails without splinter hemorrhages, skin without lesions,
acanthosis nigricans on the neck with skin tags
Pulsus: 8mmHg.
Pertinent Results:
CATH:
PCW (M/A wave /V wave) 36/42/43
RA (M/A wave/V wave) 21/26/23
AO (S/D/M) 189/135/153
PA (S/D/M) 79/35/55
RV (S/D/E) 79/17/31
CO 3.71, CI 1.74
LMCA: normal
LAD: 70% ostial D1; otherwise normal
LCX: normal
RCA: 50% ostial PL branch; otherwise normal
Supravalvular angiography; normal with no evidence of dissection
Impression: No signif CAD except for D1 lesion, unchanged,
marked systemic hypertension, marked elevation of left and right
filling pressures with reduced CO
.
CATH [**2121-6-24**]
1. branch vessel CAD 2. moderate diastolic ventricular
disease 3. mild systolic ventricular dysfunction 4. severe
pulmonary HTN
mean PCW 24, LVEDP 25, PA 74/34, central pressure 203/112,
EF 50% with global hypokinesis, no MR
[**First Name (Titles) **] [**Last Name (Titles) **] system, with LMCA, LAD, LCX, RCA free of
flow-limiting stenosis, D1 with 50% proximal stenosis, RPL
branch had 50% stenosis
.
[**2121-5-5**] ECHO EF 35%, The left and right atrium are moderately
dilated. Moderate symmetric LVH with normal cavity size and
moderate global hypokinesis. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. There
is mild pulmonary artery systolic hypertension. There is a small
circumferential pericardial effusion without evidence for
hemodynamic compromise. Compared with the prior study (tape
reviewed) of [**2121-4-1**], the findings are similar (effusion may be
minimally smaller).
.
[**2121-2-14**] PMIBI
No anginal sx or ischemic EKG changes.
Normal myocardial perfusion in setting of soft tissue
attenuation.
.
EKG: sinus at 108, QRS 140 with IVCD (LBBB morphology), poor
RWP, No ST changes, ?LVH V3
Brief Hospital Course:
Impression:
56 y/o AAF with PMH of HTN, CAD, Hyperlipidemia, DM2, Morbid
obesity, presents s/p cath with no intervenable ds complicated
by HTN, requiring ICU for IV blood pressure control.
1. HTN- After her cardiac catheterization, the patient required
IV nitroglycerin and IV nitroprusside to control her BP. She
was slowly weaned off, and started on her outpatient blood
pressure medications. The CCU team spoke with her Primary Care
Physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) 10743**], who states that the pt has been
noncompliant with BP meds at home and blood pressure control has
been a difficult issue with her. She will not be discharged on
a diuretic. The pt will go home on BB, ACEI, and Clonidine
patch. As there has been some difficulty with keeping her K
level up, despite aggressive repletion, the pt will go home on
20mEq of Kdur. She has an appointment for F/U lytes at Dr. [**Name (NI) 82029**] clinic on Wed., [**2121-8-20**].
2. CAD- Her cardiac cath demonstrated two vessel coronary artery
disease that is stable and not flow limiting, with severely
elevated right and left sided diastolic and systolic pressures
with depressed cardiac output. There was no intervention, no
stent placement. After cath, she was transferred to the MICU
under CCU level of care. Her BP was closely followed. Her
groin site from cath was without bruit or hematoma. She did
well on Aspirin and Lipitor and will continue these meds as an
outpatient.
3. Stable Pericardial effusion- Per her PCP, [**Name10 (NameIs) **] effusion is
longstanding. We checked her pulsus parodoxicus, which was 8
mmHg. She had some initial pain at her groin site, associated
with a Hct drop, and a CT abd was performed, showing apparent
slight increase in the size of the previously seen pericardial
effusion. There was no retroperitoneal hemorrhage. After she
stated she had right groin pain two days after cath, a second CT
abd was performed, with no change, stable pericardial effusion.
Her PCP is [**Name Initial (PRE) 12309**]. Her Hct is stable.
4. New LBBB- likely due to CAD.
She was stable on telemetry throughout her stay. EKGs were done
qd. Her cardiac enzymes were drawn at admission and were
negative X2 sets.
5. Type II DM- She was managed with an ISS. We restarted her
home medication, metformin 500mg po bid.
6. CRI
Her Cr was stable, at discharge, 1.2. No issues currently.
7. Hyperlipidemia
We contiunued her statin.
8. FULL CODE
Medications on Admission:
1. Clonidine 0.3/24h patch weekly q friday
2. Lipitor 40mg po qd
3. ASA 325 mg po qd
4. Norvasc 10mg po qd
5. Pantoprazole 40mg po qd
6. Lisinopril 20mg po qd
7. Triamterene-HCTZ 37.5-25mg 1 po qd
8. Labetalol 600mg po tid
9. metformin 500mg po bid
10. combivent 103-18mcg/aerosol 1-2 puffs IH qid for SOB or
wheezing
Discharge Medications:
1. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
2. 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:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-29**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*1 MDI* Refills:*2*
5. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
Disp:*20 Tablet(s)* Refills:*0*
6. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO once a day.
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
8. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSUN (every Sunday).
Disp:*4 Patch Weekly(s)* Refills:*2*
9. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hypertension
2. Coronary Artery Disease status post cath (no intervention)
3. Left Bundle Branch Block
4. Type II Diabetes Mellitus
5. Chronic Renal Insufficiency
6. Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: 2L.
If you experience any chest pain, shortness of breath, or
sweating, please report to the emergency room immediately.
Please take all of your medications.
Please follow up with your physicians (see information below).
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) 10743**], your primary care
physician, [**Name10 (NameIs) **] WEDNESDAY, [**2121-8-20**] at 12pm to her CLINIC
to check your electrolytes. She will need to check your
potassium level. Her office number is: [**0-0-**]. Her
office staff will be in touch with you.
Completed by:[**2121-8-17**]
|
[
"41401",
"4019",
"2724"
] |
Admission Date: [**2112-4-27**] Discharge Date: [**2112-5-5**]
Date of Birth: [**2069-2-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
1) Intubation
2) Central venous catheterization times two (one for temporary
dialysis)
History of Present Illness:
43 yo male with history of IDDM, prior SI, was admitted to [**First Name3 (LF) **]
on [**2112-4-23**]. Per the patient's wife, the patient was admitted to
[**Name (NI) **] after an anxiety attack during family counciling. He
initially presented to [**Hospital3 **] for medical clearance, and was
found to have normal labs including BUN 30, Crn 1.2. He has a
history of SI, but denies any ingestions at this time. The wife
reports he had no symptoms on the day of admission to [**Hospital3 **] other
than anxiety. Over the course of days, he began to complain of
nausea, vomiting, abdominal pain and fatigue starting on [**Hospital3 766**]
with progressive worsening. He also reported worsening vision.
Per [**Hospital3 **], the patient has not urinated in 3 days and has had
worsening mental status changes. It appears his BG have been
fluctuating over the course of the day as low as 40.
.
In the ED, initial vs were: T: 95.2 HR: 110 BP: 175/102 RR: 32
SatO2: 100% 10L NRB. Initially found to have EKG with wide
sinusoidal pattern concerning for hyperkalemia v. TCA or other
med overdose. He was treated with 5 amps of calcium gluconate
for empiric hyperkalemia prior to lab return. He was then found
to have a profound acidosis of 6.8, K of 9.3, lactate of 12.4,
phos 16.4, Crn of 13.7. He was subsequently treated with
boluses of bicarb as well as a drip at 250cc/hr. A right fem
line was placed, however concern for arterial placement after
ABG sent from the line with PO2 of 189. He was also given
vanc/zosyn as unclear etiology of acidosis. He was also started
on insulin drip. Toxicology was consulted and recommended high
dose thiamine as well as fomepizol which were given in the ED
for possible methanol/ethylene glycol toxicity. Renal was
consulted and recommended emergent dialysis for severe anion gap
metabolic acidosis. Has remained 100% on NRB, but RR increasing
and becoming more somnolent. The patient went to CT prior to
arrival in the MICU.
.
On the floor, the patient is somnolent but arousable. He denies
any ingestions. He complains of neck pain, but otherwise does
not have any complaints.
.
Upon discussing the patient's condition with the family, the
wife asked to speak with me separately. She endoresed that they
are separated, and he has been living with his mother. She
expressed concern that his mother may want to "find blame" in
someone for her son's condition. His wife expressed she does
not want excessive "investigation" into the cause of his illness
as he has been "poked" enough. She has also asked for the
medical team to clarify who has right to autopsy, and has asked
as HCP that she would decline at this time, despite the fact
that patient's condition is critical but stable.
Past Medical History:
-depression
-suicidal ideation
-diabetes
-hypertension
-arthritis
-chronic fatigue
-fibromyalgia
-sleep apnea: he does not wear his CPAP regularly.
-s/p back surgery
Social History:
Works at the [**Company 3596**] cleaning towels, has two daughters and is
separated from his wife.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Family History:
-mother: heart disease
-father: depression
Physical Exam:
On admission:
=============
Vitals: T: BP: 128/59 P: R: 18 O2:
General: Somnolent, but arousable, orientedx2, delirious
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
Lungs: Coarse breath sounds bl, no wheezes, rales, ronchi
CV: irregularly irregular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On discharge:
=============
Vitals:97.9(98)-134/77-71-18-95%RA.
General:Alert and Oriented x 3
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
Lungs: Coarse breath sounds bl, no wheezes, rales, ronchi
CV: Regular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley.
Ext: warm, well perfused, 2+ pulses, no cce.
Pertinent Results:
Admission labs:
===============
[**2112-4-27**] 10:15PM BLOOD WBC-15.9* RBC-4.61 Hgb-13.6* Hct-43.7
MCV-95 MCH-29.6 MCHC-31.2 RDW-13.2 Plt Ct-357
[**2112-4-27**] 10:15PM BLOOD Neuts-79.9* Lymphs-15.4* Monos-4.1
Eos-0.2 Baso-0.3
[**2112-4-28**] 01:20AM BLOOD PT-13.9* PTT-29.4 INR(PT)-1.2*
[**2112-4-27**] 10:15PM BLOOD Glucose-214* UreaN-122* Creat-13.7*
Na-132* K->10 Cl-91* HCO3-<5
[**2112-4-27**] 10:15PM BLOOD ALT-60* AST-138* CK(CPK)-567* AlkPhos-89
TotBili-0.3
[**2112-4-27**] 10:15PM BLOOD Lipase-222*
[**2112-4-27**] 10:15PM BLOOD cTropnT-0.15*
[**2112-4-28**] 01:20AM BLOOD CK-MB-6 cTropnT-0.23*
[**2112-4-28**] 07:32AM BLOOD cTropnT-0.26*
[**2112-4-27**] 11:15PM BLOOD Calcium-9.9 Phos-16.3* Mg-2.4
[**2112-4-28**] 11:06AM BLOOD Hapto-195
[**2112-4-27**] 11:15PM BLOOD Osmolal-358*
[**2112-4-28**] 11:06AM BLOOD Cortsol-23.0*
[**2112-4-28**] 11:06AM BLOOD Vanco-6.8*
[**2112-4-27**] 10:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2112-4-27**] 11:22PM BLOOD Type-ART pO2-138* pCO2-18* pH-6.80*
calTCO2-3* Base XS--33
[**2112-4-28**] 12:03AM BLOOD Type-ART pO2-77* pCO2-22* pH-6.80*
calTCO2-4* Base XS--33
[**2112-4-28**] 12:19AM BLOOD Type-ART pO2-391* pCO2-12* pH-6.86*
calTCO2-2* Base XS--32
[**2112-4-28**] 03:09AM BLOOD Type-ART Temp-35.0 pO2-84* pCO2-32*
pH-7.04* calTCO2-9* Base XS--21 Intubat-INTUBATED
[**2112-4-28**] 05:13AM BLOOD Type-ART Temp-36.8 Tidal V-550 PEEP-5
FiO2-50 pO2-71* pCO2-34* pH-7.34* calTCO2-19* Base XS--6
Intubat-INTUBATED
[**2112-4-28**] 06:59AM BLOOD Type-ART Rates-26/ Tidal V-550 PEEP-10
FiO2-60 pO2-88 pCO2-37 pH-7.37 calTCO2-22 Base XS--3 -ASSIST/CON
Intubat-INTUBATED
[**2112-4-28**] 07:36PM BLOOD Type-ART pO2-106* pCO2-45 pH-7.39
calTCO2-28 Base XS-1
[**2112-4-29**] 12:39PM BLOOD Type-ART Temp-38.4 pO2-118* pCO2-39
pH-7.26* calTCO2-18* Base XS--8 Intubat-INTUBATED
[**2112-4-30**] 08:11AM BLOOD Type-ART Temp-37.2 PEEP-10 pO2-159*
pCO2-37 pH-7.48* calTCO2-28 Base XS-4 -ASSIST/CON
Intubat-INTUBATED
[**2112-5-1**] 02:28AM BLOOD Type-ART Temp-36.9 Rates-/12 Tidal V-600
PEEP-5 FiO2-40 pO2-112* pCO2-52* pH-7.36 calTCO2-31* Base XS-3
Intubat-INTUBATED Vent-SPONTANEOU
[**2112-5-2**] 03:06AM BLOOD Type-ART Temp-37.1 pO2-84* pCO2-43
pH-7.45 calTCO2-31* Base XS-4 Intubat-NOT INTUBA
[**2112-4-27**] 10:20PM BLOOD Glucose-184* Lactate-11.2* Na-137 K-8.6*
Cl-102 calHCO3-3*
[**2112-4-28**] 12:03AM BLOOD Glucose-293* Lactate-11.8* K-8.4*
[**2112-4-28**] 12:59AM BLOOD ALCOHOL PROFILE-negative
[**2112-4-28**] 01:22AM BLOOD ETHYLENE GLYCOL-negative
[**2112-4-28**] 03:14AM BLOOD CYANIDE-negative
Imaging:
========
[**4-27**] ECG: Irregular tachy-arrhythmia of uncertain mechanism but
may be atrial fibrillation or possible multifocal atrial
tachycardia. Intraventricular conduction delay. ST-T wave
changes with prominent and peaked T waves. Findings raise the
consideration of hyperkalemia. Clinical correlation is
suggested. No previous tracing available for comparison.
.
[**4-28**] TTE: Normal left ventricular cavity size and wall thickness
with low-normal global left ventricular systolic function.
Extensive network in right atrium consistent with likely Chiari
network, as well as probable visualization of catheter tip
within the right atrium, but no discrete mass or vegetation
appreciated. No clinically significant valvular disease. Normal
pulmonary artery systolic hypertension.
.
[**4-28**] CT head: Study limited due to artifacts. No large focus of
acute intracranial hemrorhage. Vague dense foci in the upper
cervical cord and in the brain parenchyma are likely
artifactual. Consider followup study for better assessment or MR
if nto CI, if there is continued concern for abnormality.
.
[**4-28**] Renal U/S:
1. No hydroureteronephrosis or stones.
2. Major renal vasculature patent with normal waveforms. No
evidence of
renal venous thrombosis.
3. Echogenic liver, incompletely evaluated, most compatible with
diffuse
fatty change, but other forms of liver disease or advanced liver
disease
including fibrosis or cirrhosis cannot be excluded.
.
[**4-30**] CXR:
Tip of endotracheal tube now terminates 4.2 cm above the carina.
Right internal jugular catheter continues to terminate within
the right atrium. Improving atelectasis in both lower lobes with
residual patchy and linear atelectasis remaining.
.
[**2112-5-5**] 07:15AM BLOOD WBC-7.6 RBC-3.28* Hgb-9.9* Hct-28.5*
MCV-87 MCH-30.2 MCHC-34.7 RDW-13.0 Plt Ct-356
[**2112-5-5**] 07:15AM BLOOD Glucose-109* UreaN-35* Creat-2.8* Na-144
K-3.9 Cl-106 HCO3-25 AnGap-17
[**2112-4-30**] 03:15AM BLOOD ALT-37 AST-16 AlkPhos-77 TotBili-0.3
Brief Hospital Course:
43 yM h/o IDDM, depression with history of SI, admitted for
severe anion gap metabolic acidosis.
# Severe anion gap metabolic acidosis: On admission pH was
6.73 and patient had altered mental status and vision changes.
He was intubated for airway protection. Lactic acidosis
differential included metformin-associated (given ARF as below)
and ingestion though ethylene glycol, cyanide, methanol, and tox
panel was negative. He was initially started on fomipezole as an
antidote but this was stopped after negative results. Toxicology
and renal were consulted and patient was emergently dialyzed
with improvement in pH. He required 2 HD sessions on admission
with no further HD given improving acidosis and normal lactate.
Patient's HCO3 and pH continued to be acidotic for 3 days but
lactate was normal and HD was not continued. He was
hyperventilated on assist control ventilation and acidosis
resolved. Pt was successfully extubated on [**5-1**] and was patient
was transferred to the medical floor for further management of
his ARF (see below). He had large volume diuresis, and was
encouraged to take PO fluids. His kidney function continued to
improve.
# ARF: Patient's Cr had been worsening slowly prior to
admission (documented to be 0.7 at baseline and 1.2 on [**4-23**]), Cr
13.7 on admission and slowly improved to 6.1 on transfer from
MICU after 2 sessions of HD. Most likely etiology was poor PO
intake with diarrhea/vomiting prior while patient was still
taking lisinopril. Pt presented with oliguric ATN and likely
metformin-associated lactic acidosis given ongoing metformin
use. Renal ultrasound with Doppler did not show any flow
abnormalities. Patient had high urine output at time of
transfer. His metformin and lisinopril were being held. While on
the medical floor, his creatinine continued to trend down
towards the normal range. He continued to have increased urine
output and we were repleting his electrolytes as needed, with
BUN/Creatinine trending towards normal range. Pt is scheduled
to follow up with renal team to ensure that his function returns
to baseline.
# Respiratory failure: secondary to severe acidosis and altered
mental status, patient was intubated on admission for airway
protection. CXR shows some evidence of volume overload vs. ARDS
with no consolidations suggestive of pneumonia. He was initially
started on azithromycin, vanco, and zosyn. He completed a 5-day
course of azithromycin and vanco/zosyn were discontinued given
patient had negative sputum cx, afebrile and no leukocytosis and
no clinical evidence of pneumonia. Patient was successfully
extubated with no complications.
# DM: In MICU his glucose was controlled with insulin drip and
sliding scale. Metformin was held given above. Patient and his
family would like to follow up at [**Hospital **] clinic on discharge. On
the floor he was on a sliding scale. He will follow up with
[**Hospital **] clinic on discharge. He will be sent home on Lantus with
an insulin sliding scale and instructions not to take metformin.
# Psych: On admission, home regimen of abilify, effexor,
wellbutrin, topomax, klonopin, and lamictal were all held given
AMS. On the medicine floor, pt was restarted on Clonazepam,
Wellbutrin and prn abilify with the psychiatry consult service
following. The Psychiatry team felt that he was safe to return
home with outpt follow up and recommended holding the rest of
his home psychiatric medications until he is seen by his primary
outpt Psychiatrist.
.
# HLD: Restarted simvastatin 80 prior to discharge.
.
# HTN: Held lisinopril given dense renal failure. This may
need to be restarted once his renal function normalizes.
----
TRANSITIONAL ISSUES:
1. Psych - will be followed closely in an outpatient treatment
program near his home. His medications will need to be
re-evaluated and/or restarted at some point.
2. HTN - given hypotension in the unit, and renal failure these
were adjusted inpatient. These will need to be restarted once
renal function normalizes.
3. DM - patient left on insulin sliding scale.
Medications on Admission:
-abilify 2.5 mg PO BID
-effexor 37.5 mg po daily
-metformin 1000 mg po BID
-simvastatin 80 mg po qhs
-lisinopril 40 mg po daily
-topamax 50 mg [**Hospital1 **]
-lamictal 25 mg po qhs
-klonopin 0.5 mg po daily
-klonopin 1 mg po qhs anxiety
-tigan 300 mg po q4 prn emesis
-tigan 200 mg im q4 prn emesis
-imodium 2 mg po prn diarrhea
-insulin lantus 80 units sc qhs
-insulin regular sliding scale
-wellbutrin sr 150 mg po daily
Discharge Medications:
1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
2. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
4. Outpatient Lab Work
please draw blood for CBC, Chem 10 on or around [**2112-5-9**].
Please fax results to Dr.[**Last Name (STitle) 4920**] at ([**Telephone/Fax (1) 81523**]
5. insulin lispro 100 unit/mL Insulin Pen Sig: sliding scale
units Subcutaneous three times a day.
Disp:*1 pen* Refills:*0*
6. prescription
glucometer test strips - one months supply for three times a day
testing - total of 90.
7. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO QAM (once a day (in the morning)).
8. aripiprazole 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily) as
needed for agitation/racing thoughts .
9. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Forty
(40) units Subcutaneous at bedtime.
Disp:*1 pen* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1)Metabolic Acidosis
2)Acute Renal Failure
Secondary Diagnoses:
1)Bipolar Disorder
2)Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to our hospital with complaints of
nausea/vomiting, diarrhea, altered mental status.
You were briefly in our intensive care unit, intubated to reduce
severe metabolic derangements that we have found in your blood.
You were eventually extubated and transferred to the medical
floor. Your kidney function has improved greatly since your
admission.
The following changes were made to your medications:
MENTAL HEALTH MEDICATIONS
STOP Effexor, Topomax, Lamictal
CONTINUE klonipin, wellbutrin
CHANGE Abilify 2.5 mg to once daily AS NEEDED for racing
thoughts or agitation
These will have to be carefully adjusted with your psychiatrist
at some point.
OTHER MEDICATIONS
STOP Metformin - you may need to restart this medication once
your kidney function normalizes. Please discuss this with your
primary care doctor.
START Carvedilol - take 1 tablet twice a day to control your
blood pressure.
STOP lisinopril,imodium
You will need your blood drawn to evaluate your kidney function
on [**Last Name (LF) 766**], [**2112-5-9**].
Followup Instructions:
Please follow up with your psychiatrist and primary care doctor
within 4-8 days after leaving the hospital.
[**Doctor Last Name **] DAY PROGRAM: Go to [**Location (un) **] ([**Hospital 1263**] Hospital),
[**Last Name (LF) 766**], [**5-9**] at 9 am at - [**Location (un) 861**] Psychiatric Unit. Lunch
will be served.
Name: [**Last Name (LF) 81524**],[**First Name3 (LF) 6811**] A.
Location: CARITAS PHYSICIAN NETWORK
Address: [**Street Address(2) 8727**] STE 105W, [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 33743**]
*Dr. [**Last Name (STitle) **] is working on an appointment for you within one
week. If you dont hear from him by [**Last Name (STitle) 766**], please call his
office directly.
Name: [**Last Name (LF) 1557**], [**First Name3 (LF) **] PA
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
Appointment: [**Telephone/Fax (1) 766**] [**5-9**] at 1:30PM
Dr. [**Last Name (STitle) 4920**] - [**6-17**] at 10AM
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2378**]
YOU WILL BE CONTACT[**Name (NI) **] BY DR.[**Doctor Last Name 81525**] Office regarding earlier
appointment.
Completed by:[**2112-5-6**]
|
[
"5845",
"51881",
"2762",
"25000",
"2720",
"32723",
"2859"
] |
Admission Date: [**2192-4-16**] Discharge Date: [**2192-4-23**]
Date of Birth: [**2134-4-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Chest pain, DOE, fatigue
Major Surgical or Invasive Procedure:
[**4-16**] CABG x 3 LIMA->LAD, SVG->OM, SVG->PDA with re-exploration
for bleeding
History of Present Illness:
57yo M with family h/o coronary artery disease c/o chest
tightness over the last couple of years with exertion. Had +ETT
which was positive for ST depression after 6mins of exercise.
Subsequent cardiac cath at MWMC showed LAD 85%, CX 80%, OM 1
80%, OM 2 70%, RCA 75%, EF 55%. Referred to Dr. [**Last Name (STitle) 1290**] for
CABG.
Past Medical History:
Hypercholesteremia
OA
GERD
HA
rhinitis
obesity
slipped disc in L spine
s/p ventral hernia repair [**2164**]
s/p indirect inguinal hernia repair [**2185**]
Social History:
Denies Tobacco and Etoh, lives with wife in [**Name (NI) 47**]
Family History:
Brother had MI at 55, Father died of MI in 40's, paternal uncles
with MI in 40's
Physical Exam:
58yo M in bed NAD
Neuro AA&Ox3, nonfocal
Chest CTAB resp unlab median sternotomy stable, c/d/i no d/c,
RRR no m/r/g
chest tubes and epicardial wires removed.
Abd S/NT/ND/BS+
EXT warm with trace edema, LLE EVH c/d/i
5'7" 230 #
Pertinent Results:
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2192-4-21**] 11:23 AM
CHEST (PA & LAT)
Reason: assess LLL atelectasis consolidation
[**Hospital 93**] MEDICAL CONDITION:
58 year old man s/p CABG with h/o LLL consolidation
REASON FOR THIS EXAMINATION:
assess LLL atelectasis consolidation
TWO-VIEW CHEST, [**2192-4-21**]
COMPARISON: [**2192-4-18**].
INDICATION: Left lower lobe opacity.
The patient is status post median sternotomy and coronary artery
bypass surgery. Cardiac and mediastinal contours are stable in
the post-operative period. There is a resolving area of opacity
in the left lower lobe with residual patchy and linear opacity
remaining. Small pleural effusions are seen bilaterally on the
lateral projection.
IMPRESSION: Resolving left lower lobe opacity, most likely
atelectasis.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Cardiology Report ECHO Study Date of [**2192-4-16**]
PATIENT/TEST INFORMATION:
Indication: Coronary artery disease.
Height: (in) 67
Weight (lb): 240
BSA (m2): 2.19 m2
BP (mm Hg): 110/60
HR (bpm): 80
Status: Inpatient
Date/Time: [**2192-4-16**] at 14:34
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006AW584-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Ejection Fraction: 55% to 60% (nl >=55%)
Aorta - Valve Level: 2.5 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.4 cm (nl <= 3.4 cm)
Aorta - Arch: 0.0 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the
RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
systolic
function (LVEF>55%).
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: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter. Normal
aortic arch diameter. Focal calcifications in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. The patient
appears to be
in sinus rhythm.
Conclusions:
PRE-BYPASS:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and
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. The mitral valve appears
structurally normal
with trivial mitral regurgitation. There is no pericardial
effusion.
Post-Bypasss:
Normal left ventricular systolic function. EF 55%. Ascending
aorta looks
similar to prebypass period.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD on [**2192-4-16**]
14:42.
[**Location (un) **] PHYSICIAN:
Brief Hospital Course:
Mr. [**Known lastname 33179**] was admitted to the [**Hospital1 18**] on [**2192-4-16**] for further
management of his chest pain and and shortness of breath. His
catheterization at [**Hospital1 18**] revealed significant 3 vessel disease
with a preserved LVEF. Please see catheterization report for
details. Given the severity of his disease, the cardiac
surgical service was consulted for surgical revascularization.
He was worked-up in the usual preoperative manner. On [**2192-4-16**]
he successfully underwent CABGx3 (LIMA->LAD, SVG->OM, SVG->PDA).
He was taken back to the operating room for reexploration and
clot evacuation after having 400cc of bloody drainage out of his
chest tubes and a normal coagulation panel. Hemostasis was
acheived and he was reclosed. Afterward he was transferred to
the Cardiac surgery recovery unit in stable condition and
awakened neurologically intake. He was weaned from ventilator
support and extubated. On POD 2 his pressors were weaned. His
chest tubes were removed without complication. He was gently
diuresed to his preoperative weight, beta blockade and aspirin
therapy were resumed, and physical therapy service was consulted
to assist with his postoperative strength and mobility.
Electrolytes were repleted as needed. On POD 3 He was
transfused one unit of PRBC's for a HCT of 22.5. He was then
transferred to the Stepdown unit for further recovery. On POD 4
his epicardial pacing wires were removed without complication,
he continued to improve his ability to ambulate. On POD 5 Mr.
[**Known lastname 33179**] had made steady progress in his ability to ambulate
however his resting heart rate remained in the 90's for which is
lopressor was increased. His SBP dropped into the mid 90's with
ambulation up stairs. On POD6 He was had improved his exercise
tolerance, and denied SOB or Chest pain. His blood pressure was
stable. His sternotomy and leg incision were clean, dry, and
intact without evidence of infection. Discharged delayed until
pt. had a BM. He was discharged home on POD 7 with services in
good condition, cardiac diet, sternal precautions, and
instructed to follow up with his PCP/cardiologist in [**1-30**] weeks.
He will follow up with Dr. [**Last Name (STitle) 1290**] in four weeks.
Medications on Admission:
ASA 81 mg daily
Lipitor 40 mg daily
Lopressor 25 mg [**Hospital1 **]
Excedrin prn HA
Motrin prn HA
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. 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*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO daily
for 7 days.
Disp:*7 Packet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO daily for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID
Disp:*135 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
CAD
lipids
GERD
obesity
Lumbar disc injury
hernia repair
artritis
headaches
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving for one month.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 8049**] in [**1-30**] weeks [**Telephone/Fax (1) 14935**]
Dr. [**Last Name (Prefixes) **] 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**First Name (STitle) 1075**] in [**3-2**] weeks
Completed by:[**2192-4-23**]
|
[
"41401",
"4019",
"2720"
] |
Admission Date: [**2192-11-26**] Discharge Date: [**2192-12-5**]
Date of Birth: [**2155-2-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4365**]
Chief Complaint:
Altered Mental status
Major Surgical or Invasive Procedure:
Temporary groin HD cath placed. A-line placed.
History of Present Illness:
HPI: 37 gentleman with substance abuse and depression with prior
substance abuse was found to have altered mental status this
morning. Patient is unresponsive and history obtained from
family (mother, sister, father, [**Name2 (NI) 82012**] and friend). He has been
feeling depressed with suicidal ideation in the last few days.
He has a court appearance due this Wednesday. He called his ex
wife overnight and did not sound drunk. He called her again at
5 AM and sounded drunk. Around that time he was found to be
confused and soon after unconscious. He had two bottles of
antifreeze next to him with ? one bottle empty.
He was taken to [**Hospital3 **]hospital where heis ABG showed
6.74/24/551. Patient was intubated and given fomipezole 15
mg/kg one dose and bicarb. Already received Narcan 2mg prior to
arrival to the ED. He got a Head CT without contrast which did
not show any significant abnormalities. He had a neck CT which
was poor quality but did not show any significant abnormalities.
LP was done there which was within normal limits. He was placed
on neck collar and was transfered to [**Hospital1 18**] for hemodialysis.
On arrival to ICU, patient was unresponsive with vitals of T
95.5 BP 162/78 HR 165 RR 17 O2 sat 99% on Volume/AC TV 701
[**9-30**] FIO2 50%
Patient has not complained any symptoms prior to this episode.
Past Medical History:
PMHx:
Depression, h/o attempted suicide in [**2179**] by crashing car into a
tree per family.
Crack cocaine abuse
No other significant medical problems
Social History:
Social History: Carpenter. Lives occasionally with father and
friend. Rare use of alcohol. Smoker. Heavy crack coccaine
use. TB risk include incarcerated in [**2179**] for 10 months.
Family History:
Family History: Family unable to recall any.
Physical Exam:
Vitals: T 95.5 BP 162/78 HR 165 RR 17 O2 sat 99% on
Volume/AC TV 701 [**9-30**] FIO2 50%
Gen: Unresponsive, intubated on mechanincal ventillation, not
withdrawing to pain
HEENT: Pupils round, mucous membranes dry, JVP not elevated
Heart: S1S2 tachycardic, irreglulary irregular, no murmur or
rubs heard.
Lungs: Kussmal respirations, CTAB in anterior lung fields
Abdomen: Soft NTND
Ext: WWP, DP 2+ b/l, no edema
Neuro: Normal muscle tone, absent reflexes, plantar no movement
Pertinent Results:
[**2192-11-26**] 02:10PM BLOOD WBC-40.0* RBC-5.30 Hgb-17.3 Hct-52.6*
MCV-99* MCH-32.6* MCHC-32.8 RDW-12.6 Plt Ct-463*
[**2192-11-26**] 10:49PM BLOOD WBC-26.7* RBC-4.20* Hgb-13.9*# Hct-38.0*#
MCV-91# MCH-33.0* MCHC-36.5*# RDW-12.5 Plt Ct-245
[**2192-11-27**] 04:37AM BLOOD WBC-20.5* RBC-3.79* Hgb-12.4* Hct-34.4*
MCV-91 MCH-32.6* MCHC-36.0* RDW-12.7 Plt Ct-203
[**2192-11-26**] 02:10PM BLOOD Neuts-92.6* Lymphs-2.8* Monos-4.0 Eos-0.2
Baso-0.4
[**2192-11-26**] 10:49PM BLOOD Neuts-92.9* Lymphs-3.5* Monos-3.6 Eos-0
Baso-0
[**2192-11-26**] 02:10PM BLOOD PT-15.0* PTT-26.5 INR(PT)-1.3*
[**2192-11-26**] 02:10PM BLOOD Plt Ct-463*
[**2192-11-27**] 04:37AM BLOOD PT-14.5* PTT-27.1 INR(PT)-1.3*
[**2192-11-27**] 04:37AM BLOOD Plt Ct-203
[**2192-11-26**] 02:10PM BLOOD Glucose-418* UreaN-17 Creat-2.7* Na-142
K-6.0* Cl-100 HCO3-LESS THAN
[**2192-11-26**] 10:49PM BLOOD Glucose-127* UreaN-10 Creat-1.8* Na-144
K-3.2* Cl-100 HCO3-25 AnGap-22*
[**2192-11-27**] 04:37AM BLOOD Glucose-137* UreaN-13 Creat-2.5* Na-140
K-3.6 Cl-99 HCO3-27 AnGap-18
[**2192-11-27**] 09:49AM BLOOD Glucose-111* UreaN-13 Creat-2.7* Na-136
K-3.9 Cl-99 HCO3-28 AnGap-13
[**2192-11-26**] 02:10PM BLOOD ALT-22 AST-25 AlkPhos-127* TotBili-0.1
[**2192-11-26**] 09:03PM BLOOD CK(CPK)-178*
[**2192-11-26**] 10:49PM BLOOD ALT-19 AST-28 LD(LDH)-307* CK(CPK)-158
AlkPhos-61 TotBili-0.4
[**2192-11-27**] 04:37AM BLOOD ALT-18 AST-26 LD(LDH)-284* CK(CPK)-155
AlkPhos-58 TotBili-0.5
[**2192-11-26**] 09:03PM BLOOD CK-MB-9 cTropnT-<0.01
[**2192-11-26**] 10:49PM BLOOD CK-MB-8 cTropnT-<0.01
[**2192-11-27**] 04:37AM BLOOD CK-MB-8 cTropnT-<0.01
[**2192-11-26**] 02:10PM BLOOD Calcium-8.4
[**2192-11-26**] 10:49PM BLOOD Albumin-3.0* Calcium-6.2* Phos-2.6*
Mg-1.2*
[**2192-11-27**] 04:37AM BLOOD Albumin-2.9* Calcium-6.8* Phos-4.1 Mg-2.5
[**2192-11-27**] 09:49AM BLOOD Calcium-7.5* Phos-3.9 Mg-2.2
[**2192-11-26**] 02:10PM BLOOD Acetone-NEGATIVE Osmolal-373*
[**2192-11-26**] 09:03PM BLOOD Osmolal-304
[**2192-11-27**] 04:37AM BLOOD Osmolal-299
[**2192-11-26**] 02:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-11-26**] 02:21PM BLOOD Type-ART pO2-587* pCO2-16* pH-6.95*
calTCO2-4* Base XS--28
[**2192-11-26**] 10:09PM BLOOD Type-ART pO2-86 pCO2-36 pH-7.42
calTCO2-24 Base XS-0
[**2192-11-27**] 12:45AM BLOOD Type-ART
[**2192-11-27**] 04:46AM BLOOD Type-ART pO2-91 pCO2-47* pH-7.38
calTCO2-29 Base XS-1
[**2192-11-27**] 10:15AM BLOOD Type-ART pO2-120* pCO2-55* pH-7.32*
calTCO2-30 Base XS-1
[**2192-11-26**] 02:11PM BLOOD Glucose-376* Lactate-9.7* Na-144 K-5.7*
Cl-104 calHCO3-3.3*
[**2192-11-27**] 12:45AM BLOOD Lactate-6.5*
[**2192-11-27**] 04:46AM BLOOD Glucose-124* Lactate-6.8*
[**2192-11-27**] 08:37AM BLOOD Lactate-3.0*
[**2192-11-27**] 10:15AM BLOOD Glucose-113* Lactate-1.7
[**2192-11-26**] 10:09PM BLOOD freeCa-0.83*
[**2192-11-27**] 04:46AM BLOOD freeCa-0.95*
[**2192-11-27**] 10:15AM BLOOD freeCa-1.05*
.
Radiologic studies:
[**11-26**] CXR:
IMPRESSION:
ET tube positioned 6.4 cm above the carina.
Upper lobe opacities, left greater than right, may reflect
aspiration or
pneumonia.
.
[**11-27**] CXR:
IMPRESSION:
Focal consolidation has increased in the left apex, developed in
the right
supra- and infra-hilar regions consistent with widespread
pneumonia, possibly due to a previous large aspiration. Heart
size top normal. Mediastinal vascular engorgement due, in part,
to supine positioning suggests hypervolemia; there is no
pulmonary edema and pleural effusion, if any, is minimal. No
pneumothorax. ET tube in standard placement.
.
Microbiology:
[**11-26**]- blood culture NG final
12/5 blood cx - pending x3
[**11-26**] u/a neg
[**11-30**] u/a positive, cx negative
[**12-1**] - FECAL CULTURE (Final [**2192-12-3**]):
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final [**2192-12-3**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2192-12-2**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
Imaging:
[**2192-11-27**] ECHO:
IMPRESSION: Suboptimal image quality. Preserved regional and
global biventricular systolic function. No structural valvular
disease
.
[**2192-11-30**] CXR:
A left retrocardiac opacity has slightly worsened and might
represent atelectasis although aspiration cannot be excluded. No
evidence of failure is present. Right perihilar opacity has
improved in the interval.
.
[**2192-12-1**] - CT head - IMPRESSION: No evidence of acute
intracranial abnormalities.
.
MRI L spine - PRELIM as per radiologist - mild lumbar
spondlyosis at L3/L4 with some disc bulging, no evidence of
nerve root impingement, no canal stenosis, no epidural space
abnormalities
.
EKG - [**12-3**] - Sinus rhythm. Compared to the previous tracing of
[**2192-12-2**] no change
Brief Hospital Course:
37 y/o gentleman with h/o polysubstance abuse, depression, prior
suicidal ideation and who presented with altered mental status
in the setting of antifreeze ingestion.
.
# Depression/Suicide Attempt: Once patient was cleared from the
MICU, social work was consulted. Please see detailed from
social work outlining disucssions. Patient will be transferred
to [**Hospital1 **] 4 which is an inpatient psychiatric unit.
Pyschiatry also was consulted and followed the patient in house.
Reccomended starting therapy with low dose anti-depressant.
Patient was maintained on suicide precautions with one/one
sitter throughout his hospital stay and did not make any suicide
attempts or gestures.
.
# Acid/base disturbance: Anion gap metabolic acidosis with
increased osmolarity to 373 consistent with ethylene glycol
toxicity. Initially treated with bicarbonate, high dose folate,
thiamine, and pyridoxine, and fomepizole Q4H (typically dosed
Q12 but dosed Q4H while patient was on HD/CVVH). A femoral HD
dialysis catheter was placed and patient was started on HD. His
calcium was aggressively repleted throughout. Due to initial
borderline blood pressures he was switched to CVVH. He
continued on CVVH until his ethylene glycol level returned <20
and his osmolar and anion gaps closed. He received a total of 3
days of HD/CVVH. Once ethylene glycol level was <20, his
fomepizole was discontinued. His folate and thiamine were also
decreased to standard once daily dosing after 24 hours of high
dose supplementation. Patient was then transferred to floor.
.
# Altered Mental status: Most likely due to ethylene glycol
toxicity on presentation. Patient was intubated for airway
protection. Once ethylene glycol cleared patient was weaned off
sedation and was extubated on hospital day # 5. Patient
underwent a CT head whic was normal. Per report, LP was within
normal limits at OSH. Following sedation wean and sedation,
mental status improved. Patient became alert and oriented x3.
Speech initially slow however seemed to improve back to his
baseline. Patient was evaluated by psychiatry and felt to need
inpatient psychiatry.
.
# Acute renal failure: Most likely secondary to ethylene glycol
toxicity. Urine on admission showed oxalate crystals. Patient
had a femoral HD line placed and he was started on HD. Due to
borderline low BPs he was transitioned to CVVH which was
continued as above. BPs normalized and he was switched back to
HD. Once the patient was transferred to the floor he had a
tunnelled line placed and the femoral line was removed.
Discontinued foley however patient still with low urine output <
100 cc per day. Renal reccomended starting phosphate binder as
phosphorus level began to climb. Renal will continue to follow
on transfer. Plan is for patient to switch to phosp low from
lanthanum carbonate tomorrow if phosphorus levels are within
normal limits tomorrow.
.
# s/p fall: In hard collar on arrival. CT head at OSH without
significant abnormalities but poor quality neck films. He was
switched to [**Location (un) 2848**]-J collar until he was extubated and then his
c-spine was cleared clinically and collar was removed.
.
# Atrial fibrillation: Unclear etiology. Patient was noted to
have atrial fibrilliation with rapid ventricular response on
admission to the hospital which resolved with sedation, HD, and
hydration. B-blocker held due to recent cocaine use. ECHO was
without significant abnormalities. Patient had normal CK and
Ck-MBs. He spontaneously converted to normal sinus on hospital
day # 2 and remained in sinus throughout the remainder of his
hospital admission. A full dose aspirin was initiated, however
on repeat EKG patient found to be in normal sinus rhythm and
therefore aspirin was discontinued. Checked a TSH which was
normal.
.
# Leukocytosis/LUL infiltrate: Patient on admission noted to
have LUL infiltrate and was treated with ceftriaxone and flagyl,
but ceftriaxone was changed to levofloxacin given need for
aggressive calcium repletion. On hospital day #5, U/A
suggestive of UTI however UA was negative. At that time
antibiotics were changed from levo and flagyl to ceftriaxone.
Patient completed course of antibiotic therapy for community
acquired pneumonia. On the floor patient remained afebrile with
stable white blood cell count. No cough or sputum production.
.
# Anemia- patient with anemia on presentation, no clear source
of active bleeding. Anemia work-up significant for normal
b12/folate. Iron 78, TIBC 159 (low), ferritin 519 (elevated),
TRF 122 (low) so no evidence of iron deficiency anemia, but
rather likely anemia of chronic disease of unclear etiology,
however suspect acute renal failure is likely contributing to
current anemia. No previous diagnosis of any chronic disease.
Ordered patient for HIV test and got consent, however this was
not drawn during this admission. PPD was placed on admission and
was negative at 48 hours. Patient will get EPO at HD as per
renal.
Medications on Admission:
none
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
3. Lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever, headache.
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
D 4
Discharge Diagnosis:
Primary: s/p suicide attempt with ethylene glycol
Secondary:
Depression
Crack cocaine use
Alcohol abuse
Discharge Condition:
Afebrile, vital signs stable, alert, awake, oriented x 3, speech
appropriate, [**2-27**] immediate and 5 minute recall, can spell WORLD
backwards and do serial 7s.
Discharge Instructions:
You were admitted to the hospital after an overdose of ethylene
glycol which led to acute renal failure and required ICU
admission with intubation and hemodialysis. You were treated
with IV fluids and fomipazole, HD, thiamine and folate. You were
extubated and transferred to the medicine floor and your mental
status continued to improve. You were evaluated by toxicology as
well as nephrology and psychiatry. We are reccomending inpatient
psychiatry on discharge from medicine. You are currently
considered medically cleared for discharge.
.
You will continue on dialysis for now pending hopeful
improvement in renal function. In addition we have started you
on a low dose anti-depressant as per our psychiatrists.
Followup Instructions:
You should follow up with your primary care provider [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 82013**] once you are discharged from inpatient
psychiatry. We cannot make you an appointment now as we do not
know when you will be discharged.
You should also continue to see an outpatient psychiatrist and
psychologist as reccomended by psychiatry on discharge.
Completed by:[**2192-12-5**]
|
[
"5849",
"2762",
"5070",
"51881",
"2767",
"42731",
"311"
] |
Admission Date: [**2145-7-26**] Discharge Date: [**2145-7-29**]
Date of Birth: [**2089-3-13**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
1. Abdominal pain
2. Chills
3. Recent pancreatitis and known pseudocyst
Major Surgical or Invasive Procedure:
None
History of Present Illness:
56M with chronic pancreatitis, EtOH abuse, Renal Ca s/p
nephrectomy and adjuvant tx, discharged 4 days ago from OSH for
acute pancreatitis and pseudocyst who presented to OSH ED with
F(103) and chills with increasing abd pain. In [**Name (NI) **], pt was
febrile and transiently hypotensive to 90s/60s). Labs notable
for WBC 9.6 but with bandemia, Hct 36.6, Cr
1.3, Lipase 218 from 123 ([**7-17**]). CT at OSH concerning for
enlarging pancreatic tail pseudocyst; also noted multiple other
smaller pseudocysts. Given concern for infected pseudocyst, pt
admitted to OSH ICU for ?sepsis and managed with rIVF/Abx. Pt
transferred to [**Hospital1 18**] for further evaluation of need for
intervention.
Past Medical History:
PMH: EtOH(last EtOh [**7-13**], hx tremors in past, denies sz.),
pancreatitis, pseudocyst, metastatic renal CA, HTN, PVD.
PSH: s/p R nephrectomy
Social History:
12beers/d; heavy tob; remote IVDU. Lives with brother and
mother. Disabled.
Family History:
NC
Physical Exam:
On Admission:
VS 98.2 90 130/100 19 95ra
A+Ox3, NAD
RRR, clear s1/s2, no m/r/g
CTAB
soft, NABS, NT/ND
Ext WWP, no edema, 2+DPs
On Discharge:
VS: Afebrile, VSS
Gen: NAD
CV: RRR
Lungs: CTAB
Abd: Soft, nontender, nondistended, fullnes in left/epigastrium
Ext: Warm, no c/c/e
Neuro: AxO x 3, PERRL, EOMI
Pertinent Results:
[**2145-7-26**] 09:01PM WBC-10.8 RBC-4.18* HGB-12.0* HCT-36.8* MCV-88
MCH-28.8 MCHC-32.7 RDW-20.2*
[**2145-7-26**] 09:01PM NEUTS-83.2* LYMPHS-10.7* MONOS-4.6 EOS-1.2
BASOS-0.2
[**2145-7-26**] 09:01PM GLUCOSE-97 UREA N-5* CREAT-0.9 SODIUM-142
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-22 ANION GAP-13
[**2145-7-26**] 09:01PM ALT(SGPT)-56* AST(SGOT)-44* ALK PHOS-409*
AMYLASE-69 TOT BILI-0.4
[**2145-7-26**] 09:01PM LIPASE-76*
[**2145-7-27**] 04:19AM BLOOD WBC-9.0 RBC-4.23* Hgb-11.8* Hct-36.4*
MCV-86 MCH-27.8 MCHC-32.4 RDW-20.2* Plt Ct-242
[**2145-7-27**] 04:19AM BLOOD Glucose-109* UreaN-6 Creat-0.8 Na-140
K-3.6 Cl-110* HCO3-22 AnGap-12
[**2145-7-27**] 04:19AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.6
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation of the possible infected pancreatic pseudocyst.
Patient was admitted as a transfer in ICU for observation. In
ICU patient was afebrile, with stable VS. Patient was started on
CIWA protocol s/t history of alcoholism, Foley catheter was
placed to monitor urine output, and patient was NPO. He was
comfortable, with a soft and essentially nontender abdomen.
Hemodynamics were normal. He had no further fevers and the
bandemia resolved, off abx. On HD # 2 patient was transferred to
the regular floor, patient's diet was advanced to clear liquids,
and when tolerated well, advanced to regular. CIWA protocol was
discontinued and IV fluids were stopped after patient tolerated
PO. Foley catheter was d/cd. Patient remained afebrile, WBC WNL.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly, labbwork was routinely followed; electrolytes were
repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Aspirin 81 mg PO qd
Prilosec 20 mg PO qd
Amlodipine 5 mg PO qd
Simvastatin 20 mg PO qd
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Pancreatic pseudocyst
2. Acute 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 [**6-7**] 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.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] (PCP) in [**3-3**] weeks after
discharge.
.
Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD. Dr. [**First Name (STitle) **] office will contact you about
date/time of the follow up in 2 weeks. You will be scheduled to
have an abdominal CT scan prior your follow up with Dr. [**First Name (STitle) **]. If
you have any questions, please call Dr.[**Name (NI) 5067**] office at
[**Telephone/Fax (1) 2998**]. Please also call for any recurrent abdominal pain
or fevers.
Completed by:[**2145-7-29**]
|
[
"4019",
"3051"
] |
Admission Date: [**2130-12-24**] Discharge Date: [**2130-12-31**]
Date of Birth: [**2051-1-26**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Quinidine / Procainamide / Quinine / Codeine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
hypotension, hyperkalemia
Major Surgical or Invasive Procedure:
Hemodialysis catheter placement
History of Present Illness:
Mr. [**Known lastname 1349**] is a 78-year-old male with a history of ventricular
fibrillation arrest in [**2108**], status post ICD placement, dilated
cardiomyopathy,
atrial fibrillation, hypertension, and CVA who presented to the
[**Hospital1 18**] ED complaining of 8 lb weight gain with increased edema of
LE over one week despite compliance with medications. Decreased
po intake over past week. No SOB, chest pain, syncope, fatigue.
Found to be hypotensive and hyperkalemic in the ED. ROS
positive for epistaxis (was taking Afrin for this), occasional
nausea and nonbloody/nonbilious vomitting.
Past Medical History:
1. Ventricular fibrillation arrest in [**2108**] - has had ICD
placement.
2. Dilated cardiomyopathy. Echocardiogram in [**2126-2-27**]
showed an ejection fraction of 20% with inferoapical
hypokinesis plus right ventricular hypokinesis.
3. Atrial fibrillation, status post DC cardioversion in
[**2114**], on coumadin.
4. Hypertension.
5. Hypothyroidism.
6. Cerebral vascular accident in [**2117**].
7. Rheumatoid arthritis.
8. Positive lupus anticoagulant.
Social History:
Mr. [**Known lastname 1349**] lives with his wife. [**Name (NI) **] denies any tobacco or drug
use. He does note occasional alcohol use.
Physical Exam:
T 97.0. Blood pressure 84/54. Heart rate 81. Respiratory rate
10. Oxygen
saturation 100% on RA. In general, in no acute
distress, alert and oriented times three, overweight man. Head,
eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils
are equal,
round, and reactive to light and accommodation. Oropharynx
is pink without lesions, mucous membranes dry. Nares with dry
blood. Neck is supple. Unable to determine JVD secondary to
excess soft tissue at neck. No lymphadenopathy. Chest clear to
auscultation
bilaterally. Cardiovascular: RRR, S1, S2
are faint. A 2/6 systolic ejection murmur at the apex.
Abdomen soft, nontender, nondistended. Extremities: 1+
pitting edema bilaterally. No clubbing or cyanosis.
Dorsalis pedis pulses are 1+ bilaterally. Neurologically,
alert and oriented times three. Cranial nerves II through
III are intact. Strength is [**5-3**] in upper and lower
extremities bilaterally. Sensation to light touch is intact.
Deep tendon reflexes are decreased bilaterally but equal.
Pertinent Results:
[**2130-12-24**] 01:30PM PT-25.5* PTT-56.8* INR(PT)-4.1
[**2130-12-24**] 01:30PM NEUTS-94.2* BANDS-0 LYMPHS-2.3* MONOS-3.0
EOS-0.4 BASOS-0
[**2130-12-24**] 01:30PM WBC-10.0 RBC-2.45*# HGB-8.1*# HCT-24.3*#
MCV-99* MCH-33.0* MCHC-33.3 RDW-15.5
[**2130-12-24**] 01:30PM DIGOXIN-0.3*
[**2130-12-24**] 01:30PM TSH-3.3
[**2130-12-24**] 01:30PM calTIBC-267 FERRITIN-786* TRF-205
[**2130-12-24**] 01:30PM ALBUMIN-4.0 CALCIUM-8.5 PHOSPHATE-10.8*#
MAGNESIUM-2.3 IRON-104
[**2130-12-24**] 01:30PM CK-MB-22* MB INDX-3.7 cTropnT-0.36*
[**2130-12-24**] 01:30PM LIPASE-96*
[**2130-12-24**] 01:30PM ALT(SGPT)-38 AST(SGOT)-46* CK(CPK)-595* ALK
PHOS-192* AMYLASE-137* TOT BILI-0.6
[**2130-12-24**] 01:30PM GLUCOSE-123* UREA N-272* CREAT-5.4*#
SODIUM-126* POTASSIUM-7.5* CHLORIDE-92* TOTAL CO2-16* ANION
GAP-26*
[**2130-12-24**] 02:02PM LACTATE-1.8 K+-7.5*
[**2130-12-24**] 02:02PM TYPE-[**Last Name (un) **] PO2-60* PCO2-42 PH-7.21* TOTAL
CO2-18* BASE XS--10 COMMENTS-GREEN TOP
[**2130-12-24**] 03:54PM K+-6.6*
[**2130-12-24**] 05:00PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-4
[**2130-12-24**] 05:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2130-12-24**] 05:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2130-12-24**] 05:00PM URINE U-PEP-MULTIPLE P IFE-NO MONOCLO
OSMOLAL-371
[**2130-12-24**] 05:00PM URINE HOURS-RANDOM UREA N-577 CREAT-89
SODIUM-27 TOT PROT-15 PROT/CREA-0.2
[**2130-12-24**] 10:40PM PT-33.0* PTT-150* INR(PT)-6.9
[**2130-12-24**] 10:40PM PLT COUNT-79*
[**2130-12-24**] 10:40PM WBC-7.4 RBC-2.52* HGB-8.2* HCT-24.1* MCV-96
MCH-32.7* MCHC-34.2 RDW-15.2
[**2130-12-24**] 10:40PM PEP-NO SPECIFI
[**2130-12-24**] 10:40PM calTIBC-264 HAPTOGLOB-143 FERRITIN-761*
TRF-203
[**2130-12-24**] 10:40PM TOT PROT-6.6 CALCIUM-8.1* PHOSPHATE-5.2*#
MAGNESIUM-1.8 URIC ACID-3.4 IRON-90
[**2130-12-24**] 10:40PM CK-MB-20* MB INDX-3.9 cTropnT-0.34*
[**2130-12-24**] 10:40PM LD(LDH)-326* CK(CPK)-517* TOT BILI-0.7
[**2130-12-24**] 10:40PM GLUCOSE-140* UREA N-135* CREAT-2.8*#
SODIUM-137 POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-17
Brief Hospital Course:
In ED, noted to have renal failure, K+ 7.5 with EKG changes,
given HCO3, 1L IVF, insulin, kayexelate, and transferred to
MICU.
.
In MICU, interrogation of ICD showed no VT or VF but multiple
episodes of NSVT. Pt tolerated two treatments of HD for
uremia/hyperkalemia. He was started on
hydrocortisone/fludrocortisone for adrenal insufficiency. Pt was
evaluated for retroperitoneal hematoma/femoral hematoma w/
femoral US/Abd CT which and showed femoral hematoma. He received
3 units of PRBCs for decreased HCT and femoral hematoma. [**12-26**]
during HD treatment, pt developed VT w/ recurrent ICD shocks,
rhythm converted to VF, received lidocaine and amiodarone
boluses, ICD was reprogrammed. Pt then transferred to CCU
service for further observation. While in the CCU pt had
further episodes of VT and so antiarrhythmic regimen was
changed.
Patient became hypotensive in am of [**2130-12-30**] felt to be septic
secondary to line sepsis from femoral cath. Patient started on
Neo for pressure support. Patient mental status continued to
deteriorate throughout day and into night. After lengthy
discussion with family,family wished to make patient CMO.
Patient ICD was turned off on [**2130-12-30**] so it would still pace but
would not intervene if patient had arrythmia. Patient kept on
morphine drip for comfort and all other meds d/c'd. The patient
became more hypotensive and expired on [**2130-12-31**].
Medications on Admission:
Home meds: lasix 120 [**Hospital1 **], prilosec, diovan 80, coumadin,
allopurinol 100, synthroid 25, prednisone 5, aldactone, dig
.125, astelin
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2131-1-4**]
|
[
"5849",
"2767",
"2762",
"2761",
"42731",
"4280",
"2851",
"40391",
"2449"
] |
Admission Date: [**2179-3-29**] Discharge Date: [**2179-4-2**]
Date of Birth: [**2119-11-3**] Sex: F
Service: MEDICINE
Allergies:
Theophylline / Flagyl / Clindamycin / Antihistamines
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 59 yo F w/PMHx sx for substance abuse, COPD, and
asthma who presented after being discharged today from a rehab
facility. Pt had c.diff colitis, requiring emergency ex-lap with
partial colectomy and ileostomy. Patient's post-operative course
was c/b pneumonia, COPD flare. Patient states that she was
admitted to [**Hospital1 756**] for a reversal of her ileostomy one month
ago, and was sent to rehab from there. She did well there, and
was discharged to home today on multiple medications, including
oxycodone and ativan. She states that she took 3 ativan and 2
oxycodone at home due to worsening pain. She states that she
usually takes 1-2 tablets at a time. Four hours after discharge,
patient was found by her sister to be minimally responsive at
home, responsive only to painful stimuli. Upon arrival by EMS,
patient was given Narcan, and woke up completely. Pt denies any
other substance use. She does note dizziness on standing and
diarrhea, which is chronic for her.
.
In the ED, patient had a CXR which showed a right infrahilar
aspiration. Her EKG was unremarkable. She received 1L NS.
.
ROS: She denies any chest pain, palpitations, SOB, headache,
dizziness, abdominal pain, fevers, chills, rash. She notes
constant diarrhea as well as associated nausea. She notes some
dizziness on standing.
Past Medical History:
1) COPD: intubated previously, she uses O2 only when not
feeling well. FEV1 0.64L. Her functional status is poor--she
is not able to do much besides ADLs due to dyspnea.
2) Asthma
3) Parotid CA, tonsillar CA s/p surgery and XRT c/b mandibular
osteonecrosis.
4) Intermittent RLE edema: took lasix for a few days 2-3 weeks
ago. Etiology is not known.
5) Mitral valve prolapse.
NO h/o of CAD.
Social History:
Lives at home, just discharged from rehab on day of
presentation. Single. On disability. Hx substance abuse,
including alcohol, tobacco, cocaine, opiates.
Family History:
Father with h/o laryngeal CA, PE
Physical Exam:
VS: T98.2/99.4 BP 125/75 HR 115 O2sat 93% 2L NC.
Gen: cachectic appearing female in NAD. Speaking in a whisper.
HEENT: MM dry. No oral ulcers or lesions. Radiation changes on
right jaw.
Hrt: Distant heart sounds. No MRG.
Lungs: Poor air movement. Minimal expiratory wheezing. No rales
or rhonchi.
Abd: Soft, nontender. Normoactive BS. Ileostomy revision site
with full thickness wound, with no drainage. Good granulation
tissue.
Ext: Warm.
Neuro: PERRL. Pinpoint pupils. Able to move all extremities.
Pertinent Results:
Na:139 K:5.2
Cl:95 TCO2:30 Creat 1.0 Glu:170
.
9.8 \ 11.4 / 577 D
------
33.8
N:92.1 Band:0 L:5.2 M:1.8 E:0.5 Bas:0.4
UA: Neg leuks, neg nitrites, trace protein, occ bacteria, [**4-12**]
WBC.
CXR:
1. Upper zone redistribution, without other evidence of CHF.
Probable
underlying COPD with pulmonary hypertension.
2. Right infrahilar patchy air -- this could be due to
aspiration or
pneumonic infiltrate.
3. Probable scarring at the left lung base. Recommend comparison
with
previous films when they become available, to confirm this.
4. Asymmetry of breast shadows as described.
.
EKG: Sinus rhythm. PRWP. No acute ST-T changes. Intervals fine.
No significant change from prior.
.
Serum tox: negative
Urine tox: positive for cocaine, opiates
Brief Hospital Course:
Ms. [**Known lastname **] is a 59 yo F w/hx polysubstance abuse who presents
after being found unresponsive at home, likely [**3-12**] substance
abuse, now improved after Narcan administration. Hospital
course by problem:
.
#. Unresponsiveness. Most likely etiology for episode of
unresponsiveness is narcotics overdose, with reversal with
Narcan. Pt has a significant substance abuse history, and tox
screen is positive for both cocaine and opiates on admission.
We monitored her in the ICU and she returned to her baseline.
We obtained a social work consult and screened her for
placement. This event occurred within four hours of your
discharge from rehab so feel it is safest for you to return to a
rehab.
.
#. Aspiration pneumonitis. Patient with evidence of aspiration
pneumonitis on CXR, likely from episode of being down on at
home. Patient also on pureed diets at discharge from rehab,
possibly due to hx of esophageal dysmotility. We monitored her
oxygen requirement. She remained at her normal requirement of
2L NC so did not start antibiotics.
.
#. COPD/asthma. Patient with FEV1 0.64L, with history of
intubations in the past. She was breathing well on 2L NC.
-Albuterol/ipratropium nebulizers q6h
-Advair inhaler 500/50 1 puff [**Hospital1 **]
-Continue home prednisone dose of 10 mg qd with PPI and insulin
SC
.
#. S/P colostomy revision.
-we monitored site. It did not appear to be superinfected
-Tylenol for pain relief
.
#. Substance abuse. Patient with evidence of cocaine/opiates on
tox screen, and has a significant substance abuse history. Pt
denies any current use of cocaine.
-We placed a social work consult
.
#. Hx alcohol abuse.
-MVI, folate, thiamine.
-No need for CIWA scale as serum alcohol negative, and just
discharged from rehab on day of admission
.
#. Hx depression. Patient denied SI, although has a hx of
depression and episode of overdose today. She denied that it
was intentional and had no thoughts of hurting herself.
-Continued Zyprexa and Remeron
.
#. Anemia. Patient with microcytic anemia, of unclear duration.
-iron studies did not indicate chronic inflammation or iron
deficiency
-we guaiac'd stools
.
#. FEN. Pureed diet. Ensure 1 can three times a day. Aspiration
precautions. 1L LR overnight.
.
#. PPx. Heparin SC. Senna/colace. Simethicone. PPI.
Acetaminophen for pain relief.
.
#. Code. DNR/DNI.
.
#. Communcation. With patient.
Medications on Admission:
Remeron 45 mg qhs
Zyprexa 5 mg qam
Prilosec 20 mg qd
Advair 500/50 1 puff [**Hospital1 **]
FOlic acid 1 tab qd
Magnesium oxide 400 mg qd
SImethicone 80 mg tid
PRednisone 10 mg qd
Duoneb 1 treatment qid
Oxycodone 5 mg 1-2 tabs q4h prn
Ativan 0.5 mg q6h prn
.
Allergies: Theophylline, flagyl, clindamycin, antihistamines
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
2. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Inhalation twice a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day.
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. DuoNeb 2.5-0.5 mg/3 mL Solution Sig: One (1) Inhalation four
times a day.
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
13. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
14. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
15. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed: Please take according to taper:
half tab 4 times daily for one day, then 3 times daily for one
day, then two times daily for one day, then once daily for one
day, then stop.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- cocaine abuse
- opiate intake
- altered mental status
- COPD
Secondary:
- asthma
- HCV
- colostomy reversal
- esophageal dysmotility
- hx of substance abuse: cocaine, tobacco, alcohol
- parotid cancer s/p surgery and xrt c/b mandibular
osteonecrosis
- MVP
- depression and anxiety
Discharge Condition:
fair
Discharge Instructions:
You were admitted with altered mental status. This was thought
secondary to inappropriate use of your medications. You had
cocaine and opiates in your system. We treated you with Narcan
and you awoke. Given your altered mental status, we monitored
you in the intensive care unit. You improved back to your
baseline.
.
Please take your medications as instructed. Please followup
with your PCP. [**Name10 (NameIs) 357**] contact your physician or return to the
emergency department if you experience shortness of breath,
chest pain, abdominal pain, or worsening confusion. We have
decided to have your sister administer your medications. Please
follow up with your PCP as scheduled.
Followup Instructions:
1. Please followup with Dr. [**First Name (STitle) **] on [**4-7**] at 10:15am. You can
call [**Telephone/Fax (1) 101516**] if you have questions.
2. Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 101517**] of Addiction
Consultation and Evaluation Services. Call [**Telephone/Fax (1) 79298**] for an
appointment in the next week.
|
[
"5070",
"4240",
"2859",
"53081",
"311",
"3051"
] |
Admission Date: [**2199-12-24**] Discharge Date: [**2200-1-10**]
Date of Birth: [**2146-10-2**] Sex: M
Service: SURGERY
Allergies:
Strawberry
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Severe intermittent claudication with infrarenal aortic and
common iliac artery occlusion
Major Surgical or Invasive Procedure:
[**2199-12-24**]
PROCEDURES:
1. Aortobifemoral bypass with 12 x 6 aortobifemoral graft.
2. Abdominal pelvic aortogram with iliac artery runoff.
3. Thrombectomy of aortobifemoral graft with [**Doctor Last Name **]
embolectomy catheters.
4. Bilateral iliac artery angioplasty and stenting with 7
mm self-expanding stent grafts via bilateral femoral
cutdown.
[**2199-12-24**]
PROCEDURES: Exploratory laparotomy, evacuation of intra-
abdominal hematoma and open packing of the abdomen.
[**2199-12-25**]
OPERATION PERFORMED: Abdominal washout and removal of
packing and temporary abdominal closure.
[**2199-12-28**]
PROCEDURE: Exploratory laparotomy, washout and delayed
abdominal closure.
History of Present Illness:
This 54-year-old gentleman has had severe disabling claudication
for 2 years. This was originally thought to be a [**Last Name **] problem.
[**Name (NI) **] has been unable to walk.
Ultimately an MRA was done which showed that his infrarenal
aorta was occluded along with his common iliac arteries down to
the iliac bifurcation, which both external iliac arteries were
severely diseased with patent common femoral arteries and
reasonable runoff distally. He was advised to have an
aortobifemoral bypass.
Past Medical History:
hyperlipidemia, a cyst resection from his neck in [**Month (only) **]
[**2198**], an abscess removed from his neck in [**2176**], rhinoplasty in
[**2173**] and tonsillectomy in [**2156**].
Denies a history of anemia.
Social History:
Mr. [**Known lastname 4469**] is a divorced attorney
Tobacco: 40 pack year smoker
ETOH: social
Admits to prior use of MJ, LSD, cocaine in past
Family History:
Mother w/history of colon cancer in her 40's - treated
successfully. Now 82yo alive and well. Father deceased from
melanoma at 38yo.
No h/o CAD
Physical Exam:
PE:
AFVSS
NEURO:
PERRL / EOMI
MAE equally
Answers simple commands
Neg pronator drift
Sensation intact to ST
2 plus DTR
Neg Babinski
HEENT:
NCAT
Neg lesions nares, oral pharnyx, auditory
Supple / FAROM
neg lyphandopathy, supra clavicular nodes
LUNGS: CTA b/l
CARDIAC: RRR without murmers
ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness, Open wound
VAC dressing in place
GROIN: B/L groin incisions C/I, some serous drainage noted
EXT:
rle - palp fem, [**Doctor Last Name **], pt, dp
lle - palp fem, [**Doctor Last Name **], pt, dp
Pertinent Results:
[**2200-1-8**] 05:13AM BLOOD
WBC-11.5* RBC-3.43* Hgb-10.0* Hct-31.8* MCV-93 MCH-29.3
MCHC-31.5 RDW-16.2* Plt Ct-606*
[**2200-1-5**] 03:05AM BLOOD
PT-15.6* PTT-27.2 INR(PT)-1.4*
[**2200-1-8**] 05:13AM BLOOD
Glucose-108* UreaN-18 Creat-1.0 Na-141 K-4.2 Cl-106 HCO3-25
AnGap-14
[**2200-1-6**] 03:35AM BLOOD
ALT-64* AST-71* AlkPhos-116 TotBili-2.3*
[**2200-1-8**] 05:13AM BLOOD
Calcium-8.1* Phos-2.9 Mg-1.9
[**2200-1-3**] 07:50AM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-0-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1
[**2200-1-3**] 7:55 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2200-1-3**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2200-1-5**]):
Commensal Respiratory Flora Absent.
YEAST. RARE GROWTH.
RUQ US:
FINDINGS: The liver is diffusely echogenic. No focal hepatic
lesions are
identified. There is no intra- or extra-hepatic biliary ductal
dilation. The common duct measures 3 mm. The portal vein is
patent, with forward flow. The gallbladder is nondistended and
normal in appearance. There are no gallstones. There is no
gallbladder wall edema or pericholecystic fluid. The spleen is
normal in size. There is no free fluid in the right upper
quadrant.
IMPRESSION: Normal gallbladder. No biliary ductal dilation.
Echogenic liver consistent with fatty infiltration. Other forms
of liver disease including significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
Brief Hospital Course:
[**2199-12-24**]
Mr. [**Known lastname **],[**Known firstname **] was admitted on [**12-24**] with severe intermittent
claudication
with infrarenal aortic and common iliac artery occlusion. He
agreed to have an elective surgery. Pre-operatively, he was
consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were
obtained, all other preperations were made.
It was decided that she would undergo a:
PROCEDURES:
1. Aortobifemoral bypass with 12 x 6 aortobifemoral graft.
2. Abdominal pelvic aortogram with iliac artery runoff.
3. Thrombectomy of aortobifemoral graft with [**Doctor Last Name **]
embolectomy catheters.
4. Bilateral iliac artery angioplasty and stenting with 7
mm self-expanding stent grafts via bilateral femoral
cutdown.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, transferred to the PACU for further
stabilization and monitoring.
He was hypotensive in the PACU with a large volume requirement.
He dropped his hematocrit from 31 to 26. His abdomen became
increasingly tense and he was showing signs of abdominal
compartment syndrome and we decided to re-explore him.
He was taken back to the OR, he then [**Doctor Last Name 1834**] a Exploratory
laparotomy, evacuation of intra - abdominal hematoma and open
packing of the abdomen. He was closely monitored. Because of
his excessive bleeding a Heme Onc consult was obtained. The
Bleeding was thought to be from DIC.
Heme / Onc reccomendations:
1) pRBC's to keep Hct>30
2) cryoprecipitate to keep fibrinogen >100
3) FFP while actively bleeding to help correct coagulopathy
4) Platelets to keep counts above 50K (while actively bleeding)
5) Check DIC panel and CBC with coags every 3-4 hours.
6) Dose of desmopressin, for vWF deficiency
The patient did recieve all of the above. His Abdomen was left
open. He was then transferred to the CVICU for further recovery.
While in the CVICU he recieved monitered care.
Peri operative AB
[**2199-12-25**]
He was taken back for Abdominal washout and removal of packing
and temporary abdominal closure.
He was then transferred to the CVICU for further recovery. While
in the CVICU he recieved monitered care. He remained in guarded
condition. His cagulopathy improved. Was 10 liters positve.
lasix drip for fluid overload.
Remained intudated, on pressors.
Recieved bronchoscopy for RUL collapse
Peri operative AB
[**2199-12-26**]
Remained in the CVICU, intubated, IV lasix continued, aggressive
electrolytes repletion. Neo for BP control. Resp acidosis, Tube
feeds.
General Surgery was consulted for open Abdomen.
[**2199-12-27**]
Remained paralyzed and sedated, Pressors DC'd. BP improved, c/w
vent wean, NPO with TF, HLIV, Good UOP.
Peri operative AB
[**2199-12-28**] - [**2199-12-30**]
PROCEDURE: Exploratory laparotomy, washout and delayed abdominal
closure.
Remained paralyzed and sedated, BP stable on nitro, c/w vent
wean, NPO with TF, HLIV, Good UOP.
Peri operative AB DC'd.
Bronchial Specimans: HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE
NEGATIVE. Pt started on Ampicillan. He recieved these antbiotic
untill time of DC.
Wet to Dry dressing changes to abdomen.
[**2199-12-31**]
Paralytic DC'd, remained sedated, BP stable on nitro, c/w vent
wean, NPO with TF, HLIV, Good UOP.
C/W ampicillan
Vac dressing placed on abdomen.
CVL change. Pt still with WBC
[**2200-1-1**] - [**2200-1-2**]
Paralytic DC'd, remained sedated, BP stable on nitro, c/w vent
wean, NPO with TF, HLIV, Good UOP. Lasix drip
C/W ampicillan for PNA, Cipro and flagyl started. Wound looked
psuedomonial, Flagyl for increase stool. C-Diff negative.
Treated emperically
[**2200-1-4**]
Pt extubated, lasix drip DC'd - put on IV lasix, speech and
swallow - TF stopped. Mecahnical soft diet started. c/w
antibiotics as above.
[**2199-1-5**] - [**2199-1-9**]
Transfered to the VICU, When stable he was delined. He continued
to have decreased PO intake. Nutrition Consult obtained. Calorie
counts. No need for TF. Encouraged to take PO for nutrion.
He did fail voiding trial. Flomax started. Foley replaced.
A PT consult was obtained. Recommended Rehab. Case management
involved. Placed successfully
He progressed with physical therapy to improve her strength and
mobility. He continues to make steady progress without any
incidents. He was discharged to a rehabilitation facility in
stable condition.
Medications on Admission:
simvastatin 20'
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-28**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
4-6 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO QID (4
times a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-1**]
hours: prn for pain.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **] Center - [**Location (un) 701**]
Discharge Diagnosis:
1. Severe intermittent claudication with infrarenal aortic and
common iliac artery occlusion
2. Intra-abdominal hemorrhage following aortobifemoral bypass.
3. Open abdomen status post aortobifemoral bypass graft with
abdominal compartment syndrome
4. Open abdomen
5. Hyperlipidemia
6. DIC, requiring massive amounts of fluid resusitation,
including blood products, FFP, cryo.
7. Right upper lobe collapse, post op - bronchoscopy
8. Hospital aquired PNA
9. Urinary retention requiring foley and flomax
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**1-29**]
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) 8318**], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2200-1-23**] 10:30
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2200-1-16**] 2:00
Completed by:[**2200-1-10**]
|
[
"51881",
"5180",
"2762",
"2724"
] |
Admission Date: [**2150-9-27**] Discharge Date: [**2150-10-10**]
Date of Birth: [**2091-4-23**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Avandia / Combivir / Lasix / Levofloxacin
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Intubation
Right IJ catheter
Left radial arterial line
Left PICC
History of Present Illness:
Ms. [**Known lastname **] is a 59 y/o woman w/ HTN, diastolic dysfunction, DM,
CAD s/p RCA stent, restrictive pulmonary disease on 2L home O2,
OSA, obesity, CKD, and on chronic narcotics for DJD, who was
transferred to [**Hospital1 18**] from [**Hospital 730**] Hospital for respiratory
failure. History comes from records as she is currently
intubated and sedated, and no family members are present. Per
records from [**Name (NI) **], pt came to ED via car, stated "I need
oxygen" and became unresponsive and apneic. Per ED signout, she
was already at that ED to bring her son for evaluation. She
maintained her pulse and BP, and was intubated, sedated, and
paralyzed. Initial gas at OSH on 100% FiO2 was 6.92/72/58/14.
CXR was c/w pulm edema. Given SL NTG, SL captopril, and NTG
paste. At request of her brother [**Name (NI) **]. [**Last Name (STitle) 4001**], the director of
[**Hospital1 1388**] exercise stress lab), she was transferred to [**Hospital1 18**],
where she generally receives her care. Systolic BP was reported
to be 88 en route.
.
In the [**Hospital1 18**] ED, initial vs were: T P 111 BP 133/65 R 17 O2 sat
78%. Febrile to 101.8 rectal. Frothy blood was suctioned. She
was initially answering questions, per report, and MAE.
Pressures dropped as low as 50s systolic. She was given versed
and etomidate for sedation, dobutamine then switched to levophed
for blood pressure support, as well as vancomycin, Zosyn, and
lasix 40 mg IV. The MICU team placed an art line and a right IJ.
Past Medical History:
- Restrictive lung disease [**2-10**] obesity
- IDD
- CAD s/p RCA stent
- CHF (EF 55% [**2148**])
- [**1-18**] stable MIBI and neg stress test
- Pulmonary HTN
- Mitral regurgitation
- Hyperlipidemia
- HTN
- Obstructive sleep apnea
- Chronic renal insufficiency
- GERD
- DJD
- Depression
- Iron deficiency anemia
- Glaucoma
Social History:
Patient works as a manager at Papa [**Male First Name (un) 45193**] and spends a great
deal of time on her feet. She does not smoke but formerly smoked
[**1-10**] ppd for 5-6 years. She has not smoked for 3-4 years now. She
denies alcohol use. She denies ilicit drugs of non-prescription
meds. She is a widow and has two sons, the [**Name2 (NI) 1685**] of which has
autism and lives with her. Her brother is an EP doctor [**First Name (Titles) **] [**Last Name (Titles) 18**].
Family History:
Significant for coronary artery disease and arrhythmia in both
parents and diabetes mellitus in mother.
Physical Exam:
ON ADMISSION:
Vitals: 101.1 95 140/72 13 94%
General: Intubated, sedated, not interactive, obese body habitus
HEENT: Sclera anicteric, pupils 2 mm, ETT in place
Neck: supple, R IJ line in place
Lungs: Ronchorous breath sounds throughout
CV: Distant heart sounds, difficult to assess for murmurs. All
pulses difficult to palpate.
Abdomen: obese, soft, non-distended, bowel sounds
present/diminished
GU: foley in place
Ext: warm, well perfused. R foot significantly warmer than L
foot. No clubbing, cyanosis or edema.
Lines: R IJ, L radial art line, R AC PIV, R hand PIV, L PIV
.
ON DISCHARGE:
Vitals: 97.9, 135/59, 81, 18, 100% on 2L
General: Alert, comfortable, NAD
HEENT: Sclera anicteric, pupils reactive, clear oropharynx, MMM
Neck: Supple, no JVD, no LAD
Lungs: Good air entry, lungs clear bilaterally, no wheezes or
crackles
CV: RRR, nml S1/S2, no M/R/G
Abdomen: Obese, soft, ND, NT, NABS
Ext: WWP, 2+ radial/DP pulses, no edema
Neuro: A&Ox3, CNs II-XII intact, strength improving, able to
lift arms and legs further off the bed, able to feed herself,
right foot still with decreased sensation and 1/5 strength
Pertinent Results:
ADMISSION LABS:
[**2150-9-27**] 01:00AM BLOOD WBC-23.1* RBC-5.24 Hgb-13.9 Hct-44.3
MCV-85 MCH-26.5* MCHC-31.3 RDW-16.1* Plt Ct-432
[**2150-9-27**] 01:00AM BLOOD Neuts-79.3* Lymphs-14.2* Monos-5.6
Eos-0.3 Baso-0.7
[**2150-9-27**] 01:00AM BLOOD PT-12.4 PTT-20.3* INR(PT)-1.0
[**2150-9-27**] 07:36PM BLOOD Fibrino-718*
[**2150-9-27**] 01:00AM BLOOD Glucose-393* UreaN-43* Creat-2.3* Na-133
K-8.4* Cl-98 HCO3-22 AnGap-21*
[**2150-9-27**] 12:39PM BLOOD ALT-40 AST-83* LD(LDH)-568* CK(CPK)-5440*
AlkPhos-146* TotBili-0.6 DirBili-0.3 IndBili-0.3
[**2150-9-27**] 07:36PM BLOOD Calcium-8.2* Phos-3.2 Mg-2.0
.
PERTINENT LABS:
[**2150-9-27**] 07:36PM BLOOD Fibrino-718*
[**2150-10-6**] 03:40AM BLOOD Ret Aut-4.8*
[**2150-10-6**] 03:40AM BLOOD calTIBC-277 Ferritn-143 TRF-213
[**2150-10-5**] 03:25AM BLOOD VitB12-794 Folate-15.4
[**2150-9-27**] 12:39PM BLOOD Hapto-112
[**2150-9-27**] 04:10PM BLOOD %HbA1c-7.6* eAG-171*
[**2150-9-29**] 02:45AM BLOOD TSH-1.0
[**2150-9-29**] 02:45AM BLOOD Free T4-0.84*
[**2150-9-27**] 04:35AM BLOOD Cortsol-18.0
[**2150-9-27**] 11:00PM BLOOD CK-MB-69* MB Indx-0.3 cTropnT-0.14*
[**2150-9-27**] 07:36PM BLOOD CK-MB-51* MB Indx-0.4 cTropnT-0.16*
[**2150-9-27**] 12:39PM BLOOD CK-MB-38* MB Indx-0.7 cTropnT-0.21*
.
DISCHARGE LABS:
[**2150-10-10**] BLOOD WBC-14.8, Hgb-8.7, Hct-26.9, Plt-412, PT-14.2,
PTT-22.7, INR-1.2, Glu-86, BUN-25, Creat-1.4, Na-140, K-4.2,
Cl-101, HCO3-30
.
MICRO:
[**9-27**] Blood cx: no growth
[**9-27**] Urine cx: negative
[**9-27**] Urine legionella antigen: negative
[**9-27**] Sputum cx: gram pos cocci in pairs
[**9-27**] RSV viral screen and cx negative
[**9-28**] BAL: no growth, no fungus, no AFB
[**9-28**] Blood cx: no growth
[**9-29**] Blood cx: no growth
[**9-29**] Urine cx: negative
[**9-29**] Catheter tip cx: no growth
[**9-29**] Sputum cx: yeast, rare growth
[**9-30**] Blood cx: no growth
[**9-30**] Urine cx: negative
[**10-1**] Sputum cx: yeast, rare growth
[**10-1**] Catheter tip cx: no growth
[**10-2**] Blood cx: no growth
[**10-2**] CMV DNA not detected
[**10-3**] Blood cx: no growth
[**10-3**] Urine cx: negative
[**10-3**] Sputum cx: no growth, no legionella
[**10-4**] Blood cx: no growth to date
[**10-4**] Urine cx: negative
[**10-4**] Sputum cx: negative
[**10-4**] Stool cx: no C. diff
[**10-8**] Blood cx: no growth to date
[**10-9**] Stool cx: no C. diff
[**10-9**] Wound cx (left arm PICC): pending
.
IMAGING:
[**10-8**] PA/LAT CXR: 1. Decreased vascular congestion and improved
aeration.
2. Faint residual opacity at left lung base may represent
persistant infection or atelectasis.
.
[**10-1**] CT Chest/Abd/Pel w/ con: 1. Persistent but improved
multifocal pneumonia as compared to [**2150-9-27**]. New
bilateral small pleural effusions with compressive atelectasis.
2. No acute intra-abdominal or intra-pelvic process. 3. A 2 x
1.6 cm right thyroid nodule is present. This is not encompassed
on the [**2143-10-17**] chest CT.
.
[**9-30**] RLE U/S: no DVT
.
[**9-28**] TTE: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
free wall is hypertrophied. The right ventricular cavity is
mildly dilated with normal free wall contractility. The number
of aortic valve leaflets cannot be determined. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is a trivial/physiologic pericardial effusion.
.
[**9-27**] CT Head w/o con: 1. No acute intracranial findings. Mild
parenchymal atrophy and small vessel ischemic disease.
Brief Hospital Course:
59 yo woman with diastolic CHF, CAD s/p RCA stent, DM, HTN,
restrictive pulmonary disease (on 2L home O2), OSA, pulmonary
HTN, CKD, who originally presented to an OSH in respiratory
distress. She was intubated and transferred to [**Hospital1 18**] MICU where
she was treated for septic shock in the setting of pneumonia.
Hospital course was complicated by rhabdomyolysis, anemia, ICU
myopathy, and right sciatic nerve compression. Brief hospital
course by problem:
.
# Respiratory failure: The pt presented to [**Hospital 730**] Hospital on
[**9-27**] c/o respiratory distress. She became unresponsive, apneic,
and was intubated. CXR was c/w pulmonary edema and the patient
became hypotensive. She was then transferred to [**Hospital1 18**] for
further managment of presumed sepsis. In the MICU an arterial
line and right IJ were placed and she was started on pressors,
vancomycin, and zosyn. A CXR revealed multifocal pneumonia and
an ECHO showed a dilated and hypokinetic right ventricle, normal
LV systolic function (LVEF>55%), and no clinically significant
valvular disease. She eventually improved hemodynamically so
pressors were stopped, she was extubated, and the vanco and
zosyn were switched to levofloxacin and she was transferred to
the floor. She continued to improve clinically and remained
afebrile with an O2 sat of 95-97% on 2L (her baseline at home).
She completed a total of 14 days of antibiotics and the
levofloxacin was stopped. She was restarted on all of her home
medications including the advair. She was encouraged to use the
CPAP at night.
.
# Leukocytosis: Throughout this admission the pt's WBC have
waxed and waned. Her WBC rose to 15.9 two days prior to
discharge with 7% eosinophilia. WBC are currently 14.8 on the
day of discharge. The pt has remained afebrile with negative
blood cultures. Her lungs are clear with no sputum production.
UA was negative and stool was negative for C. diff. Her left arm
PICC site was clean and w/o erythema, but the tip was sent for
culture when the PICC was pulled on [**10-9**]. It is unlikely that
there is any source of infection, and the eosinophilia suggests
that there is likely a hypersensitivity reaction, perhaps to the
antibiotics since all other medications the pt is currently
taking are her home meds. The last day of levofloxacin was today
([**10-10**]). Recommend trending the WBC.
.
# Rhabdomyolysis: CK peaked to 34,000 but has been trending down
and is currently 716. She denies myalgias, although reports
weakness in her arms and legs with difficulty lifting
extremities off the bed. Despite thorough workup, no etiology
was found to explain the cause of the rhabdomyolosis. Muscle
weakness is likely due to ICU myopathy since pt has been
bedbound for such an extended length of time. Her strength is
gradually improving and she is now able to lift her arms and
legs midway off the bed and feed herself. The pt would benefit
from physicial therapy to help regain her stregth.
.
# Right foot pain/paresthesias/foot drop: This is a new finding
that developed while the pt was in the MICU. Neurology evaluated
the patient and believe that it is due to sciatic nerve
impingement. The patient has an outpatient appt with neurology
on [**2150-11-6**]. She is written for morphine 7.5-15 mg q4 PRN, with
the intention to switch to tylenol when possible.
.
# Chronic renal insufficiency (baseline cr ~ 1.4): On admission
the pt's creatine was 2.3, and peaked to 3 while in the MICU in
the setting of critical illness. The patient was catheterized
and continued to have good UOP. Her creatinine has returned to
baseline and is 1.3 upon discharge.
.
# Anemia: Patient??????s Hct has been stable in the mid 20s
throughout this hospital admission. Borderline
microcytic/normocytic pattern. Ferritin, TIBC, B12, folate,
haptoglobin, are all WNL. Reticulocyte index is 2.1% indicating
appropriate bone marrow response. Continued home dose of ferrous
sulfate 325 mg daily.
.
# Abnormal LFTs: The pt was noted to have a rise in her AST,
ALT, and Alkaline phosphatase while in the MICU. She has no
known h/o liver or biliary disease and was asymptomatic. Most
likely multifactorial due to shock liver and rhabdomyolosis.
LFTs returned to [**Location 213**] after transfer to the floor.
.
# Diabetes: Blood sugars were poorly controlled in the MICU,
requiring an insulin drip. After transfer to the floor we
uptitrated her insulin and she is now on her home dose of
novolog ISS and lantus 55 units every morning and 65 units every
evening. Her sugars were well controlled in the mid-100s to low
200s. Last HgA1c was 7.6% on [**9-24**].
.
# Thyroid nodule: On the CT chest on [**2150-10-1**] an incidental 2 x
1.6 cm thyroid nodule was seen which was not visualized on a
previous CT chest on [**2143-10-17**]. Pt should f/u with her PCP
regarding this.
.
# CAD s/p RCA stent: Continued plavix 75 mg daily.
.
# Diastolic heart failure: Patient was hypervolemic in the
setting of critical illness in the MICU. After transfer to the
floor she was restarted on her home dose of bumex and is now
euvolemic.
.
# Depression: Stable, patient was restarted on her home dose of
fluoxetine 20 mg daily.
.
# Code status: Full code (confirmed with patient after transfer
from the MICU to the floor).
.
# Outstanding issues:
- Blood cultures from [**10-4**] and [**10-8**]: pending
- Left arm PICC tip culture from [**10-9**]: pending
Medications on Admission:
*All medications were confirmed with the patient and her
pharmacy:
1. Novolog sliding scale as directed (pt seen at [**Last Name (un) **])
2. Advair 250-50, 1 puff [**Hospital1 **]
3. Pravastatin 80 mg, 1 tab daily
4. Xalatan 0.005% eye drops, 1 drop into both eyes QHS
5. Bumetanide 1 mg, 1-2 tabs [**Hospital1 **]
6. Zetia 10 mg, 1 tab daily
7. Isosorbide MN ER 60 mg, 1 tab daily
8. Lantus, 55 units QAM, 65 units QPM
9. Potassium chloride ER 10 meq, 1 cap every other day
10. Plavix 75 mg, 1 tab daily
11. Metoprolol succinate ER 100 mg, 1 tab daily
12. Metoclopramide 10 mg, 1 tab QAM
13. Acetaminophen-Codeine #3, 1 tab TID PRN pain
14. Clonazepam 0.5 mg, 1 tab daily PRN
15. Fluoxetine 20 mg, 1 cap daily
16. Diovan 40 mg, 1 tab daily
17. Ranitidine 300 mg, 1 tab QHS
18. Vitamin D 50,000 units, one cap every week
19. Brimonidine tartrate 0.15% drops, 1 drop into both eyes [**Hospital1 **]
20. Fluticasone 50 mcg, 2 sprays into each nostril daily
21. Docusate 100 mg q8h PRN
22. Ferrous sulfate 325 mg SR daily
23. Multivitamin daily
24. Metamucil
25. Senna 8.6 mg daily
26. Aspirin 325 mg daily
Discharge Medications:
1. Insulin Aspart 100 unit/mL Solution Sig: Sliding scale
Subcutaneous four times a day.
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): 1 drop to both eyes at bedtime.
5. Bumetanide 1 mg Tablet Sig: 1-2 Tablets PO twice a day.
6. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Lantus 100 unit/mL Solution Sig: Fifty Five (55) units
Subcutaneous every morning.
9. Lantus 100 unit/mL Solution Sig: Sixty Five (65) units
Subcutaneous every evening.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO every other day.
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
14. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO three times a day as needed for pain.
15. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed for anxiety.
16. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
17. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at
bedtime.
19. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a
week.
20. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
21. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
22. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO Q 8H
(Every 8 Hours).
23. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
24. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
25. Metamucil Oral
26. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
27. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
28. Morphine 15 mg Tablet Sig: 0.5-1 Tablet PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] HealthCare at [**Location (un) 3320**]
Discharge Diagnosis:
Primary:
- Pneumonia
- Rhabdomyolosis
- Anemia
- Myopathy
- Right sciatic nerve impingement
- Thyroid nodule
Secondary:
- Diastolic heart failure
- Restrictive lung disease
- Obstructive sleep apnea
- CAD s/p stent
- Diabetes
- Chronic renal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of bed with assistance to chair or
wheelchair. Advance activity as tolerated.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to the hospital with respiratory distress and
found to have pnemonia which we treated with an antibiotic
called levofloxacin. During your hospitalization you developed
right foot weakness and "pins and needles" which is due to
compression of the sciatic nerve. The neurologist would like for
you to follow up with him for this (see below for appt details).
You also developed muscle weakness. We would like for you to
work with the physical therapist at rehab.
.
On a CT scan we discovered a 2 x 1.6 cm thyroid nodule that was
not seen on your [**2143-10-17**] chest CT. Please follow up with
your primary care doctor regarding this finding.
.
Please continue to take all of your home medications. We have
not started any new medications or made any changes.
.
Weigh yourself every morning, and call your doctor if your
weight goes up more than 3 lbs.
Followup Instructions:
Department: NEUROLOGY
When: FRIDAY [**2150-11-6**] at 1 PM
With: [**Name6 (MD) 4677**] [**Name8 (MD) 4678**], MD [**Telephone/Fax (1) 3506**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital3 249**]
When: MONDAY [**2150-12-7**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 198**] [**Last Name (NamePattern4) 199**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2150-10-10**]
|
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] |
Admission Date: [**2170-12-16**] Discharge Date: [**2170-12-29**]
Date of Birth: [**2111-2-17**] Sex: M
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Confusion and malaise.
HISTORY OF PRESENT ILLNESS: The patient was a pleasant 59
year old man known to the hepatobiliary transplant service
with a past medical history of diabetes mellitus,
hypertension, hepatitis C cirrhosis, endstage liver disease
and end stage renal disease, status post cadaveric renal
transplant. He presented to the [**Hospital1 190**] Emergency Department on [**2170-12-16**],
complaining of increased episodes of confusion for about 24
hours. He has been a resident of [**Hospital3 7**] since his
prior discharge. The patient on his admission reported
recent increase in abdominal girth, lower extremity edema and
a slight diffuse abdominal pain. His wife reported that he
was confused the night prior to admission, talking about
"[**Doctor First Name **]". He was also mentioning spiders crawling around his
room. Given this state, the staff at rehabilitation made a
decision to transfer the patient back to the hospital. On
arrival, he denied fever, chills, nausea, vomiting, diarrhea,
cough, chest pain and shortness of breath.
PAST MEDICAL HISTORY: Diabetes mellitus.
Hypertension.
Hepatitis C.
Cholelithiasis.
Coronary artery disease.
Elevated cholesterol.
Anemia.
Asbestos exposure.
Stroke in [**2169**].
End stage renal disease, status post transplant.
End stage liver disease.
PAST SURGICAL HISTORY: Cadaveric renal transplant [**2170-7-26**].
SOCIAL HISTORY: Old history of intravenous drug abuse, lives
with wife, denies use of alcohol or tobacco.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On arrival, temperature is 96.8, pulse
54, blood pressure 129/69, respiratory rate 18, oxygen
saturation 96 percent in room air. In general, a middle age
man in no acute distress, appearing jaundiced and lying in
bed. Scleral icterus. The pupils are equal, round and
reactive to light and accommodation. There is no jugular
venous distention or lymphadenopathy in the neck. Chest
examination - There are rales bilaterally at the bases.
Cardiovascular examination is regular rhythm and no murmurs.
Abdominal examination distended abdomen with fluid and mild
diffuse tenderness without rebound or guarding. Extremity
examination - Warm extremities with one plus palpable
dorsalis pedis and posterior tibial pulses. Neurologic
examination - Cranial nerves II through XII are intact
bilaterally, moving all extremities and no asterixis.
LABORATORY DATA: Pertinent laboratories on admission
included white blood cell count 7.8, hematocrit 35.8,
platelet count 80,000, creatinine 2.2, INR 1.3, total
bilirubin 8.7.
HOSPITAL COURSE: The patient was assessed by the medical
service in the Emergency Department and he was admitted to
the medical service for care of his confusion with the
differential diagnosis of hepatic encephalopathy or possible
infection, quite possibly spontaneous bacterial peritonitis.
A transplant surgery consultation and hepatobiliary service
consultation was also obtained. For the first two days, the
patient received his nightly tube feeds and his doses of
insulin for which he had been stabilized over the last month.
He also received a paracentesis which by diagnostic studies
revealed no evidence of infection. His antibiotics were
therefore stopped. On the night of [**2170-12-18**], the patient
was noticed to be in his usual clinical state with occasional
bouts of confusion. The wife noticed that the patient may
have been slightly more confused earlier in the night.
During the middle of the night, the patient was found
unresponsive by the nursing staff and code was called for
assistance. On arrival, the house staff found him
unresponsive, was oxygenating, and with adequate blood
pressure. A quick check of blood glucose found a blood sugar
of 9. The tube feeds were noticed to be running adequately
at this time. Given this, he was given a bolus of dextrose
and the blood sugar rising to 170. After the glucose
infusion, however, the patient was noticed to have some
tonoclonic activity which subsided with Ativan
administration. At this time, the patient continued to be
agitated, unresponsive necessitating orotracheal intubation.
After the intubation, he was transferred to the Intensive
Care Unit for further resuscitative care. Initially in the
Intensive Care Unit, the patient received placement of Swan-
Ganz catheter for optimal hemodynamic management. His
ventilatory settings were set to optimize and reduce any
cerebral edema. He received a head CT scan which showed no
signs of ischemia or hemorrhage and he received a neurology
consultation to assess his neurological status. Empiric
antibiotics were started for infection prophylaxis. The
diagnosis at this time was liver failure causing worsening
encephalopathy made significantly worse by hypoglycemia.
There was also possible seizure activity likely secondary to
the hypoglycemic episode. The patient's subsequent hospital
course was focused on maintaining his hemodynamics,
preventing infection and awaiting neurological improvement so
that he could receive a liver transplant. Unfortunately as
days progressed, his neurological status worsened and he
became completely unresponsive to stimulation or pain. He
also became febrile on antibiotics and received a broadening
of his antibiotics and cultures. Initially his cultures were
negative, however, the blood culture on [**2170-12-26**], grew out
[**Female First Name (un) 564**] albicans. Given no improvement in neurological
status and unresponsive state for days without any sedation,
episodes of fevers now with fungal cultures positive by
blood, and marginal renal status, the patient was deemed
nontransplantable. Given that the patient would not safely
receive a transplant, the condition given his liver failure
(bilirubin up to 19), extensive discussions were begun with
the family. Discussions between the nursing staff, the
Intensive Care Unit staff, the family, transplant staff and
hepatobiliary staff all concurred that the [**Hospital 228**] medical
condition is futile without possibility of a liver
transplant. Given that he was not a candidate to
successfully undergo a liver transplantation, the family
decided to withdraw care as this was what the patient would
have desired. Given this, on [**2170-12-29**], the patient was
made comfort measures only. He was placed on a Morphine drip
and the ventilatory support was withdrawn. The Morphine drip
was started at 1:30 p.m. The patient was extubated at 2:00
p.m. and the patient expired at 2:45 p.m. with family at
bedside.
DISCHARGE DIAGNOSES: Liver failure secondary to hepatitis C.
Renal failure, status post cadaveric renal transplant [**2170-7-26**].
Elevated cholesterol.
Anemia.
Stroke.
History of right inguinal hernia repair.
History of vasectomy [**2139**].
Hypertension.
Diabetes mellitus type 2.
Coronary artery disease.
Hepatic encephalopathy.
Sepsis.
DISCHARGE DISPOSITION: Death.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Name8 (MD) 22102**]
MEDQUIST36
D: [**2171-1-3**] 17:01:56
T: [**2171-1-4**] 09:14:03
Job#: [**Job Number 22103**]
|
[
"2760",
"40391",
"99592",
"486",
"V5867",
"5845"
] |
Admission Date: [**2144-1-31**] Discharge Date: [**2144-2-4**]
Date of Birth: [**2091-4-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
angina, dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2144-1-31**] Coronary artery bypass grafting x3 with
left internal mammary artery graft to left anterior
descending, reverse saphenous vein graft to the ramus
intermedius branch and the first marginal branch.
History of Present Illness:
This is a 52 year old male with known coronary disease, who has
now developed recurrent angina. Despite undergoing successful
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] to the ramus in [**2143-4-24**], he continued to
experience chest pain. A recent cardiac catheterization showed
50% left main lesion with patent ramus DES. Given his worsening
angina, he was referred for surgical revascularization.
Past Medical History:
- Ishemic Heart Disease, s/p Taxus stent to Ramus [**2143-4-24**]
- Hypertension
- Dyslipidemia/Elevated TG's
- Metabolic Syndrome
- Anemia
- History of Migraine
Past Surgical History:
- Left Hip Replacement
- Facial surgery
Social History:
Mr. [**Known lastname 34428**] lives with his wife. [**Name (NI) **] works in construction. He
quit smoking 5 years ago after a 20 pack year history. He is a
recovering alcoholic, sober for the last 5 years.
Family History:
Mr. [**Known lastname 34429**] uncle died from a myocardial infarction at age 52.
Physical Exam:
Pulse: 62 Resp: 16 O2 sat: 100%
B/P Right: 131/72 Left: 138/73
General: WDWN male in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] - no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [X]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit - none
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 34430**] (Complete)
Done [**2144-1-31**] at 9:05:40 AM PRELIMINARY
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2091-4-28**]
Age (years): 52 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Chest pain. Coronary artery disease. Left
ventricular function.
ICD-9 Codes: 786.51, 424.2
Test Information
Date/Time: [**2144-1-31**] at 09:05 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW001-0:00 Machine: AW5
Echocardiographic Measurements
Results Measurements Normal Range
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.5 cm <= 3.0 cm
Findings
LEFT ATRIUM: Normal LA size. No thrombus/mass in the body of the
LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler. Prominent
Eustachian valve (normal variant).
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
Pre-bypass:
The left atrium is normal in size. No thrombus/mass is seen in
the body of the left atrium. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion.
Post bypass: Preserved biventricular funciton, LVEF >55%. Aortic
contours intact. Reamaining exam is unchanged, all findings
discussed with surgeons at the time of the exam.
Brief Hospital Course:
On [**2144-1-31**] Mr. [**Known lastname 34428**] was taken to the operating room and
underwent a Coronary artery bypass grafting x3 with left
internal mammary artery graft to left anterior descending,
reverse saphenous vein graft to the ramus intermedius branch and
the first marginal branch. This procedure was performed by Dr.
[**First Name (STitle) **] [**Name (STitle) **]. Please see the operative note for details. He
tolerated this procedure well and was transferred in critical
but stable condition to the surgical intensive care unit. He
was extubated and weaned from pressors. His chest tubes were
removed. He was transferred to the surgical step down floor.
His epicardial wires were removed and he was seen in
consultation by the physical therapy service. By post-operative
day four he was ready for discharge to home per Dr. [**Last Name (STitle) **].
All follow-up appointments were advised.
Medications on Admission:
Toprol XL 50mg qd, Simvastatin 40mg qd, Tricor 100mg qd, Aspirin
81mg qd, Plavix 75mg qd, Relpax prn, Effexor XR 225mg QD, Ambien
CR prn
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. 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*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
Disp:*30 Tablet(s)* Refills:*2*
6. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
Disp:*90 Capsule, Sust. Release 24 hr(s)* Refills:*2*
7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*2*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
coronary artery disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with dilaudid prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr [**First Name8 (NamePattern2) 30623**] [**First Name8 (NamePattern2) 30624**] [**Doctor Last Name **] in [**1-25**] weeks [**Telephone/Fax (1) 30837**]
Cardiologist Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14522**] in [**1-25**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2144-2-4**]
|
[
"41401",
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"V1582",
"2859"
] |
Admission Date: [**2140-5-3**] Discharge Date: [**2140-5-10**]
Date of Birth: [**2070-9-26**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
UTI
Major Surgical or Invasive Procedure:
R IJ central line placement/removal
History of Present Illness:
69F with DM, HTN, breast cancer on tamoxifen, lumbar spinal
stenosis admitted to the ICU for sepsis likely secondary to UTI.
Pt reports sore throat, dry cough, shaking chills, and runny
nose starting on Monday. Says her legs and arms were shaking
violently starting at 4pm. She said she called her daughter to
tell her she was at home feeling sick. She does not know if her
daughter called the ambulance and does not remember the
ambulance showing up. She reports to me that she opened the
door for the ambulance and fell but does not remember all of
this. In ED, had fever to 104, was tachycardia, had FS of 600.
She got tylenol, 2L IVF, 10mg IV insulin bolus, started on
insulin gtt 7units/hour later changed to 2units/hr, then 3.5
units/hr, and then 4 units sc insulin. She initially had a gap
which closed. Her gap closed and her FS trend was 600-> 255 ->
230. She was also placed on D5 1/2 NS for fluids. Her ABG
showed 7.49 pCO2
33 pO2 101 HCO3 26 BaseXS 2. Her lactate was 7.1->5.4-> 3.8->
3.4. She was given ceftazidine 1gm, azithromycin 500mg IV, and
vancomycin.
In the ED she was not encephalopathic, belly soft, CXR
unremarkable, urine with small leuks/blood/nitrite
nge/wbc>50/mod bacteria. RIJ placed was placed. She had chest
pain [**7-13**] and given, ASA, morphine 2mg IV x2, no EKG changes,
and first set of enzymes pending.
.
On arrival to the ICU her vitals were T=99.1 BP=111/62 HR=97
RR=19 O2=97%RA. Her chest pain had resolved and her EKG was
unchanged from prior. On further questioning she denied
diarrhea, epigastric pain, increased frequency of urination,
pain with urination, hematuria, changes in vision, headache,
increased SOB on exertion (baseline for last few months SOB
after 1 flight of stairs), PND, orthopnea, CP prior to today,
jaw pain, arm pain.
.
Review of systems is otherwise negative.
Past Medical History:
-breast cancer s/p wide excision, radiation, and current
endocrine therapy with tamoxifen
-diabetes
-hypertension
-lumbar spinal stenosis
Past oncologic history:
Stage I (T1cN0M0) Infiltrating ductal carcinoma of the
right breast, diagnosed in [**2136**], ER +, PR -, HER2Neu -, LVI -,
grade III.
Wide excision with sentinel lymph node
procedure. Radiation. Enrolled in clinical trial MA27 and
randomized to exemestane [**2136-10-28**]. Exemestane held due to
musculoskeletal side effects, and the patient subsequently taken
off study and placed briefly on Arimidex. Arimidex was later
discontinued due to intolerable hot flashes. On [**8-/2137**],
initiated tamoxifen.
Social History:
She is originally from Barbados, however lives in [**Location 686**].
She
is separated. She is here with her sister and [**Name2 (NI) 12496**] today.
As noted above, she quit smoking several yrs ago (started
smoking at 18 yo [**2-6**] PPD) and drinks alcohol only very
occasionally socially. She is retired.
Family History:
Her family history is notable for both parents having died in
advanced years from natural causes. Her mother died in her 80s.
She has one sister who died last yr of respiratory illness. She
has one brother who is healthy. The only diseases that run in
the family are diabetes and hypertension.
Physical Exam:
T=99.1 BP=111/62 HR=97 RR=19 O2=97% RA
.
PHYSICAL EXAM
GENERAL: Tired appearing, A & O x3 NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD.
CARDIAC: tachycardic, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=difficult to access given recent placement
of central line and body habitus
LUNGS: CTAB, somewhat decreased breath sounds bilaterally
diffusely
ABDOMEN: NABS. Soft, mild tenderness in lower abd
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. 5/5 strength
throughout.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Labs on admission:
[**2140-5-3**] 05:35PM BLOOD WBC-12.3*# RBC-4.17* Hgb-12.7 Hct-37.2
MCV-89 MCH-30.5 MCHC-34.2 RDW-14.0 Plt Ct-192
[**2140-5-3**] 05:35PM BLOOD Neuts-92.8* Lymphs-3.8* Monos-3.1 Eos-0.1
Baso-0.1
[**2140-5-3**] 05:35PM BLOOD PT-14.5* PTT-19.8* INR(PT)-1.3*
[**2140-5-3**] 05:35PM BLOOD Glucose-600* UreaN-18 Creat-1.4* Na-133
K-3.8 Cl-91* HCO3-25 AnGap-21*
[**2140-5-3**] 05:35PM BLOOD ALT-29 AST-32 CK(CPK)-324* AlkPhos-107
Amylase-32 TotBili-0.6
[**2140-5-3**] 05:35PM BLOOD cTropnT-<0.01
[**2140-5-4**] 09:01AM BLOOD CK-MB-4 cTropnT-<0.01
[**2140-5-4**] 09:01AM BLOOD CK(CPK)-347*
[**2140-5-4**] 12:21AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.8
[**2140-5-3**] 05:35PM BLOOD CRP-GREATER TH
[**2140-5-3**] 06:07PM BLOOD Type-ART pO2-101 pCO2-33* pH-7.49*
calTCO2-26 Base XS-2
[**2140-5-3**] 05:43PM BLOOD Lactate-7.1*
.
Microbiology:
[**5-3**] urinalysis - positive, no urine culture sent
[**5-4**] urinalysis positive, urine culture > 100K e coli
Urine culture [**5-4**]:
URINE CULTURE (Final [**2140-5-6**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
[**5-3**] blood culture - e coli
[**5-4**], [**5-5**], [**5-6**], [**5-7**] blood cultures - no growth to date
.
Blood culture [**5-3**]:
**FINAL REPORT [**2140-5-7**]**
Blood Culture, Routine (Final [**2140-5-7**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
Imaging:
[**5-3**] Chest x-ray:
IMPRESSION: No acute cardiopulmonary process
.
[**5-4**] Chest x-ray:
Mild vascular engorgement is new, though heart size is normal
and edema if any is limited to a peribronchial cuffing.
Plate-like subsegmental atelectasis at the right lung base is
new. No focal consolidation to suggest pneumonia. Pleural
effusion is minimal, on the left, if any.
.
[**5-5**] Chest x-ray:
There are lower lung volumes but no evidence of acute focal
pneumonia. Elevation of the right hemidiaphragm is seen with
minimal
atelectatic change. The pulmonary vascularity is essentially
within normal
limits on this image.
.
[**5-7**] CT torso:
STUDY: CT torso with contrast and reconstructions.
INDICATION: Diabetes, hypertension, and breast cancer.
Currently, on
tamoxifen, presenting with urosepsis and continued fevers,
shortness of
breath.
COMPARISON: Pelvic ultrasound [**2140-3-2**].
TECHNIQUE: MDCT axially acquired images were obtained from the
thoracic inlet
to the symphysis after the uneventful intravenous administration
of 100 ml
Optiray 350 contrast material. Multiplanar reformatted images
were obtained
and reviewed.
CT CHEST WITH CONTRAST AND RECONSTRUCTIONS: The thyroid gland is
grossly
within normal limits. Moderate plaque is present within the
thoracic aorta.
No filling defects identified within the pulmonary arteries,
however, this
study was not optimized to evaluate this finding. Bibasilar
atelectasis and
trace left pleural effusion demonstrated. No axillary,
mediastinal or hilar
adenopathy per CT size criteria. Ill defined soft tissue within
the right
breast, not able to be correlated on the left given lack of
inclusion in the
imaging volume. Please correlate with mammographic findings.
CT ABDOMEN WITH CONTRAST AND RECONSTRUCTIONS: Diffuse fatty
infiltration of
the liver. 1.4 cm hypoattenuating lesion within the left lobe of
the liver
is most consistent with a cyst. Several sub-centimeter
hypoattenuating foci
in the left lobe are too small to adequately characterize.
Gallbladder is not
well demonstrated suggesting removal or collapse. No intra- or
extra-hepatic
biliary ductal dilatation. The spleen and abdominal large and
small bowel
appear within normal limits.
The kidneys are heterogeneous bilaterally involving the cortices
with a large
region in the right upper pole and significant region in the
left mid pole
consistent with significant pyelonephritis. The abdominal aorta
and iliac
branches demonstrate moderate calcified atherosclerotic plaque
without
aneurysmal dilatation. No free fluid or free air within the
abdomen.
CT PELVIS WITH CONTRAST AND RECONSTRUCTIONS: A 4.5 x 3.8 cm
presumed
exophytic fibroid is demonstrated within the left adnexa as
depicted on pelvic
ultrasound from [**2140-3-2**]. A focus of calcification is
again
demonstrated abutting the endometrium on the sagittal
projection, also
correlated on prior pelvic ultrasound. A new 2.1 cm fluid
collection is noted
within the right adnexa, possibly representing an adnexal cyst.
The bladder
appears within normal limits.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are
identified.
IMPRESSION:
1. Bilateral severe pyelonephritis. No adjacent perirenal fluid
collections
identified. No hydronephrosis.
2. Multilevel degenerative changes.
3. Bibasilar atelectasis, mild.
4. Fluid attenuation lesion within the right adnexa measuring
2.1 cm, not
seen on prior pelvic ultrasound. Finding may reflect an adnexal
cystic lesion
and recommend correlation with pelvic ultrasound on a non-urgent
basis in
this postmenapausal female.
.
Brief Hospital Course:
69 year old woman with history of DM, HTN, breast cancer (in
past, currently on tamoxifen) who presented with sepsis due to E
Coli UTI and E Coli bacteremia and DKA.
.
#. Sepsis due to E Coli UTI/E Coli bacteremia/pyelonephritis:
Patient presented with fever, tachycardia, leukocytosis,
positive urinalysis, urine culture with e coli, with subsequent
blood cultures growing gram negative rods, consistent with
urosepsis. She was initially admitted to the ICU, aggressively
volume rescusitated, started on vancomycin and levofloxacin.
When urine and blood cultures grew out pan sensitive e coli,
vancomycin was discontinued and she was maintained on
levofloxacin alone. With these measures, her tachycardia,
leukocytosis and elevated lactate resolved. Patient continued to
have low grade fevers and complained of right lower quadrant
abdominal pain. Therefore a CT abdomen was obtained that
demonstrated bilateral pyelonephritis, no discreet fluid
collection. Surveillance blood cultures were with no growth to
date at time of discharge and she was discharged to complete a
14 day course of levofloxacin. Of note, pt did still have low
grade temps at night to 100.1 prior to discharge, no localizing
symptoms, felt to be due to resolving pyelonephritis. Pt had no
further abdominal pain at time of discharge. Pt was asked to
monitor her temperature at home.
.
#. Hyperglycemia/DKA/Diabetes: Patient presented hyperglycemic,
with anion gap acidosis, glucose and ketones in urine,
consistent with DKA. She was treated initially with IV fluids
and insulin drip, with closure of anion gap, resolution of her
hyperglycemia. She was restarted on her outpatient insulin
regimen with fingersticks still up into the 300s. HgbA1c was
elevated at 8.7. The patient's NPH was increased from 62 U in AM
to 70 U in AM and from 4 U at night to 5U at night. The pt was
asked to check her fingersticks at varying times of day and to
bring in these recordings with her to her follow up appointment
with her PCP.
.
# Shortness of breath: Patient noted some episodes of shortness
of breath, initially had some wheezing on exam, chest x-ray with
some evidence of mild volume overload. Treated with nebulizers
and 1 dose of lasix during her hospitalization. Given continued
symptoms, obtained a CT torso to rule out pulmonary embolism
that was negative for any clot. Her complaints of SOB had
resolved at discharge and pt was satting upper 90s on room air.
Was discharged on albuterol inhaler, with outpatient follow up.
.
#. Acute renal failure: Creatinine on admission was up to 1.4
up from baseline of 0.8-1.1 on admission. Resolved to baseline
with IV fluids. On [**5-5**] Creatinine started to trend up again to
1.5 on [**5-9**]. CT of the abdomen had shown no hydronephrosis, but
+pyelonephritis. Pts ARF was felt to be most likely due to
pyelonephritis vs mild ATN from CT dye. Ulytes showed FeNa of
1.6%. Pt was given fluid challenge with 2 L NS. Her HCTZ was
held. Cr trended down to 1.3 prior to discharge. HCTZ will be
held until follow up with PCP.
.
# R adnexal 2.1 cm lesion: Incidentally noted on CT scan--fluid
attenuating lesion which may be a adnexal cyst. Pt needs
outpatient pelvic US. Pts PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], is aware.
.
#. Hypertension: Outpatient meds Amlodipine 5 mg daily,
Hydrochlorothiazide 25mg daily held on admission. Both were
resumed once BP normalized, but HCTZ was again held in the
setting of worsening renal function. HCTZ will not be restarted
until pt follows up with her PCP. .
.
#. Breast cancer: Continued outpatient tamoxifen.
Medications on Admission:
Tamoxifen 20mg daily
Amlodipine 5 mg daily
Hydrochlorothiazide 25mg daily
Hydromorphone 2mg [**2-5**] tab qid PRN (last filled in [**Month (only) **]- d/c in
[**10-11**] on this med not in OMR)
Trazodone 50mg daily
Humalin 62units qam and 4 units qhs
Naproxen 500mg [**Hospital1 **] PRN
Ibuprofen 600mg TID PRN (not in OMR)
Tramadol 50mg 4x a day PRN
Flexeril 10mg TID PRN (not reflected in OMR)
Gabapentin 300mg qhs (inactivated in OMR)
.
Not from pharmacy from OMR
Calcium
Vit D
Omega 3 fatty acids-Vit E
Discharge Medications:
1. Tamoxifen 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation: This is a stool softener and
can be purchased over the counter.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): This is a stool softener and can be purchased over
the counter.
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 2 to 4 hours as needed for
shortness of breath or wheezing.
Disp:*1 cartridge* Refills:*0*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48 () for
7 days.
Disp:*4 Tablet(s)* Refills:*0*
11. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for constipation: This is a stool softener and can be
purchased over the counter.
12. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
unit Subcutaneous as directed: Take 70 units in the morning and
5 units a night (this is your humulin).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
E coli urosepsis
Pyelonephritis
Diabetic ketoacidosis
Acute renal failure
Discharge Condition:
Stable. Improved symptoms, low grade temp max of 100.1 over
past 24 hrs.
Discharge Instructions:
You were admitted to the hospital with urinary tract
infection/sepsis, and treated with antibiotics with improvement
in your symptoms. You will need to complete this course of
antibiotics.
.
You had some kidney failure, likely due to the kidney infection.
This seems to be improving. You will need to have you kidney
function rechecked (a blood test) next week when you see your
doctor.
.
Please take medications as directed. Your hydrochlorothiazide
has been discontinued until you follow up with your doctor next
week (this can worsen kidney function). You will need to
complete 4 more doses of levofloxacin to treat your kidneys.
Your Humulin has been increased to 70 units in the morning and 5
units a night. You will need to check your fingersticks several
times a day (twice a day at least---try to record some fasting
morning fingersticks, some evening fingersticks, and some in the
mid-afternoon when your sugars tend to run high (ie 3 PM).
Record these readings and bring them with you next week to your
doctor's appointment.
.
Please follow up with appointments as directed.
.
Please contact physician if develop fevers/chills, shortness of
breath, fingerstick over 400 or less than 60, or any other
questions or concerns.
Followup Instructions:
1. Please follow up next Monday at 1:10 PM with Dr. [**Last Name (STitle) **] and
[**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) **]. Please call [**Telephone/Fax (1) 608**] if you need to
cancel this appointment.
|
[
"5849",
"4019"
] |
Admission Date: [**2154-11-23**] Discharge Date: [**2154-11-25**]
Date of Birth: [**2097-5-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
57 yo M with h/o DMII, HTN, family h/o [**First Name3 (LF) 499**] CA (last
colonoscopy [**2153**] with adenomatous polypectomy) presents with an
episode of "tarry black stool" at 3 AM on the day of admission.
He reports a feeling of urgency, chills, and diaphoresis prior
to the episode. He denies lightheadedness, SOB, or chest pain.
He was seen on [**2154-11-18**] by his PCP for intermittent epigastric
abdominal pain radiating across his abdomen and up into his
chest x1 year. No known precipitants. At times if feels like
"indigestion". The pain is associated with nausea and anorexia.
He reports decreased appetite x4-5 days. Four days ago, he took
Citrate resulting in nausea and emesis. He describes the emesis
as brown with purple clots. He also notes an episode of tarry
black stools two weeks ago. He denies BRBPR, weight loss, fever,
diarrhea, chest pain, or shortness of breath.
.
In the ED a rectal exam revealed melanotic stool. NG lavage
revealed coffee grounds. His vital signs were stable. HR
100's/SBP 140's. Hct was 33 (10 points below baseline). He was
typed and crossed and started on IV PPI. GI was consulted; he
was transferred to the [**Hospital Unit Name 153**] for an endoscopy.
.
Upon arrival to the [**Hospital Unit Name 153**] he feels well w/o complaints.
Past Medical History:
- DMII
- HTN
- erectile dysfunction
- s/p right total hip replacement [**3-9**] for OA
Social History:
Denies Tob or Illicit drug use. Occasional EtOH. Works as an
accountant. Not married. Has a daughter.
Family History:
Father with [**Name2 (NI) 499**] cancer. Brother with h/o bleeding ulcer and
lymphoma.
Physical Exam:
Tc 98.5 BP 148/79 HR 90 RR 14 Sat 100 % RA
Gen: well appearing male, NAD
HENNT: MMM, anicteric, PERRL
Neck: no LAD, no JVD
CV: RRR, nl S1S2, No M/R/G
Lungs: CTAB
Abd: soft, right sided tenderness to deep palpation, ND, +BS, No
HSM, no rebound or guarding
Ext: no edema, strong DP/PT pulses bilaterally
Neuro: A&Ox3
Pertinent Results:
[**2154-11-23**] 05:10AM WBC-10.5 RBC-3.71* HGB-11.4* HCT-32.9* MCV-89
MCH-30.6 MCHC-34.6 RDW-12.7
[**2154-11-23**] 05:10AM NEUTS-71.7* LYMPHS-22.3 MONOS-5.3 EOS-0.4
BASOS-0.4
[**2154-11-23**] 05:10AM PLT COUNT-259
[**2154-11-23**] 05:10AM PT-13.4* PTT-23.7 INR(PT)-1.2
[**2154-11-23**] 05:10AM GLUCOSE-191* UREA N-43* CREAT-1.1 SODIUM-138
POTASSIUM-5.1 CHLORIDE-104 TOTAL CO2-22 ANION GAP-17
[**2154-11-23**] 05:10AM ALT(SGPT)-11 AST(SGOT)-22 ALK PHOS-76
AMYLASE-65 TOT BILI-0.6
[**2154-11-23**] 05:10AM LIPASE-46
[**2154-11-23**] 12:00PM HCT-29.9*
[**2154-11-23**] 05:15PM HCT-29.9*
[**2154-11-23**] 11:30PM HCT-28.0*
Brief Hospital Course:
1) Upper GI bleed: Pt came in with a lower Hct than baseline
but was hemodynamically stable. Pt was admitted to [**Hospital Unit Name 153**] where a
EGD was done. This showed 2 duodenal ulcers which were
cauterized. After this his pain improved though it did not
subside completely. His Hct remained stable at 28-29 for the
entire hospital stay. He had one melanotic BM on day of
discharge that was thought to be due to old blood passing. He
ate with minimal discomfort thought to be due to persistent
ulcer. There were no signs of active bleeding, howevere. He
was kept on a PPI [**Hospital1 **]. His H. pylori serology was positive and
pt was discharged on PrevPac for 2 weeks.
.
2) DM2: Initially, oral hypoglycemics were held. When pt
started on clears, metformin was restarted. Glyburide was held
and pt instructed to restart that when he is taking regular
solids for at least 24hours.
.
3) HTN: Continued on lisinopril after acute bleeding episode
resolved.
Medications on Admission:
Metformin 1000+500mg [**Hospital1 **]
Glyburide 5mg daily
Aspirin
Lisinopril 40mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
start taking after completing PrePac (in 2 weeks).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
4. Metformin 500 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
5. Prevpac 500-500-30 mg Combo Pack Sig: One (1) daily
administration pack PO twice a day for 2 weeks.
Disp:*1 pack* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcer
Discharge Condition:
Good--tolerating POs, hematocrit stable.
Discharge Instructions:
Maintain a low-fat, low-residue (limiting the amount of fibre in
the diet. Foods that have a high fibre content are wholegrain
cereals, wholemeal bread/ biscuits, nuts, seeds, dried fruits,
and skin/stalks of fruits and vegetables. Milk should be
consumed in moderation.) diet for next 2 days.
You may continue to have black stools over the next 2-3 days,
however, if they persist beyond that or if pain persists or you
feel weak or dizzy at all, please come to the ER. If you feel
weak or dizzy, stop taking your lisinopril, and come to the ER.
For your diabetes continue taking the metformin. Wait 1 day
until you are eating regularly until you restart the glyburide.
You have been prescribed PrevPac (antibiotics plus antacid)
which you should take as instructed for 2 weeks. Once you
complete that, fill the prescription for pantoprazole (Protonix)
and continue on that.
Do not take aspirin until you are evaluated again by Dr. [**Last Name (STitle) 10689**]
or Dr. [**Last Name (STitle) **].
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10689**] on [**12-3**] per your
previous appointment.
If you have any trouble seeing him, call Dr. [**Last Name (STitle) 107416**] office
([**Telephone/Fax (1) 250**]) to schedule an appointment. It is very important
that you see a doctor next week to have your hematocrit checked.
|
[
"4019"
] |
Admission Date: [**2135-6-14**] Discharge Date: [**2135-6-15**]
Date of Birth: [**2093-9-7**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Hydralazine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
intubation/extubation
hemodialysis x2
History of Present Illness:
41 y/o F with hx of ESRD on HD for last two months, unclear
etiology for renal failure, presents with acute respiratory
distress. She has a hx of getting headaches with HD and so they
have been taking off less fluid than usual at HD. She is a
Tues/Thurs/Sat HD patient and had her last session on Saturday.
Unable to get more of a history of cough, sputum, or
precipitating events around her acute respiratory distress.
.
In the ED, initial vitals were T 97, HR 122, BP 177/125, R 30,
82% on RA. She had rales at bilateral bases. She was aggitated
adn very upset. She received 80 mg IV laix and 1 mg ativan. She
was "hysterical" and intubated for airway protection with
etomidate and vecuronium. Renal was consulted in the ED and plan
for emergent dialysis once in the ICU was initiated. She was
started on a propofol gtt, and she was difficult to sedate.
.
On arrival to the floor, she is intubated and minimally sedated
and aggitated. The dialysis nurses are in the room already about
to begin dialysis on the patient.
Past Medical History:
- ESRD (GN) s/p placement HD line on [**3-22**], missed [**1-12**] HD
sessions
- HTN
Social History:
Immigrated from [**Country 27587**] approx 20 years ago. Denies alcohol,
tobacco, or illicit drug use. Lives at home with her husband and
son. Is a biologist, formerly worked at biotech firm, not
currently employed.
Family History:
Sister who died from complications of a renal transplant, a
mother who has severe chronic kidney disease, and a maternal
grandfather who also had some form of glomerulonephritis.
Physical Exam:
Vitals - 96.4, 166/119, 87, 97% on FiO2 100% with PEEP 10,
400x26
Gen - intubated and sedated, aggitated
HEENT - ET tube, PERRLA, EOMI, supple neck
CV - RRR, no m,r,g
Lungs - diffuse crackles, mild expiratory wheezes
Abd - soft, NT, ND, no hsm or masses
Ext - warm, well perfused, no edema
Neuro - intubated and sedated
Pertinent Results:
[**2135-6-14**] 02:41AM BLOOD WBC-8.6 RBC-3.75* Hgb-11.4* Hct-36.0
MCV-96 MCH-30.3 MCHC-31.6 RDW-22.5* Plt Ct-101*
[**2135-6-14**] 05:34AM BLOOD WBC-10.9 RBC-3.01* Hgb-9.1* Hct-28.5*
MCV-95 MCH-30.3 MCHC-32.0 RDW-22.7* Plt Ct-72*
[**2135-6-15**] 05:35AM BLOOD WBC-7.7 RBC-2.53* Hgb-8.1* Hct-23.5*
MCV-93 MCH-31.9 MCHC-34.5 RDW-22.9* Plt Ct-64*
[**2135-6-14**] 02:41AM BLOOD PT-12.1 PTT-21.8* INR(PT)-1.0
[**2135-6-14**] 02:41AM BLOOD Glucose-125* UreaN-50* Creat-7.6* Na-143
K-5.8* Cl-104 HCO3-22 AnGap-23*
[**2135-6-14**] 05:34AM BLOOD Glucose-110* UreaN-51* Creat-7.2* Na-140
K-6.6* Cl-107 HCO3-20* AnGap-20
[**2135-6-14**] 11:16AM BLOOD Glucose-66* UreaN-15 Creat-3.2*# Na-140
K-3.4 Cl-104 HCO3-21* AnGap-18
[**2135-6-15**] 05:35AM BLOOD Glucose-89 UreaN-31* Creat-5.4*# Na-139
K-4.7 Cl-102 HCO3-22 AnGap-20
[**2135-6-14**] 05:34AM BLOOD ALT-61* AST-76* AlkPhos-137* TotBili-0.4
[**2135-6-15**] 05:35AM BLOOD Calcium-7.7* Phos-6.1*# Mg-2.1
[**2135-6-14**] 03:49AM BLOOD Type-ART Temp-37.7 Rates-18/ Tidal V-442
PEEP-5 FiO2-100 pO2-101 pCO2-66* pH-7.10* calTCO2-22 Base XS--10
AADO2-564 REQ O2-91 -ASSIST/CON Intubat-INTUBATED
[**2135-6-14**] 08:46AM BLOOD Lactate-0.8
.
[**6-14**] Echo
The left atrium is normal in size. 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.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a small to
moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade.
.
[**6-14**] CXR:
FINDINGS: [**Doctor Last Name **] tip of a central access catheter is in the region
of the right atrium. Marked bilateral hilar and lung parenchymal
opacities are present. Bilateral pleural effusions are also
present. The cardiac silhouette is indistinct. There is no
pneumothorax.
IMPRESSION: Bilateral opacities in a hilar distribution with
prominence of
pulmonary vasculature compatible with pulmonary edema.
Superimposed infection cannot be excluded.
.
[**6-14**] follow up CXR:
FINDINGS: The ET tube is 3 cm above the carina. The right-sided
dialysis
catheter tip is in the right atrium. Nasogastric tube courses
inferiorly and out of the field of view. The heart size is
mildly enlarged. Mediastinal contours appear within normal
limits. The hila are normal appearing bilaterally. Previously
described right-sided opacity throughout both lungs has improved
significantly, most consistent with resolving pulmonary edema.
Retrocardiac opacity persists consistent with atelectasis. There
is no large pleural effusion or pneumothorax. The osseous
structures appear intact.
IMPRESSION: Improving pulmonary edema.
Brief Hospital Course:
41 y/o F with hx of HTN, ESRD of unknown etiology on HD with
recent GNR bacteremia presents with acute respiratory distress
in the ED, likely from fluid overload secondary to incomplete HD
treatments. She had HD x2 here and was easily extubated after
the first session. She has difficult to control HTN. See below
for discussion of each problem.
.
# Respiratory Distress: had acute respiratory distress from what
appeared to be massive fluid overload on CXR. She was having
less fluid removed at HD per her history. She also had recent hx
of bacteremia with new MR on her echo concerning for question of
endocarditis. Most likely is acute flash edema in setting of
fluid overload and HTN. Her echo did not show worsening MR,
which we were intially concerned as a possiblity for her fluid
overload. We controlled her BP, did HD to have her fluid
removed. She was extubated the day of admission after her first
HD session. She then had a second HD session the day of
discharge. She remained on room air and felt well.
.
# ESRD: likely from GN, although etiology is still somewhat
unclear given no biopsy in the past. She has been have less
fluid removal. Also has hx of non-compliance with HD at times
and trying herbal/alternative medicine instead. She was
dialyzed twice as above. She was kept on sevelemer and
nephrocaps.
.
# Hyperkalemia: in setting of being due for HD on admission.
She had no EKG changes. It improved with dialysis.
.
# GNR bactermia: had GNR bacteremia per prior discharge summary,
was enterobacter [**First Name8 (NamePattern2) **] [**Location (un) 745**] [**Location (un) 3678**] records. Initially it had
been worrisome for continued involvement of the heart valves,
but echo again did not show endocarditis or valve dysfunction.
Was on course of ceftaz during HD. Her blood cx were
preliminarily negative here. We continued her HD dosing. ABX
course should continue until [**6-19**].
.
# HTN: hypertensive at baseline, had not taken her home meds
given her acute respiratory distress. Was high in the 170s-200s;
baseline is apparently around 170s. We increased her amlodipine
from 2.5 [**Hospital1 **] to 5 mg [**Hospital1 **]. Otherwise we kept her on her home
labetolol. Once she was extubated, her BPs stabalized and she
felt better. She was discharged with a sBP in the 150s.
Medications on Admission:
Amlodipine 2.5 mg [**Hospital1 **]
Labetolol 300 mg qAM and qPM
Labetolol 200 mg qNoon
Senna
Docusate
Nephrocaps
Calcium Acetate 667 mg 2 caps TID
Ceftaz 1 gm until [**6-19**] qHD
Discharge Medications:
1. Labetalol 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
2. Labetalol 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. CefTAZidime 1 g IV QHD Start: [**2135-6-14**]
4. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
5. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO three
times a day: take with meals.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
respiratory failure
flash pulmonary edema
end-stage renal disease on HD
htn
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for respiratory distress and
very high blood pressures. This was caused by having extra
fluid in your lungs from not enough fluid being taken off at
dialysis and high blood pressures. You were intubated and then
emergently dialyzed to remove the fluid. After the fluid
removal, we were able to take extubate you and you were
breathing better on your own.
.
We did dialysis again today and removed more fluid.
.
You should take all your medications as you had been taking
before this admission except your amlodipine. We increased your
amlodipine from 2.5 mg [**Hospital1 **] to 5 mg [**Hospital1 **] for better blood pressure
control.
.
Please follow up as previously scheduled. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 10807**]s sessions, it is very important you attend them. You
should restart your normal dialysis tomorrow as previously
planned.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name (STitle) 6624**], [**6-22**] at 9:15am. Her number is [**Telephone/Fax (1) 3329**]. Please call if that
time does not work for you.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2135-6-15**]
|
[
"51881",
"40391",
"2767"
] |
Admission Date: [**2197-12-6**] Discharge Date: [**2198-1-3**]
Date of Birth: [**2135-3-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7616**]
Chief Complaint:
found down at home
Major Surgical or Invasive Procedure:
EGD x 3
TIPS
[**Last Name (un) **] tube
Intubation
History of Present Illness:
62 yo m w/ h/o "liver dz", and history of ulcer, who called EMS
due to feeling like he was going to "pass out". Has been feeling
LH for the past day. Due to pre-syncopal symtptoms called EMS.
EMS found the patient to be hypotensive, sbp 60s, and in transit
vomited approx 500cc BRB.
.
Patient reports that he had been in his USOH until approx 3 wks
ago when he noted the onset of post-prandial diffuse abdominal
pain. Desrcibed as mild and crampy. Also noted with taking
pills. Some relief when accompanied by milk. No n/v/d. No prior
hematemesis. No melana. No history of variceal bleeding.
.
In the ED, hypotensive 86/48, vomited 800cc BRB. NGL performed,
returned 500cc BRB and did not clear. 2 14g PIV, placed rec'd 4U
PRBC, 2L NS, octreotide, protonix.
Past Medical History:
"ulcer dz"
"liver dz"
CHF
Social History:
No etoh. +remote smoking history. Stopped 30 yrs ago.
Family History:
NC
Physical Exam:
t 96.2, bp 112/68, hr 68, rr14, 98% 2L NC
Elderly, well appearing male, alert and oriented, w/ NGT in
place draining BRB.
PERRL
OP w/ dried blood.
JVP could not be appreciated
Regular s1,s2. No m/r/g
LCA b/l
Distended, protuberant abdomen. +bs. soft. nt. No fluid wave.
Trace LE edema. No c/c
No asterixis, palmar erythema, gynecomastia, spider angiomata.
Pertinent Results:
ADMISSION LABS:
[**2197-12-6**] 06:40AM WBC-4.8 RBC-2.57* HGB-8.4* HCT-25.0* MCV-97
MCH-32.6* MCHC-33.5 RDW-14.1
[**2197-12-6**] 06:40AM PLT COUNT-98*
[**2197-12-6**] 06:40AM PT-14.4* PTT-25.2 INR(PT)-1.3*
[**2197-12-6**] 06:40AM FIBRINOGE-228
[**2197-12-6**] 06:40AM UREA N-37* CREAT-1.0
[**2197-12-6**] 06:40AM AMYLASE-47
[**2197-12-6**] 06:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2197-12-6**] 07:03AM PO2-122* PCO2-40 PH-7.32* TOTAL CO2-22 BASE
XS--5 COMMENTS-GREEN TOP
[**2197-12-6**] 07:31AM URINE MUCOUS-FEW
[**2197-12-6**] 07:31AM URINE GRANULAR-0-2 HYALINE-[**2-19**]*
[**2197-12-6**] 07:31AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0
[**2197-12-6**] 07:31AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-NEG
[**2197-12-6**] 07:31AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2197-12-6**] 07:57AM PLT COUNT-66*
[**2197-12-6**] 07:57AM WBC-6.0 RBC-2.95* HGB-9.9* HCT-28.1* MCV-95
MCH-33.6* MCHC-35.3* RDW-14.3
[**2197-12-6**] 09:19AM FIBRINOGE-246
[**2197-12-6**] 09:19AM PT-14.1* PTT-22.9 INR(PT)-1.3*
[**2197-12-6**] 09:19AM ALBUMIN-3.1* CALCIUM-7.4* PHOSPHATE-2.9
MAGNESIUM-1.6
[**2197-12-6**] 09:19AM LIPASE-35
[**2197-12-6**] 09:19AM ALT(SGPT)-27 AST(SGOT)-28 LD(LDH)-147 ALK
PHOS-88 AMYLASE-47 TOT BILI-0.6
[**2197-12-6**] 09:19AM GLUCOSE-72 UREA N-36* CREAT-0.9 SODIUM-142
POTASSIUM-4.9 CHLORIDE-113* TOTAL CO2-19* ANION GAP-15
[**2197-12-6**] 09:32AM freeCa-1.06*
[**2197-12-6**] 09:32AM LACTATE-2.1* NA+-140 K+-4.9 CL--114* TCO2-21
[**2197-12-6**] 09:32AM TYPE-[**Last Name (un) **] TEMP-35.7 PH-7.33*
[**2197-12-6**] 10:20AM HCT-31.4*
[**2197-12-6**] 12:34PM PT-15.3* PTT-48.1* INR(PT)-1.4*
[**2197-12-6**] 12:34PM PLT COUNT-134*#
[**2197-12-6**] 12:34PM WBC-11.1*# RBC-4.23*# HGB-13.4*# HCT-39.2*
MCV-93 MCH-31.6 MCHC-34.1 RDW-14.6
[**2197-12-6**] 12:34PM CALCIUM-6.5*
[**2197-12-6**] 12:34PM GLUCOSE-104 UREA N-34* CREAT-0.9 SODIUM-140
POTASSIUM-5.7* CHLORIDE-114* TOTAL CO2-16* ANION GAP-16
[**2197-12-6**] 02:31PM PLT COUNT-158
[**2197-12-6**] 02:31PM WBC-10.8 RBC-4.28* HGB-13.3* HCT-39.2* MCV-92
MCH-31.1 MCHC-33.9 RDW-14.8
[**2197-12-6**] 02:32PM FIBRINOGE-205
[**2197-12-6**] 02:32PM PT-14.0* PTT-27.3 INR(PT)-1.2*
[**2197-12-6**] 02:32PM calTIBC-280 FERRITIN-33 TRF-215
[**2197-12-6**] 02:32PM CALCIUM-7.0* PHOSPHATE-3.2 MAGNESIUM-1.5*
IRON-196*
[**2197-12-6**] 02:32PM GLUCOSE-136* UREA N-34* CREAT-0.9 SODIUM-139
POTASSIUM-5.6* CHLORIDE-114* TOTAL CO2-16* ANION GAP-15
[**2197-12-6**] 02:43PM TYPE-ART TEMP-36.7 RATES-14/ TIDAL VOL-700
PEEP-5 O2-50 PO2-146* PCO2-31* PH-7.35 TOTAL CO2-18* BASE XS--7
-ASSIST/CON INTUBATED-INTUBATED
[**2197-12-6**] 05:00PM FIBRINOGE-208
[**2197-12-6**] 05:00PM PT-13.7* PTT-29.0 INR(PT)-1.2*
[**2197-12-6**] 05:00PM PLT COUNT-182
[**2197-12-6**] 05:00PM WBC-13.1* RBC-4.27* HGB-13.6* HCT-39.1*
MCV-91 MCH-31.8 MCHC-34.8 RDW-14.8
[**2197-12-6**] 05:00PM HCV Ab-NEGATIVE
[**2197-12-6**] 05:00PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc
Ab-NEGATIVE HAV Ab-POSITIVE
[**2197-12-6**] 05:00PM CALCIUM-7.8* PHOSPHATE-3.4 MAGNESIUM-1.6
[**2197-12-6**] 05:00PM GLUCOSE-140* UREA N-34* CREAT-0.9 SODIUM-141
POTASSIUM-4.5 CHLORIDE-114* TOTAL CO2-17* ANION GAP-15
[**2197-12-6**] 05:17PM TYPE-ART RATES-14/ TIDAL VOL-600 PEEP-5 O2-40
PO2-108* PCO2-30* PH-7.35 TOTAL CO2-17* BASE XS--7 -ASSIST/CON
INTUBATED-INTUBATED
[**2197-12-6**] 07:54PM HCT-37.1*
[**2197-12-6**] 09:49PM FIBRINOGE-224
[**2197-12-6**] 09:49PM PT-13.2* PTT-28.1 INR(PT)-1.1
[**2197-12-6**] 09:49PM PLT COUNT-111*
[**2197-12-6**] 09:49PM WBC-10.5 RBC-3.91* HGB-13.0* HCT-35.4* MCV-90
MCH-33.2* MCHC-36.7* RDW-15.2
[**2197-12-6**] 09:49PM CALCIUM-7.9* PHOSPHATE-3.5 MAGNESIUM-2.3
[**2197-12-6**] 09:49PM GLUCOSE-156* UREA N-32* CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-114* TOTAL CO2-17* ANION GAP-13
Brief Hospital Course:
62 yo m w cirrhosis and varices admitted for an upper GI bleed x
2. The following issues were investigated during this
hospitalization:
.
1) GIB: Shortly after admission to the ICU the pt. having
massive hemoptysis with resultant hypotension. He was scoped
emergently after intubation and found to have stage 3 variceal
bleeding which was unable to be stopped with banding. He was
started on Protonix and Octreotide drips with Ciprofloxacin
prophylaxis. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] esophageal balloon was placed with
stabilization of bleeding. He required 12U pRBCs and 7U FFP on
HD1. A TIPS was successfully placed on [**12-8**], but followed by
continued bleeding. He was transfused once more on [**12-22**]. A RUQ
u/s on [**12-21**] an [**12-23**] confirmed patency of TIPS. His hematocrit
remained stable after the transfusion on [**12-22**] and he was
transferred to the general medicine floor for continued
management.
.
2) Liver disease: Etiology is unclear but has been described as
NASH and cryptogenic in nature. There is no report of a liver
biopsy. During this hospitalization, initial work-up revealed
negative hepatology serologies and no evidence of
hemochromotosis. An abdominal CT showed a 1.5 cm lesion in the
right lobe of the liver and AFP is elevated to 13.7. Additional
work-up was deferred given his acute medical problems
necessitating ICU hospitalization. He should pursue further
work-up of this lesion as an outpatient. An appointment has been
scheduled for him in the liver clinic here at [**Hospital1 18**].
.
3) Altered mental status - Etiology unclear, but initially
concerning for anoxic brain injury in the setting of hypotension
upon presention, but repeat imaging showed resolution of initial
changes, which was more suggestive of resolving metabolic
condition (i.e. hepatic encephalopathy). Infectious work-up in
the MICU was negative. On the general floor, the patient was
maintained on Lactulose and Rifaximin for ammonia control. His
mental status gradually and significantly improved and he was
noted to be awake, alert and oriented x 3, often communicative.
He was discharged on Rifaximin and Lactulose, which he should
continue given his TIPS.
.
4) Seizure activity: Patient was observed to be have brief
episodes of tonic-clonic seizure activity on [**12-13**], and
subsequently found to have frequent, intermittent seizure
activity on EEG in the following 24 hours essentially c/w status
epilepticus. He was seen by the neurology consult service and
started on Dilantin. His hospital course was thereafter
significant for no seizure activity. The patient was discharged
on Dilantin with instructions to have Dilantin levels checked,
with goal of 15-20 (corrected for albumin).
.
5) DM: The patient's outpatient Metformin was held given the
extent of his liver disease. His blood sugar was monitored and
treated with an insulin sliding scale and Glargine QHS.
.
6) Ventilator-acquired pneumonia: Pt. was intubated in the ICU
to protect his airway. During this time, he developed a
pneumonia with Coag + Staph aureus growing in his sputum. He was
started on Vancomycin, which was later switched to Nafcillin
once sensitivies came back showing MSSA. He was treated for a
total of 8 days.
.
7) F/E/N: The patient was started on tube feeds in the ICU,
which were continued on arrival to the general medicine floor.
During his hospitalization on the floor, he self d/c'd the
Dobhoff tube twice, the last of which was done the evening
before his discharge from the hospital. Prior to this last self
d/c, the patient had just been started on pureed diet and
nectar-thickened liquids after a speech and swallow evaluation
which showed thin aspiration. Because of this self d/c, there
was not enough time for accurate calorie counts. Thus, it is
important that his nutrition be closely followed on discharge
and tube feeds should be reconsidered if the patient's appetite
or food intake should decline.
Medications on Admission:
lisinopril 10mg QD
protonix 40 [**Hospital1 **]
nadalol 40mg TID
aspirin 81 mg qday
insulin 70QAM 65QPM
metformin 1000 [**Hospital1 **]
cyanocobalmin
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Hospital1 **]: One (1)
Appl Ophthalmic PRN (as needed).
2. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: [**12-19**] Sprays Nasal
TID (3 times a day) as needed.
3. Levetiracetam 500 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO BID (2
times a day).
4. Phenytoin 100 mg/4 mL Suspension [**Month/Day (2) **]: Two Hundred (200) mg PO
Q 8H (Every 8 Hours).
5. Propranolol 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times
a day).
6. Lactulose 10 g/15 mL Syrup [**Month/Day (2) **]: Thirty (30) ML PO TID (3
times a day): give for goal 3 BMs/day.
7. Rifaximin 200 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO TID (3 times a
day).
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
9. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
10. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) nebulizer
treatment Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
11. Lantus 100 unit/mL Cartridge [**Last Name (STitle) **]: Fifty Five (55) units
Subcutaneous at bedtime.
12. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: One (1)
unit Subcutaneous QACHS: give per attached sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Cryptogenic cirrhosis
Esophageal varices
Hepatic encephalopathy
Seizure activity
Diabetes mellitus, Type 2
Ventilator-acquired pneumonia
Liver mass
Discharge Condition:
stable, tolerating po with pureed diet, alert and oriented x3
Discharge Instructions:
You were admitted to the hospital for bleeding from your
stomach, which is a complication of your liver disease. You
were also found to have seizures.
Call your doctor or return to the ER for fevers, chills, nausea,
vomiting, abdominal pain, confusion, lethargy, tarry stool, or
blood in your stool.
It is very important that you take all of your medications as
prescribed. Your doctors [**First Name (Titles) 4801**] [**Last Name (Titles) **] your lactulose to make
sure you are having at least 3 bowel movements per day.
Your doctors at the nursing home need to check your dilantin
levels every other day, and correct this for your albumin. The
equation is: corrected dilantin level = measured dilantin level
divided by [(0.2 x albumin) +0.1]. Your goal corrected dilantin
level is between 15 and 20. If your level is persistently low
or high, your doctors should [**Name5 (PTitle) 138**] your neurologist, Dr. [**First Name4 (NamePattern1) 1104**]
[**Last Name (NamePattern1) 4638**], at [**Telephone/Fax (1) 44**].
Followup Instructions:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2198-2-28**] 4:30 (Neurology)
.
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2198-1-31**] 2:30 (Hepatology)
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 7619**]
|
[
"51881",
"4280",
"25000",
"V5867"
] |
Admission Date: [**2142-7-3**] Discharge Date: [**2142-7-4**]
Date of Birth: [**2117-8-7**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet / Morphine
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
dyspnea, hypertension
Major Surgical or Invasive Procedure:
Hemodialysis
History of Present Illness:
24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES,
prior ICH, with frequent admission for hypertensive
urgency/emergency, with chronic abdominal pain. She was recently
discharged on [**7-1**] after presenting for hypertensive urgency and
dyspnea for which she received iv medication in the ED, but was
otherwised managed with oral antihypertensives and CPAP.
.
She was doing well until the evening of [**7-2**] when she notes the
gradual onset of dyspnea. She denied f/c/cp/ha/abd
pain/diarrhea, or constipation. She was having regular, soft,
daily BMs.
.
On [**7-3**] she awoke, and describes n/v x 2, with increasing
dyspnea, and headache. She did not want to wait until dialysis
at 4PM and therefore presented to [**Hospital1 18**].
.
In ED VS= 97.7 [**Telephone/Fax (2) 43606**] 100%RA. Labs were notable for HCT
23, PLT 66, WBC 3.3, all roughly at baseline. CXR without acute
process, ECG unchanged from prior. No UA sent, though she does
make some urine. She was started on nitro gtt with modest
improvement of SBPs to 210s, then labetalol 20mg iv x1 followed
by labetalol gtt with BP 221/130 at the time of transfer. She
refused abdominal CT. Renal was consulted, but felt HD not
indicated today.
.
.
ROS: Negative for fevers, chills, chest pain, diarrhea, rash,
joint pains. +n/v as above. +abdominal pain unchanged from her
baseline. +dyspnea, +HA. denies visual changes, slurrring
speech, numbness, weeakness.
Past Medical History:
1. Systemic lupus erythematosus since age 16 complicated by
uveitis and end stage renal disease since [**2135**].
-s/p treatment with cyclophosphamide and mycophenolate and now
maintained on prednisone
2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD
and now HD with intermittent refusal of dialysis, currently only
agrees to be dialyzed one time/wk
3. Malignant hypertension with baseline SBP's 180's-220's and
history of hypertensive crisis with seizures.
4. Thrombocytopenia
5. Thrombotic events with negative hypercoagulability work-up
- SVC thrombosis ([**2139**]); related to a catheter
- Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**])
- Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**])
- Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**])
6. HOCM: Last noted on echo [**8-17**]
7. Anemia
8. History of left eye enucleation [**2139-4-20**] for fungal infection
9. History of vaginal bleeding [**2139**] lasting 2 months s/p
DepoProvera injection requiring transfusion
10. History of Coag negative Staph bacteremia and HD line
infection - [**6-16**] and [**5-17**]
11. Thrombotic microangiopathy
12. Obstructive sleep apnea on CPAP
13. Left abdominal wall hematoma
14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**],
[**2142**].
15. Pericardial effusion
16. CIN I noted in [**2139**], not further worked up due to frequent
hospitalizations and inability to see in outpatient setting
17. Gastric ulcer
18. PRES
Social History:
Denies tobacco, alcohol or illicit drug use. Lives with mother
and is on disability for multiple medical problems.
Family History:
No known autoimmune disease.
Physical Exam:
Vitals - 97.7 88 220/150 19 100%2L BC.
General: A&Ox3. NAD, oriented x3.
HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear,
nonerythematous, MMM.
Neck: supple, no LAD, full ROM.
Lungs: CTA B, with few crackles at bases.
CV: RR, nl S1, S2 +S3, no rubs appreciated.
Abdomen: soft, minimally distended, diffuse mild tenderness to
palpation, negative [**Doctor Last Name **], no rebound, gaurding.
Ext: WWP, 1+ dp/pt pluses, no clubbing, cyanosis or edema.
Neuro: CN 2-12 intact. moving all four extremities
spontaneously.
Pertinent Results:
Lab Results on Admission:
[**2142-7-3**] 11:37AM GLUCOSE-95 UREA N-40* CREAT-7.4*# SODIUM-140
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
ALT(SGPT)-14 AST(SGOT)-44* LD(LDH)-264* ALK PHOS-115 TOT
BILI-0.4 ALBUMIN-3.2*
WBC-3.6* RBC-2.61* HGB-7.6* HCT-23.4* MCV-90 MCH-29.0 MCHC-32.4
RDW-18.3*
[**2142-7-3**] 11:37AM NEUTS-71.6* LYMPHS-23.0 MONOS-3.7 EOS-1.5
BASOS-0.2 PLT COUNT-66* PT-14.0* PTT-34.5 INR(PT)-1.2*
[**2142-7-3**] 06:00PM CK-MB-5 cTropnT-0.17*CK(CPK)-58
[**2142-7-3**] CXR:
IMPRESSION: Unchanged moderate cardiomegaly with pulmonary
edema. Again
underlying pneumonia in the lung bases cannot be completely
excluded and
evaluation after appropriate diuresis could be performed if
pneumonia remains a clinical concern.
Brief Hospital Course:
24F with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome,
PRES, prior ICH, and recent SBO, p/w n/v, and hypertensive
urgency.
.
# hypertensive urgency - On presentation she denies chest pain,
but continues to have mild headache, and resolving shortness of
breath, likely [**2-12**] hypertension. states she did take her PO
meds. Hypertensive urgency was treated as follows with nitro and
labetalol gtt which were quickly weaned as blood pressures
dropped below SBP 120. She evenutally became hypotensive to SBP
of 90 which resolved on its own. She was continued on CPAP
overnight and discontinued in the am. She was continued on her
home regimen of oral labetolol, nifedipine, hydralazine,
aliskerin. She remained normotensive the following morning and
was taken to hemodialysis after which she was discharged home on
all of her old home medications.
.
# abdominal pain - On presentation she was without n/v, soft
abdomen, passing flatus, and having daily bowel movements. She
did have hypoactive bowel sounds on admission. She was
maintained on outpt pain regimen of po dilaudid, fentanyl patch,
lidoacine patch, neurontin with HD with plan to follow BMs
closley. Her pain improved the am of discharge and she had no
further vomiting.
.
# ESRD on HD - She is currently getting HD SaTuTh, though did
not get HD on the day of presenation. As there was no acute
indication for HD on presentation, she received HD on the
following am, day of discharge. She was continued on sevelamer.
.
# anemia - chronic anemia, likely [**2-12**] CKD and SLE, currently
above baseline, though has h/o GIB. She received 2 unit PRBCs
and epo with hemodialysis.
.
# h/o gastric ulcer - she was continued on her outpatient dose
of PPI [**Hospital1 **].
.
# SLE - continue home regimen of prednisone 4mg po qdaily.
.
# h/o SVC thrombosis - pt with goal INR [**2-13**], but this was
stopped after recent admission [**2-12**] supratherapeutic INR. INR
currently sub-therapeutic and she was resumed on warfarin at 3
mg qdaily without heparin bridge.
.
# seizure disorder - continued on keppra 1000 mg PO 3X/WEEK
(TU,TH,SA).
.
# depression - continued on celexa.
Medications on Admission:
1.Nifedipine 90 mg PO DAILY (Daily).
2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime).
3.Lidocaine 5 % PATCH Q24HR.
4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID
5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H
7.Prednisone 4 mg PO DAILY (Daily).
8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday).
9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday).
10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH
MEALS).
11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD
12.Labetalol 1000 mg Tablet Tablet PO TID
13.Hydralazine 100 mg Tablet PO Q8H
14.Warfarin 3 mg Tablet PO Once Daily at 4 PM.
15.Pantoprazole 40 mg PO Q12H (every 12 hours).
16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA).
Discharge Medications:
1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO HS (at bedtime).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours).
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal
every seventy-two (72) hours.
6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for hypertension.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
12. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day). Tablet(s)
14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each
hemodialysis).
15. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA
(TU,TH,SA).
Discharge Disposition:
Home With Service
Facility:
VNA
Discharge Diagnosis:
Primary:
hypertensive emergency
anemia, erythropoetin deficiency
Secondary:
chronic renal failure on hemodialysis
lupus nephritis
Discharge Condition:
Hemodynamically stable.
Discharge Instructions:
You were admitted for hypertensive urgency and treated in the
intensvie care unit with IV medications to decrease your blood
pressure. You also received 2 units of blood and hemodialysis
before you were discharged home.
It is essential that you take all of your prescribed blood
pressure medications and present regularly for your Tuesday,
Thursday, Saturday dialysis.
Please return to the emergency department or call your primary
care physician if you develop any chest pain, shortness of
breath, fevers, or any other concerning symptoms.
Followup Instructions:
You have the following appointment scheduled. Please contact
your provider if you are unable to make these appointments.
Your dialysis is scheduled for Tuesday, Thursday, Saturday.
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2142-7-30**] 2:00
Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2142-8-8**] 3:15
|
[
"2875",
"32723",
"V5861"
] |
Admission Date: [**2108-7-18**] Discharge Date: [**2108-7-19**]
Date of Birth: [**2064-12-19**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
5mm parclinoid aneurysm
Major Surgical or Invasive Procedure:
Cerebral angiogram with coiling of a left paraclinoid aneurysm.
History of Present Illness:
Ms. [**Known lastname 77625**] 43-year-old female who was
found to have a 4 x 3 mm aneurysm of the anterior communicating
artery, which was detected as part of workup for neck mass.
Past Medical History:
Negative
Social History:
She graduated from high school and is
unemployed currently. She lives with her husband and both
in-laws. She had a history of heavy smoking but quit two weeks
ago, is on Chantix. She does not consume alcoholic beverages.
Family History:
Family History of Diabetes and uterine cancer in mother, heart
disease in father, kidney problems in a sister.
Physical Exam:
On examination, she was a pleasant young lady in no distress.
She was awake, alert, oriented x3. Her heart rate was 84 per
minute, blood pressure was 118/70, respiratory rate was 16 per
minute. She was awake, alert, oriented x3. Her memory recent
and remote was good. Attention and concentration is
appropriate.
Language and fund of knowledge is good. Cranial nerves II
through XII are intact. Her motor strength was [**6-16**] in all four
extremities. Gait and coordination was normal. Chest showed
good air entry bilaterally. Heart: S1, S2 heard, no murmurs.
Exam on Discharge:
Neurologically intact
Pertinent Results:
[**2108-7-18**] Cerebral Angiogram: Final read pending.
Brief Hospital Course:
Ms. [**Known lastname 77625**] was admitted to the hospital on [**7-18**] to undergo a
an elective Cerebral angiogram with coiling of her left ICA
aneurysm under general anesthesia.
Procedure was uncomplicated, post coiling the patient was taken
to the NICU.
On Post procedure day one, the patient was complaining of a
moderate headache despite Oxycodone and Fioricet. She was given
one dose of Decadron and a prescription for a Medrol dose pack
was included in her discharge medications.
She was discharged from the ICU with appropriate follow up
instructions.
Medications on Admission:
Zoloft 25mg daily, Chantix
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**2-13**]
Tablets PO Q4H (every 4 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): While on Medrol dose pack.
Disp:*14 Tablet(s)* Refills:*0*
6. Medrol (Pak) 4 mg Tablets, Dose Pack Sig: One (1) Tablets,
Dose Pack PO As directed: Take as directed.
Disp:*1 Tablets, Dose Pack(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
5 mm Left paraclinoid aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please call our office to make an appointment to see Dr. [**First Name (STitle) **]
in 4 weeks for follow up.
Completed by:[**2108-7-19**]
|
[
"3051"
] |
Admission Date: [**2123-8-10**] Discharge Date: [**2123-8-14**]
Date of Birth: [**2049-11-16**] Sex: F
Service: NMED
Allergies:
Codeine / Morphine
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
right sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 73 year old RH woman with a history of
hypertension and hypercholesterolemia now presenting from an
outside hospital after an acute onset of right sided weakness
and
facial droop. As per the patient, she was at home eating dinner
when she suddenly felt weakness on her right side. She stumbled
from the dinner table to the couch, where as per the son her
speech seemed garbled and less coherent, her face appeared
asymmetric as well. She was taken to an OSH, where they did not
have a functioning CT scanner, thus she was transferred to [**Hospital1 18**]
for further management. She denied any associated headache,
dizziness, or visual disturbances during the event.
In our [**Last Name (LF) **], [**First Name3 (LF) **] MRI reveal an acute infarct in the left internal
capsule. TPA was given and the patients deficits (dsyarthria
and
right-sided weakness) continued to show improvement. She was
tranferred to the NICU and now is stable for management on the
floor.
ROS:
no recent history of diarrhea, urinary symptoms, chest pain,
shortness of breath. She has had some increased fatigue lately,
but is unable to elaborate beyond this vague complaint.
Past Medical History:
Past Medical History:
-hypertension
-hypothyroidism
-hypercholestrolemia
-arthritis
Social History:
-lives with husband and daughter
-no recent history of tobacco or etoh
Family History:
-cad history, unclear which members
-no history of seizures or strokes
Physical Exam:
Vitals: 98.4 146/80 66 18 98% on 2L
General: elderly woman in no acute distress
Neck: supple, no carotid bruit
Lungs: decreased breath sounds at the bases, otherwise clear
CV: RR, normal S1, S2
Abdomen: non-tender, non-distended, bowel sounds present
Ext: warm, no edema, faint DP pulses
Neurologic Examination:
Mental Status: Awake and alert, cooperative with exam, normal
affect
Oriented to person, thought she was at "Mohegan", knew month and
president
Attention: Can spell "world" backward
Language: Fluent, mild dysarthria, occassional paraphasic
errors,
naming intact; difficulty with repeating complex phrases
Registration: [**3-31**] items, Recall [**1-30**] items at 3 minutes with
prompting
No apraxia, no neglect
Cranial Nerves: Visual fields are full to confrontation. Pupils
equally round and reactive to light, 4 to 2 mm bilaterally.
Extraocular movements intact, no nystagmus. Facial sensation
equal; right facial droop with decreased NLF. Hearing intact to
finger rub bilaterally. Tongue midline, no fasciculations.
Sternocleidomastoid and trapezius normal
bilaterally.
Motor:
Normal bulk and tone bilaterally
No tremor.
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 3 3 4 4 3 4 3 3 3 4 3 3 4 4 3
Left 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Pronator drift on right
Sensation was intact to Light touch, pin prick, temperature
(cold), vibration, and proprioception
Reflexes: B T Br Pa Pl
Right 2 2 2 2+ 1
Left 2- 2- 2- 2+ 1
Plantar reflexes were withdrawal.
Coordination: fnf slowed and slightly ataxic on right, rapid
alternating movements slowed on right
Gait exam deferred at patient request
Pertinent Results:
Cbc: 9.5/36.5/369
Chem: 143/5.1 111/22 16/1.1 91
Coags: 12.9/20.0/1.1
CK: 139
MR [**Name13 (STitle) 430**]: (from OMR)
Diffusion weighted scans consistent with an acute area of brain
ischemia within the left caudate nucleus/anterior limb of left
internal capsule/left lentiform nucleus with probable high grade
stenosis or occlusion of the left middle cerebral artery in its
M1 segment.
Carotid US: no stenosis
Right shoulder xray: no fracture or dislocation
TEE:
1. No spontaneous echo contrast or thrombus is seen in the body
of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage.
2.No spontaneous echo contrast or thrombus is seen in the body
of the right
atrium or the right atrial appendage.
3.No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler
or saline contrast with maneuvers.
4.Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Regional left ventricular wall motion is normal.
Overall left
ventricular systolic function is normal (LVEF>55%).
5.Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
6.There are simple atheroma in the aortic root. There are simple
atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are
simple atheroma in the descending thoracic aorta.
7.The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation
is seen.
8.The mitral valve leaflets are mildly thickened. Mild to
moderate ([**1-29**]+)
mitral regurgitation is seen.
9.There is no pericardial effusion. There is an anterior space
which most
likely represents a fat pad, though a loculated anterior
pericardial effusion
cannot be excluded.
Brief Hospital Course:
The patient received t-PA within three hours of the onset of her
symptoms in the emergency department and was admitted to the
MICU for monitoring of her blood pressure and neurologic status.
The following morning she had significantly improved speech
with good repetition, naming, and memory as well as improved
right arm weakness. Serial no[**Serial Number 58381**]. She was
transferred to the neurology floor two days following admission.
A tranthoracic echocardiogram showed mild global left
ventricular hypokinesis with an EF 45%, but no evidence of
thrombus or valvular abnormality. A transesophageal
echocardiogram was obtained for better evaluation of the aorta
and valves which was also negative. Duplex carotid ultrasound
showed no significant stenosis in the carotid arteries
bilaterally. The patient was started on intravenous heparin 24
hours following t-PA administration and was started on coumadin
5mg po qhs the day prior to discharge for oral anticoagulation.
She will be taken off heparin when her INR reaches goal [**3-2**].
The patient received three days of Bactrim therapy for a UTI
which was discontinued after her urine cultures had no growth.
The patient was evaluated by physical and occupational therapy
who recommended acute rehab with three hours of therapy per day.
Her language is fluent and she has mild right arm weakness upon
discharge.
Medications on Admission:
Atenolol 50 mg po qd
Lipitor 20 mg po qd
Naproxen 500 mg po bid prn
Cyclobenzapine 5 mg qhs
Levoxyl 112 mcg po qd
Meclizine 25 mg po tid prn
Discharge Medications:
1. Levothyroxine Sodium 112 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: Eight Hundred (800) units Intravenous qhour: keep ptt
between 40-60.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
1. stroke
2. high cholesterol
3. hypothyroidism
Discharge Condition:
Stable, still with weakness on the right side but improving.
Discharge Instructions:
Please return to the nearest ER if symptoms of difficulty
speaking, weakness on one side of the body, or dizziness occurs.
Please take medications as prescribed.
You will need to have your inr monitored closely on the warfarin
and the iv heparin stopped when you are therapeutic ([**3-2**]).
Followup Instructions:
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] 4 weeks or
as needed.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2123-8-14**]
|
[
"2720",
"2449",
"4019"
] |
Admission Date: [**2140-4-16**] Discharge Date: [**2140-5-12**]
Date of Birth: [**2074-2-1**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Ceftriaxone / Strawberry / Bleach
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
66 year old female presents to the ER on [**2140-4-16**] with bleeding
from a recent right groin abscess that had been incised and
drained.
Major Surgical or Invasive Procedure:
[**2140-4-26**]:Right groin exploration with take down of right
common femoral and right profunda artery arteriovenous
fistulas.
History of Present Illness:
Ms [**Known lastname **] was at dialysis when her groin wound spontaneously
started oozing blood on [**2140-4-16**]. She was sent to the emergency
department, where her hematocrit was 30, from a baseline of 36,
and she was hypotensive into the 80s. The bleeding was
successfully stopped with lidocaine with epi and surgifoam. Her
INR was 3.0 at the time. Her wound was examined by ACS who
repacked the wound and recommended admission for further
evaluation.
Past Medical History:
- h/o bilateral lower extremity DVT's
- atrial tachycardia: seen by Dr. [**Last Name (STitle) **] in [**10-24**] and felt to
be atrial tachy [**2-18**] illness, no indication for ablation
- hemorrhagic pericardial effusion
- Bilateral internal jugular thromboses, restarted on coumadin
[**8-24**]
- ESRD on HD T, Th, Sat [**Doctor First Name 12074**] Dialysis [**Telephone/Fax (5) 23864**] [**Numeric Identifier 23865**]
- IDDM
- Diastolic heart failure
- Pulmonary hypertension
- Hypercholesterolemia
- OSA, noncompliant with CPAP as outpatient (on 2L home O2)
- OA
- h/o C. Diff
- GERD
- Depression
- Morbid obesity
- Fibroid uterus; vaginal bleeding
- h/o Osteomyelitis at the T9 Vertebrae [**5-24**]; tx with Vanc
- h/o Multiple line infections
Social History:
Patient denies tobacco, alcohol or illicit drug use. She lives
in a nursing home ([**Hospital3 2558**]) since the last 10 years. She
is separated from her husband. She has 5 children in [**Location (un) 86**]
[**Doctor Last Name **] area. Uses electric wheelchair.
Family History:
Two children with asthma. Strong family hx of cancer (many
uncles/aunts with lung cancer, father had prostate cancer,
mother has HCC [**2-18**] alcoholic hepatitis)
Physical Exam:
Alert and oriented x 3
VS:BP 108/40 HR 68
Resp: Lungs clear
Abd: Soft, non tender
Right groin wound: wound bed partially granulated, 50% slough.
Scant serosang drainage. Measures 6cm long x 9 cm wide x 4 cm
deep.
Pertinent Results:
CTA pelvis [**2140-4-18**]:
1. Bilateral common femoral DVT's. Atretic left SFA indicating
prior
thrombosis.
2. Right AV fistula. No evidence of pseudoaneurysm.
3. Fibroid uterus.
4. New discrete enhancing rounded hyperdensity within the right
labia
adjacent to the skin defect site. This could represent a small
hematoma or lesion. Clinical correlation is recommended.
[**2140-5-12**] 06:35AM BLOOD WBC-6.5 RBC-3.02* Hgb-9.2* Hct-30.3*
MCV-100* MCH-30.4 MCHC-30.4* [**Month/Day/Year 23866**]-17.2* Plt Ct-356
[**2140-5-12**] 06:35AM BLOOD PT-17.6* PTT-36.1 INR(PT)-1.7*
[**2140-5-12**] 06:35AM BLOOD Glucose-117* UreaN-45* Creat-5.7*# Na-134
K-5.2* Cl-96 HCO3-29 AnGap-14
[**2140-5-12**] 06:35AM BLOOD Calcium-9.7 Phos-4.3 Mg-2.3
[**2140-5-9**] 06:00AM BLOOD PTH-491*
[**2140-5-2**]: Right groin culture
_________________________________________________________
PROTEUS MIRABILIS
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- 8 R =>64 R
CEFEPIME-------------- <=1 S 2 S
CEFTAZIDIME----------- <=1 S =>64 R
CEFTRIAXONE----------- <=1 S 16 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ 8 I 8 I
MEROPENEM-------------<=0.25 S <=0.25 S
TOBRAMYCIN------------ 4 S 8 I
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
Brief Hospital Course:
Ms [**Known lastname **] is a 66 year old woman who was recented hospitalized
for an abscess incision and drainage in the right groin from
[**Date range (3) 23867**]. On [**2140-4-16**], she
was at dialysis when her groin wound spontaneously started
oozing blood. She was sent to the emergency department, where
her hematocrit was 30 from a baseline of 36 and she was
hypotensive into the 80s systolic. The bleeding was
successfully stopped with lidocaine with epi and surgifoam. Her
INR was 3.0 at the time. Her wound was examined by ACS who
repacked the wound and recommended admission for further
evaluation. A duplex ultrasound demonstrated a small 1.4 x 1.2
cm pseudoaneurysm likely originating from an epigastric arterial
branch.
Over the course of the next week, she developed recurrent
bleeding into her right thigh with associated anemia and
hypotension. A CT was performed confirming a the fistula
emanating from the femoral profunda and possibly from branches
off the common femoral with distended femoral vein and multiple
dilated venous branches extending into her pannus and into her
vulvar region consistent with her presentation of bleeding
episodes from her groin wounds. She therefore underwent
a right groin exploration with take down of right common femoral
and right profunda artery arteriovenous fistulas on [**2140-4-26**].
The procedure was without complications although she did have a
4500cc blood loss requiring 6 liters crystalloid, 6 units packed
red blood cells, 2 units FFP, 1150 cc Cell [**Doctor Last Name **].
She was closely monitored in the ICU and then was ready for
transfer to the floor on POD 1. On POD 6, she developed erythema
and drainage from her groin incision. She was started on
vancomycin, cipro and flagyl. The incision was opened and packed
with NS w>d. The wound culture eventually grew klebsiella and
proteus. Her antibiotic was changed to IV meopeneum. The
wound was assessed daily and debided as needed. A wound VAC was
placed on [**2140-5-6**]. As she no longer needs debridement, and the
wound has started to granulate, she is ready for discharge. She
is now on her regular Tuesday, Thursday and Saturday dialysis
schedule. Her blood sugars have consistently been less well
controlled. Her coumadin has been restarted. She is tolerating
a regular diet. She has remained hemodynamically stable since
surgery. Follow-up has been arranged with Dr. [**Last Name (STitle) **] in
2 weeks.
Medications on Admission:
Vanc with HD x 1 more day (End [**4-17**])
fleet enema 19g - 7g / 118 mL daily prn constipation
glucagon 1 mg IM for FSBS < 60
cepacol 4.5 mg lozenge 1 tab PO q4h prn sorethroat
calcium 600 with vitamin D3 1 tab PO BID
senna 8.6 mg tab PO daily
NPH insulin 10 units sc qAM
duoneb 0.5mg-2.5mg/3ml neb solution IH q6h prn dyspnea
Sevalemer 1600 TID with [**Month/Day (4) 16429**]
Neprocaps 1 tab PO daily
bactrim DS 800 mg - 160 mg 1 tab PO before hemodialysis, 1 tab
PO
after hemodialysis
acetaminophen 500 mg PO q6h PRN pain or fever
ex-lax milk of magnesia 400mg/5ml 5 ml PO q6h prn constipation
albuterol sulfate 2.5 mg / 3 ml IH q6h prn dyspnea
simvastatin 10 mg PO daily
omeprazole 40 mg PO daily
amiodarone 200 mg PO daily
paroxetine 20 mg PO daily
docusate 100 mg PO BID
bisacodyl 10 mg PR daily
warfarin 5 mg PO daily
vitamin B-100 complex 1 tab PO daily
folic acid 1 mg PO daily
Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY
(Daily).
6. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. meropenem 500 mg Recon Soln Sig: One (1) Intravenous once a
day for 14 days days.
8. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
11. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/[**Month/Day (4) **] (3 TIMES A DAY WITH [**Month/Day (4) **]).
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Groin abscess, AV fistula.
SECONDARY DIAGNOSES:
Diabetes Mellitus 2
End stage renal disease
Chronic Diastolic Heart Failure
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 low blood pressures,
concern for bacteria in your blood and bleeding from you groin.
You were found to have an infection in your groin and a
arterial/venous fistula which we resected on [**2140-4-26**].
We are discharge you with a special wound VAC to the right groin
and an PICC line for IV antibiotics.
Followup Instructions:
Department: VASCULAR SURGERY
When: WEDNESDAY [**2140-5-25**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2140-5-12**]
|
[
"4168",
"486",
"2851",
"4280",
"25000",
"2720",
"32723",
"53081",
"V5861"
] |
Admission Date: [**2181-3-8**] Discharge Date: [**2181-3-13**]
Date of Birth: [**2118-2-26**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Demerol
Attending:[**First Name3 (LF) 18051**]
Chief Complaint:
post menopausal bleed
Major Surgical or Invasive Procedure:
supracervical hysterectomy, lysis of adhesions, pelvic washings
History of Present Illness:
63 G1P1 presenting with post menopausal bleed. Unable to obtain
endometrial biopsies due to cervical stenosis. Pt did not
tolerate TVUS. MRI showed thickened endometrium to 1cm. Denies
F/C/N/V. No dysuria/change in bowel habits. No other sxs
referrable to pelvis.
Past Medical History:
PMH: 1. Colon cancer: [**Location (un) **] B2 in [**2172**] status post resection
followed
by chemotherapy and radiation. She had a subsequent adenoma of
the right colon that was resected in [**2175**].
2. Two slipped discs in her neck.
3. Anal fissure.
4. Hypertension.
5. Type 1 diabetes x 52 years complicated by retinopathy and
neuropathy. microalbuminuria last creat 1.2
6. Pneumovax within the past 2 years.
7. Flu vaccine yearly.
8. h/o lung nodules.
9. EF 70% mild LVH, tr MT, tr TR, mild AI
10. h/o sz d/o
11. glaucoma
PSH: C/S, colectomy x2,
OB: C/S x1
Gyn: no abnl pap, no sti
Social History:
divorced, lives alone.
previously worked as a clinical laboratory scientist and was
exposed to benzine and "other chemicals", however denies any
occupational or known inhalation exposure. She smoked up to 2
packs a day for 15 years and quit in [**2154**]. She drinks only [**2-1**]
glasses of wine a week.
Family History:
Her father died at 63 from a cerebrovascular accident, her
mother is 96 alive and well. She has 2 sisters and 1 brother
who
are alive and well.
Physical Exam:
Initial exam notable for
nl vulva, atrophic vagina,
cervix not well visualized
limited but normal bimanual and rectovaginal exam
Pertinent Results:
[**2181-3-8**] 12:02PM BLOOD Hct-26.6*
[**2181-3-10**] 08:00AM BLOOD WBC-5.9 RBC-3.52* Hgb-11.5* Hct-32.9*
MCV-94 MCH-32.7* MCHC-35.0 RDW-13.4 Plt Ct-116*
[**2181-3-12**] 05:25AM BLOOD WBC-3.4* RBC-3.43* Hgb-11.0* Hct-31.6*
MCV-92 MCH-32.2* MCHC-34.8 RDW-13.5 Plt Ct-106*
[**2181-3-9**] 04:05AM BLOOD PT-12.4 PTT-21.1* INR(PT)-1.0
[**2181-3-8**] 12:02PM BLOOD Glucose-233* UreaN-21* Creat-1.6* Na-141
K-4.0 Cl-107 HCO3-24 AnGap-14
[**2181-3-10**] 08:00AM BLOOD Glucose-174* UreaN-26* Creat-2.6* Na-141
K-4.4 Cl-109* HCO3-19* AnGap-17
[**2181-3-10**] 08:00AM BLOOD Calcium-8.3* Phos-4.2 Mg-1.9
[**2181-3-12**] 05:25AM BLOOD Glucose-113* UreaN-28* Creat-2.1* Na-138
K-3.8 Cl-105 HCO3-24 AnGap-13
[**2181-3-12**] 05:25AM BLOOD Calcium-7.9* Phos-3.8 Mg-1.6
[**2181-3-13**] 05:40AM BLOOD UreaN-30* Creat-1.6*
Brief Hospital Course:
The patient was admitted to the ICU following her surgery on
[**2181-3-8**] for management of oliguric acute renal failure and blood
sugar control. She was transferred to gyn oncology on [**3-9**].
Her surgery was difficult due to the effects of prior radiation
therapy. See report for details.
Her post operative course is as follows
1) Acute renal failure/oliguria: the patient had minimal output
for several hours following the case. Her catheter was
functional and hematocrit was appropriate for intraoperative
losses. She was given fluid challenge as well as 2 units of
pRBC with no improvement in uop. Her creatine increased to 2.4
from preop of 1.0. Urology was consulted to eval for post renal
causes - A renal US showed no hydronephrosis, she had no CVA
tenderness, and a CT of her pelvis showed no evidence of
ureteral or bladder injury. Nephrology was also consulted to
evaluate for intrinsic renal dysfunction. Her urine sediment
was non-specific. Her oliguric renal failure was thought to be
secondary to intraoperative hemodynamic change in the setting of
existing diabetic nephropathy. It was recommended than an MRA
be obtained to assess for renal artery stenosis. The patient
was unable to get this scan due to clostrophobia and anxiety.
She will arrange for outpatient open MRA with her PCP. [**Name10 (NameIs) **]
urine output gradually improved and she had brisk diuresis on
post op day 2. Her creatinine was followed closely and is 1.6 at
time of this discharge summary.
2) Acute blood loss anemia: her HCT fell from a preop of 30 to
26.6 post op. Due to her age and medical history and oliguria
she was transfused 2 units of PRBC with appropriate rise in HCT.
Her HCT remained stable for the remainder of her
hospitalization.
3) Type 1 Diabetes: Her blood sugars were followed closely in
the perioperative period. She was continued on a regular
insulin sliding scale and NPH. These were adjusted as her diet
increased. She continued on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet and her blood sugars
remained in control.
4) Hypertension: Her blood pressures were moderately controlled
in the immediate post op period. Her ACE inhibitor was held in
the setting of acute renal failure. She was continued on
metoprolol which was increased to 100mg [**Hospital1 **]. Hydralazine was
added for improved control in place of enalapril. She was
restarted on her Enalapril on day of discharge
5) Dispo: she was followed by PT who felt she was stable for
discharge without services. Her PCP [**First Name4 (NamePattern1) 11894**] [**Last Name (NamePattern1) 12923**] was
contact[**Name (NI) **] and will see the patient in follow up for continued
management of her diabetes, hypertion, and renal function.
Medications on Admission:
Keppra 500 mg po bid
NPH 22 u q am
HISS
enalapril 20 mg po bid
metoprolol 50 mg po bid
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
2. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
Disp:*90 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*0*
4. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
5. Enalapril Maleate 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
Continue insulin, Kepra as usual
Discharge Disposition:
Home
Discharge Diagnosis:
uterine cancer
acute renal failure with oliguria
acute blood loss anemia
hypertension
diabetes
Discharge Condition:
good. stable
Discharge Instructions:
no heavy lifting, nothing in vagina, no exercise 6 weeks
no driving 2 weeks
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/GYN NON-PPS CC8 Where: [**Hospital 4054**] OBSTETRICS & GYNECOLOGY Phone:[**Telephone/Fax (1) 2664**]
Date/Time:[**2181-4-9**] 4:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 33176**], M.D. Where: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 96976**] Date/Time:[**2181-5-2**] 10:00
Dr. [**First Name4 (NamePattern1) 11894**] [**Last Name (NamePattern1) 102346**], [**Hospital1 2177**] - [**Telephone/Fax (1) 102347**] Call to schedule
appointment for this week to check blood pressure and kidney
function
Obtain MRA of renal arteries
|
[
"5849",
"2851",
"4019"
] |
Admission Date: [**2147-8-21**] Discharge Date: [**2147-8-23**]
Date of Birth: [**2067-3-4**] Sex: M
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
C1 fracture, hypertensive urgency
Major Surgical or Invasive Procedure:
Hard C collar placed for C1 fracture
History of Present Illness:
80 M with CABG, HTN, DM2, was leaving a friend's house after
dinner in the dark, tripped on the back stairs, and had
mechanical fall. No dizziness, palpitations, chest
pain/pressure, SOB, seizures, confusion before falling, patient
describes the fall as "thinking there was a stair where there
was no stair". He fell on his left forehead and left hip, no
LOC. He immediately got up by himself from the ground, thought
he was fine and got in his friend's car to be driven home,
noticed that he couldn't bend his head down well, friend drove
him to OSH for assessment.
At OSH, CT head was negative, CT C spine showed C1 fracture. One
hour after his fall, he vomited x1, no blood, had no abdominal
pain at the time. Has chronic constipation, cannot remember last
BM. Was transferred here for ortho spine fracture consultation.
When he arrived at [**Hospital1 18**] ED, ortho assessed patient, placed him
in hard collar, admitted to ortho for observation, but he was
hypertensive to 220s, HR 60-70s, and he was placed to MICU
service instead. In the ED, he was placed on nitro gtt with
difficulty controlling his SBP in 190s.
Past Medical History:
DM2 x 40 years with neuropathy, nephropathy
Hypertension
Hyperlipidemia
Depression
s/p CABG [**49**] years ago
Leg claudication with walking
COPD - diagnosed 15 years ago, quit smoking since diagnosis
Benign tremor
Social History:
Lives alone in 1 bdrm apartment at [**Location (un) 74908**]in [**Location (un) 1456**],
independent living retirement community. No ETOH, 50 pky smoking
history but quit 15 years ago, no illicit drugs. Has close
girlfriend and son. Worked as psychology professor [**First Name (Titles) **] [**Last Name (Titles) **], now
retired.
Family History:
Noncontributory.
Physical Exam:
VS: 96.4 / 180/95 / 75 / 18 / 98% RA
GENERAL: Articulate, very mildly demented, speaks and answers
questions clearly
HEENT: Cannot assess JVD or LAD because of hard C collar, L>R
eye ecchymosis, OP clear, dry mm
LUNGS: CTA B
HEART: RRR, no m/r/g
ABDOMEN: Soft, obese, +BS, ND, NT
EXTR: Rash of multiple flat maculopapular circular brown plaques
1x1 cm on legs, both hands shaking but not pill-rolling,
amputated right first toe
NEURO: Cannot assess gait, [**4-1**] motor, decreased sensation in
feet
Pertinent Results:
[**2147-8-21**] 10:07AM POTASSIUM-5.2*
[**2147-8-21**] 06:03AM COMMENTS-GREEN TOP
[**2147-8-21**] 06:03AM K+-5.6*
[**2147-8-21**] 02:50AM GLUCOSE-208* UREA N-35* CREAT-1.6* SODIUM-139
POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-26 ANION GAP-14
[**2147-8-21**] 02:50AM estGFR-Using this
[**2147-8-21**] 02:50AM ALT(SGPT)-12 AST(SGOT)-23 LD(LDH)-247
CK(CPK)-275* ALK PHOS-116 AMYLASE-79 TOT BILI-0.4
[**2147-8-21**] 02:50AM LIPASE-26
[**2147-8-21**] 02:50AM CK-MB-12* MB INDX-4.4 cTropnT-0.03*
[**2147-8-21**] 02:50AM ALBUMIN-3.7 IRON-78
[**2147-8-21**] 02:50AM calTIBC-307 FERRITIN-100 TRF-236
[**2147-8-21**] 02:50AM TSH-5.0*
[**2147-8-21**] 02:50AM FREE T4-1.2
[**2147-8-21**] 02:50AM WBC-13.7* RBC-4.16* HGB-13.1* HCT-37.8*
MCV-91 MCH-31.5 MCHC-34.6 RDW-14.4
[**2147-8-21**] 02:50AM NEUTS-89.7* BANDS-0 LYMPHS-7.2* MONOS-2.7
EOS-0.3 BASOS-0.2
[**2147-8-21**] 02:50AM PLT SMR-NORMAL PLT COUNT-197
[**2147-8-21**] 02:50AM PT-11.9 PTT-24.7 INR(PT)-1.0
CT C-spine:
IMPRESSION:
1. Fractures across the right anterior arch of C1 and central
right posterior arch of C1, with 5 mm of distraction of the
right anterior arch fragments, as well as mild atlanto-occipital
offset on the right.
CT Head:
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Incompletely visualized fracture of the C1 vertebral body,
please refer to the cervical spine CT for full details.
XR L femur:
IMPRESSION: No evidence of fracture.
CXR:
IMPRESSION: 2 areas of increased opacification bilaterally with
prominence of the left hilum. Comparison with previous films is
essential. If these are not available, CT should be obtained.
Brief Hospital Course:
80 M with CABG, HTN, DM2, s/p mechanical fall, here with C1
fracture and hypertensive urgency.
# C1 fractures:
CT C-spine showed fractures across the right anterior arch of C1
and central right posterior arch of C1, with 5 mm of distraction
of the right anterior arch fragments, as well as mild
atlanto-occipital offset on the right. Ortho recommended wearing
hard C collar for three months with no surgery, and followup in
one week after discharge with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]. His phone number
is [**Telephone/Fax (1) 3573**]. Please call his office to schedule an
appointment.
# Hypertensive urgency:
Patient was found to have SBP 220s in ED, had not taken his home
antihypertensive regimen. In the ED, he was placed on nitro gtt
with SBP 140s, and patient was transferred to the MICU. Nitro
gtt was titrated off and patient was transitioned to home
regimen of ramipril and Toprol with SBP 120-130s. His blood
pressures remained elevated and he was started on norvasc 5mg.
The norvasc was just increased to 10mg daily today (only got 5mg
this [**Last Name (un) 44550**] prior to leaving for rehab). Please titrate up his
metoprolol as needed for futher blood pressure control.
# Mechanical fall:
CT head was negative for fracture or hemorrhage. CT C spine
showed C1 fractures. XR L femur was negative for fracture.
Possible etiology of fall includes strict mechanical fall in the
evening dark, infection, cardiogenic syncope, retinopathy
etiology. EKG shows TWI V1-V4, 0.5-1mm STE III, 1mm STD I and L,
RBBB, with no previous EKG for comparison and cardiac enzymes
were cycled. Patient was maintained on ASA, metoprolol, and
statin. Patient states recent ophthalmology appointment for
diabetic retinopathy was normal, but it was recommended that
patient follow up regularly in case vision was contributing
factor to fall.
# Cardiac:
Patient has history of CABG years ago. EKG showed anterolateral
ischemic changes, RBBB, previous EKG was not available for
comparison and was rechecked. Patient was maintained on ASA,
metoprolol, statin. TTE was not available in [**Hospital1 18**] records.
Cardiac rhythm was NSR 60-70s. Patient was asymptomatic
throughout admission with no chest pain/pressure, no shortness
of breath.
# Diabetes mellitus, presumed type 2:
He reports DM2 diagnosed 40 years ago. He was maintained on ISS.
His home regimen is lantus 40 units QAM, Novolog 12-20 units per
meal. If his sugars are elevated at rehab, his insulin sliding
scale should be increased.
# Hyperkalemia/chronic sinusitis:
Patient reported that he takes potassium iodide tablets for
chronic sinusitis daily. He was advised to stop taking potassium
iodide as an outpatient and was told that his potassium was
elevated likely due to this medication.
# Chest Opacifications
Chest X ray on [**2147-8-21**] noted two opacifications in the left
upper lobe. Patient should have a follow-up chest CT performed
as an outpatient.
Medications on Admission:
Ramipril 10 daily
Toprol XL 50 [**Hospital1 **]
Lipitor
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO BID (2 times a day).
7. Carbidopa-Levodopa 25-100 mg Tablet Sig: .5 Tablet PO DAILY
(Daily).
8. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
9. Simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO QID (4 times a day) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed.
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Hospital
Discharge Diagnosis:
C1 fracture
Hypertensive urgency
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted after a fall with a fracture of your cervical
spine. It is important that you wear the cervical collar for
three months. You will need to see Dr [**Last Name (STitle) 363**] next week. His
phone number is [**Telephone/Fax (1) 3573**]. Please call his office to
schedule an appointment.
You should not drive with this collar on.
While you were in the hospital your blood pressure was elevated.
We added new medication called norvasc which you will need to
take daily.
You should also talk with your primary care physician about
obtaining [**Name Initial (PRE) **] chest CT to follow-up abnormalities on his CXR.
Please call if you have any further pain, lightheadedness,
dizziness, confusion or any other concerning symptoms.
Followup Instructions:
You should follow up with the Orthopedic Surgeon Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 363**], [**Telephone/Fax (1) 3573**], early next week. Please call his office
to schedule an appointment.
|
[
"4019",
"496",
"2767",
"2724",
"V4581"
] |
Admission Date: [**2108-4-10**] Discharge Date: [**2108-4-18**]
Date of Birth: [**2033-9-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Caffeine / Quinine / Ampicillin
Attending:[**First Name3 (LF) 18369**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
74yo F w/ hx Addison's, HTN, and metastatic spindle cell sarcoma
with recent initiation of chemotherapy (gemcitabine, adriamycin,
prednisone) 1 weeks PTA. Over the past week, she has been
generally feeling "sick" and tired. The night prior to
admission, she had one episode of vomiting and had non-bloody
watery/mucousy diarrhea and a mild cough. The morning of
admission, she had a fever to 101 and came to the ED. She
otherwise denied any sore throat, dyspnea, chest pain, abdominal
pain, dysuria, new rashes or sick contacts.
In the ED, her temp was 101, WBC 0.8, and her SBP was 80. She
was given 2L IVF NS and her SBP increased to 110. She was also
given a dose of cefepime and hydrocortisone 100mg. She was then
transferred to the [**Hospital Unit Name 153**].
Past Medical History:
1. Addison disease diagnosed at 37 years of age.
2. Hypercholesterolemia, on Lipitor in the past. The patient
recently stopped the Lipitor, which resulted in improved kidney
function, which allowed her to enter the chemotherapy trial.
3. Hypotension.
4. Chronic renal insufficiency.
5. COPD.
6. Peripheral vascular disease with bilateral carotid stenoses
status post TIA. In [**8-/2103**], the patient had left upper
extremity weakness and slurred speech with complete resolution
in less than 24 hours.
7. Coronary artery disease (1 vessel). The first cardiac cath
in [**8-/2103**] showed total occlusion of right coronary artery. PCI
failed at that time. However, there were significant
left-to-right collaterals. Second cardiac cath in [**12/2107**] showed
no progression of her coronary artery disease. 60% diag, 40%lad
8. Preserved EF in past--echo [**2103**]-50%, cath showed normal index
in [**2107**] and RVG [**2108-3-28**] recently with ef of 72%
9. Osteoporosis, on Fosamax for 2 years and then on Forteo for 2
months, which she stopped at the end of [**Month (only) 359**]. Status post
undisplaced pathological fracture of her right pelvis, both
inferior and superior rami in 09/[**2107**].
10. Metastatic sarcomatoid kidney cancer.
11. Right ear deafness.
12. RAD
Social History:
The patient used to smoke a pack and a half since [**17**] years of
age until 65 years of age. She does not drink alcohol. She is a
widow. She has 6 children and 18 grandchildren. She currently
lives with her son and his family. She used to work as a
waitress and then she had an office job.
Family History:
One brother died at a young age probably secondary to Addison
disease. One brother has prostate cancer. One daughter has
melanoma. Her father had [**Name2 (NI) 499**] cancer. Two brothers have
coronary artery disease. There is no history of
osteoporosis in her family.
Physical Exam:
general: alert, pleasant, interactive and in NAD
HEENT: PERRL, EOMI, anicteric, MMM, oropharynx clear,
neck: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
lungs: crackles bilaterally
chest: kyphosis, tenderness at former port-a-cath site;
erythematous, warm and indurated
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or HSM
extremities: no cyanosis, clubbing or edema
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch
Pertinent Results:
CXR AP [**4-10**]:
1. Pleural and pulmonary metastatic spread of known renal
carcinoma.
2. Bilateral interstitial opacities which may represent
congestive heart failure or infectious process. Clinical
correlation is suggested.
CXR AP [**4-12**]:
1. Prominent interstitial markings. This could be either due to
interstitial pulmonary edema or drug reaction.
2. Multiple pulmonary nodules consistent with known metastases
from renal cell carcinoma.
CXR PA/Lat [**4-16**]:
Emphysema and pulmonary metastases as previously demonstrated.
No evidence of new pneumonia or pulmonary edema.
[**2108-4-10**] 01:00PM BLOOD WBC-0.8*# RBC-3.10* Hgb-9.3* Hct-25.3*#
MCV-82 MCH-29.8 MCHC-36.5* RDW-13.3 Plt Ct-100*#
[**2108-4-16**] 06:36AM BLOOD WBC-31.3*# RBC-3.20* Hgb-9.1* Hct-27.4*
MCV-86 MCH-28.5 MCHC-33.3 RDW-14.0 Plt Ct-73*#
[**2108-4-18**] 06:10AM BLOOD WBC-22.5* RBC-3.15* Hgb-9.2* Hct-27.0*
MCV-86 MCH-29.2 MCHC-34.1 RDW-14.8 Plt Ct-98*
[**2108-4-10**] 01:00PM BLOOD Neuts-4* Bands-0 Lymphs-88* Monos-0
Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2108-4-15**] 06:46AM BLOOD Neuts-62 Bands-12* Lymphs-5* Monos-10
Eos-0 Baso-0 Atyps-0 Metas-9* Myelos-2*
[**2108-4-10**] 01:00PM BLOOD Plt Smr-LOW Plt Ct-100*#
[**2108-4-14**] 07:00AM BLOOD Plt Ct-34*
[**2108-4-11**] 05:52AM BLOOD Gran Ct-40*
[**2108-4-13**] 06:35AM BLOOD Gran Ct-1160*
[**2108-4-10**] 01:00PM BLOOD Glucose-99 UreaN-32* Creat-1.7* Na-133
K-3.7 Cl-99 HCO3-22 AnGap-16
[**2108-4-18**] 06:10AM BLOOD Glucose-101 UreaN-22* Creat-1.5* Na-140
K-3.7 Cl-102 HCO3-30 AnGap-12
[**2108-4-10**] 01:00PM BLOOD ALT-14 AST-18 AlkPhos-78 Amylase-53
TotBili-0.5
[**2108-4-11**] 05:52AM BLOOD ALT-14 AST-14 LD(LDH)-149 AlkPhos-70
TotBili-0.3
[**2108-4-10**] 01:00PM BLOOD Calcium-10.4* Phos-1.0* Mg-0.9*
[**2108-4-18**] 06:10AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.7
[**2108-4-17**] 01:00PM BLOOD PTH-141*
[**2108-4-10**] 01:08PM BLOOD Lactate-3.4*
[**2108-4-10**] 04:49PM BLOOD Lactate-1.4
Brief Hospital Course:
74yo F w/ recent diagnosis of spindle cell sarcoma s/p 1st cycle
of chemotx who presents w/ neutropenic fever, hypotension,
vomiting and fatigue.
Neutropenic fever: She had no obvious infectious etiology, CXR
notable only for intersitial markings c/w pulmonary edema or
drug reaction. Changed cefepime to ciprofloxacin when she was
afebrile and no longer neutropenic. Neupogen increased from 300
[**Hospital1 **] to 480 [**Hospital1 **].
Hypotension: This was likely due to poor po, relative adrenal
insufficiency, sepsis, or cardiomyopathy from adriamycin. Pt
responded to IVF boluses and stress dose steroids which support
sepsis, adrenal insufficiency and hypovolemia. Hydrocortisone
100 tid was started in ICU given h/o Addison's, and this was
tapered as described below. After transfer to the floor, she
became more hypertensive, and her home medications were
restarted without further episodes of hypotension.
Pancytopenia: Likely from bone marrow suppression, and she was
continued on neupogen.
Metastatic sarcomatoid kidney cancer: s/p 1st cycle chemotx and
will continue chemotherapy as an outpatient.
Addison's: She had erratic and uncontrolled BP while receiving
chemotherapy. Endocrine service was consulted to help manage her
steroid dosing. They recommended tapering down hydrocortisone
100 tid to 50 tid for 24hrs, then 25 tid for 24hrs followed by
prednisone 10mg daily. Arranged for transfer of her endocrine
care to [**Hospital1 18**] physician, [**Name10 (NameIs) **] she will follow up with
endocrinologist after discharge.
CAD: She continued ASA and plavix; held briefly for port
placement.
HTN: Could attribute some fluctuation of BP to endocrine issues.
Restarted lisinopril, atenolol, isosorbide when BP stabilized.
COPD: She was given nebs prn; she had 2L NC O2 requirement w/
ambulation at time of discharge.
CRI: Baseline creatinine is 1.5, and she did not have worsening
renal function during this admission.
PPX: Pt was provided with bowel regimen and heparin SC for
prophylaxis.
Code: full
Medications on Admission:
atenolol
diovan
isosorbide
lisinopril
prednisone 2.5mg [**Hospital1 **]
aspirin 325
magnesium 60 qd
calcium 600 [**Hospital1 **]
plavix
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary:
1. Neutropenic Fevers
2. Spindle Cell Sarcoma
3. Addison's disease
Discharge Condition:
Afebrile and no longer neutropenic; still requiring 2L NC for
ambulation.
Discharge Instructions:
Please take all your medications as prescribed. Please restart
your aspirin; plavix should be restarted w/ guidance from Dr.
[**Last Name (STitle) 7047**].
Please follow up in the hematology/oncology clinic as listed
below. Also, an appointment was made for you to see an
endocrinologist here at [**Hospital1 18**]. The information is provided
below.
Please call your doctor or return to the hospital if you develop
fevers, chills, nausea, vomiting, unable to tolerate food or
have any other concerns.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 3972**] [**Last Name (NamePattern1) **] - endocrinologist.
Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2108-4-20**] 4:00 [**Hospital Ward Name 23**] [**Location (un) 436**].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2108-4-23**] 1:30
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2108-4-23**] 1:30
Completed by:[**2108-7-28**]
|
[
"5849",
"5859",
"496",
"4019",
"41401",
"2724"
] |
Admission Date: [**2181-2-18**] Discharge Date: [**2181-2-28**]
Date of Birth: [**2119-7-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Name14 (STitle) 80860**] is a 61M with a PMH s/f CMML who is being
transferred from [**Hospital3 3583**] for continued management of
hypoxia. The patient was in his usual state of health when he
began to experience mild abdominal and rectal pain three weeks
ago. He saw his gastroenterologist and was told to complete a
course of ciprofloxacin and flaygl. He then went to [**Country 149**] on a
business trip, where he decided not to take the flagyl given its
disulfiram-like side effects. When he returned home, he
continued to have persistent rectal pain, with a new cough and
increasing shortness of breath and left-sided chest pain.
Specifically, his rectal pain was worsened with bowel movements
and associated with constipation and LLQ crampy pain, and he
noted scant red blood in his stools after bowel movements. His
chest pain was described as sharp and worsened with activity and
with coughing, but without nausea, vomiting, diaphoresis, or
radiation to the back or arms.
.
He presented to [**Hospital3 3583**] on [**2181-2-5**] where a CXR showed a
right sided pneumonia, for which he received levofloxacin,
zosyn, IV solumedrol (long smoking history and concern for
COPD), and nebulizers. A rectal exam revealed a new mass, which
was biopsied under general anesthesia, results are pending. A
CT abdomen and pelvis showed mild diverticulitis. On the fourth
hospital day, he had new, volumnious diarrhea, with 15 bowel
movements each night. Stool was sent for C. diff, which was
positive on the third set. PO vancomycin was started for this
rather than flagyl, based on renal recommendations. CXRs
cleared over the course of antibiotic therapy, and the patient
remained afebrile throughout his hospital course. His WBC count
climbed over his hospital course, however, from 40 on admission
to 109, in the setting of CMML, PNA, C. diff, and steroid
treatment. Heme-onc was consulted, and performed a bone marrow
biopsy, which [**Name8 (MD) **] MD sign-out showed "mild blasts on flow
cytometry"; however, it was felt that this was likely
demargination from steroids, C.diff, and PNA. He continued to
experience dyspnea, with worsening hypoxia, sating 70s on room
air, requiring a non-rebreather to maintain sats in the 90s. A
d-dimer was negative, though it was performed while the patient
was already started on empiric anticoagulation with heparin for
presumed PE, and a V/Q scan was indeterminate. The heparin was
stopped after the negative d-dimer. The patient is requesting
transfer for continued management of hypoxia.
Past Medical History:
#. Chronic metamyelocitic leukemia
-managed by Dr. [**Last Name (STitle) **] at [**Hospital1 2025**]
#. Nephrotic Syndrome with membranous nephropathy, bx proven per
report. Was treated with cyclophosphamide and prednisone.
-Baseline Cr 3.1
#. Hypertension
#. Diverticulosis
#. Colonic polypectomy
#. Status post right inguinal hernia
#. Vasectomy
#. Penile implant for erectile dysfunction
Social History:
He lives with his wife and quit smoking twelve years ago but has
a 2 to 3 pack-per-day history x 35 years. He drinks [**12-22**] glasses
of wine nightly. Regarding employment, he works as an insurance
broker. All four of his children live nearby.
Family History:
Father had lung cancer. No family history of hematological
malignancies.
Physical Exam:
T=98.4 BP=114/78 HR=75 RR=18 O2=94% 5L
.
.
PHYSICAL EXAM
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=
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. [**12-22**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
EKG [**2181-2-11**]: NSR, HR 67, nl axis, nl intervals, no acute ST/T
wave abnormalities
.
CT Chest [**2181-2-8**] : borderline LNs in mediastinum, large spleen,
bilateral patches of feathery infiltrates, no consolidation,
small bilateral pleural effusion
.
CT Abd/Pelvis [**2181-2-5**]: inflammation posterior to proximal
descending colon with small fluid in pericolic gutter suggestive
of diverticulitis; mild splenomegaly; small AAA
.
CXR:
[**2181-2-5**]: limited exam, LLL infiltrate
[**2181-2-7**]: partial clearing of LLL infiltrate, small bilateral
pleural effusions
[**2181-2-11**]: no acute cardiopulm process
[**2181-2-14**]: no acute cardiopulm process
[**2181-2-15**]: no acute cardiopulm process
[**2181-2-18**]: new RUL airspace disease, minimal LUL airspace disease,
these findings consistent with pneumonia, lung bases are clear
.
Echocardiogram [**2181-2-8**]: LVEF 55%, 1+ TR, 1+ MR
.
V/Q scan [**2181-2-17**]: multiple subsegmental matched perfusion
defects, no unmatched perfusion defects, indeterminant result
.
Renal U/S [**2181-2-12**]: normal appearing kidneys
.
[**2-23**] MRI pelvis: IMPRESSION:
1. The anal tumor appears to extend into the distal-most rectum
for
approximately the anterior margin through the left lateral
margin. There
appears to be involvement of the levator muscle on the left as
well as
possibly the prostate.
2. 6-mm iliac chain lymph node.
3. Bone marrow signal abnormality likely reflecting the
patient's underlying
leukemia.
Brief Hospital Course:
Mr. [**Known lastname **] is a 61M with a PMH s/f [**Hospital 80861**] transfered to [**Hospital1 18**] for
further management of hypoxic respiratory distress.
#. Hypoxic respiratory distress: Possible etiologies for the
patient's hypoxia were thought to include pneumonia, PE,
noncardiogenic pulmonary edema, and leukostasis. He was
empirically started on vancomycin and zosyn, and though he had a
negative D-dimer and V/Q scan at [**Hospital3 3583**] an ECHO and
LENIs were attained and demonstrated no evidence of right heart
strain or DVT. A Broncoscopy was down and viral cultures were
RSV postive. He was also started on hydroxyurea to prevent
leukostasis, though the heme/onc service thought that this was
unlikely to be the etiology for his hypoxia and CXR infiltrates.
His respiratory status slowly imroved and pulmonary was
consulted to have determine when his pulmonary status had
improved enough to preceed to surgery for his anal cancer.
Pulmonary function test were performed which showed mild
restrictive and obstructive ventilatory defect and reduced
diffusing capacity. He was no longer on oxygen about 6 days
prior to discharge, and pulmonary felt that it was okay to
proceed on [**2181-3-5**].
#. Leukocytosis: Patient's WBC count increased from 40K on
admission to [**Hospital3 3583**] to 104K at time of transfer. This
was attributed to infection and steroid-effect causing massive
demargination in the setting of known CMML. Steroids were
discontinued and hydrea was started with improvement in his
white count to 30 at discharge. He was also continued on po
flagyl for C. diff. Blood cultures were negative. Please see
discussion below re: CMML.
#. C. diff: Diagnosed four days after starting antibiotics at
[**Hospital3 3583**] and treated with po vancomycin per renal reccs
by their consult service because of his renal insufficiency. He
was, however, converted to po flagyl upon admission to [**Hospital1 18**].
#. Rectal mass: Patient was found to have a rectal mass that
was biopsied by the surgical service under anesthesia (secondary
to significant pain) at [**Hospital3 3583**]. The mass was
concerning for squamous cell carcinoma per report and the biopsy
results are pending at the time of discharge. MRI of the pelvis
was performed and showed extension into the distal rectum,
levator muscle as well as iliac lymph nodes. The tumor was close
to obstructing the rectum. Multiple approaches to treatment were
discussed with hematologic malignancy, solid tumor, and surgical
experts. It was decided that the anal cancer took priority over
the CMML given the danger of obstruction. There it was decided
to pursue a diverting colostomy followed by chemo and radiation
which will be performed at [**Hospital6 33**] under the care
of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**]. The patient did not tolerate an anal
pap smear secondary to pain. We were unable to order HPV viral
load as an inpatient here. The patient underwent anesthesia
pre-op evaluation prior to discharge on [**2181-2-28**].
#. CMML: Diagnosed in [**2178**] and managed conservatively with close
monitoring. Has not previously received chemotherapy for this,
but started on hydroxyurea for leukocytosis as described above.
Incidentally, the etiology of the patient's CMML may be related
to her history of cyclophosphamide for membranous nephropathy. A
bone marrow was performed at [**Hospital3 **] and showed 19%
blasts, close to the 20% cut off for conversion to AML. Priority
was given to treating the anal cancer as explained above. The
CMML will be readdressed after chemo and radiation for the anal
cancer are completed. He will be discharged on hydrea 500mg [**Hospital1 **].
#. Nephrotic syndrome: Membranous nephropathy. Renally dosed
meds.
.
#. Thrush: started clotrimazole troches
CODE STATUS: full, discussed with patient
EMERGENCY CONTACT: Mrs. [**Name (NI) 1123**] [**Name (NI) 57495**], wife, Phone:
[**Telephone/Fax (1) 80862**], [**Name2 (NI) **] Phone: [**Telephone/Fax (1) 80863**]
Medications on Admission:
Levofloxacin 750 mg iv q48h
Zosyn 2.25 g iv q8h
Methyprednisolone 20 mg iv qd
Albuterol inhaler 2.5 mg q4h
Atrovent 0.5 mg q4h
Vancomycin 125 mg po q6h
Vitamin D 50,000 u po qSatruday
Megestrol 400 mg po qd
Hydrocortisone 2.5% apply topically tid
Hydromorphone 1-2 mg iv q3h
Lorazepam 0.5-1 mg iv q4h
Reglan 5-10 mg iv q6h
Acetaminophen [**Telephone/Fax (1) 80864**] mg po q6h
Diphenoxylate/atropine 1-2 tabs po tid
Colace 100 mg po bid
Loperamide 2 mg po prn diarrhea
Ranitidine 150 mg po bid
Senna 2 tabs po qd
Ambien 5 mg po qhs
Guaifenesin with codeine 50 cc po q6h prn cough
Lactulose 50 cc po qd
Magaldrate 10 cc po qid prn constipation
Milk of magnesia 30 cc po qd prn constipation
Lidocaine 1% as directed topically qid
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 4 days.
Disp:*12 Tablet(s)* Refills:*0*
2. Megestrol 400 mg/10 mL Suspension Sig: Ten (10) ml PO DAILY
(Daily).
Disp:*1 bottle* Refills:*2*
3. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO twice a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] home care
Discharge Diagnosis:
squamous cell carcinoma of the anus
CMML
RSV pneumonia
C diff colitis
.
nephrotic syndrome
Discharge Condition:
good
Discharge Instructions:
You were transfered to [**Hospital1 18**] for further treatment of your
hypoxia and high white blood cell count. You were found to have
a viral infection on broncoscopy called RSV. Your breathing
slowly recovered.
.
The biopsy of your rectal mass proved to be squamous cell
carcinoma. An MRI showed extension into your muscles and rectum.
It was decided that you will follow-up with [**Location (un) **] Atrius
in [**Location (un) **]. You will have surgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1120**] on
Monday, [**2181-3-5**]. You will be contact by her office
prior to this surgery for instructions.
.
Your bone marrow biopsy also showed poor markers for your CMML.
This disease will have to be further addressed after treatment
of the anal cancer is completed.
,
You were also treated with antibiotics for an infection in your
colon called c diff. You should continue to take Flagyl for the
next 4 days.
.
The following changes were made to your medication regimen:
Flagyl 500mg by mouth three times a day for the next 4 days
Megestrol 400mg by mouth daily to help increase your appetite
Hydroxyurea 500mg by mouth twice a day
.
Please follow up with your doctors as detailed below.
.
Please call your doctor or go to the emergency room for fevers,
chills, abdominal pain, diarrhea, severe constipation,
difficulty breathing, chest pain, or any other worrisome
symptom.
.
Surgery on Monday [**2181-3-5**].
-Dr.[**Name (NI) 3377**] secretary, [**Doctor First Name **], will call you on Friday to let
you know what time you need come arrive to the hospital on
Monday. Your surgery time will be sometime in the afternoon on
Monday, but NO SET time has been established.
-Please do not drink or eat after midnight on Sunday. NO bowel
preparation is required.
-Call Dr.[**Name (NI) 3377**] office with any concerns regarding your
bowels.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 61767**]
.
[**Location (un) **] Atrius Doctors:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], radiation oncology
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**], hematology oncology
.
You will be contact by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office
[**Telephone/Fax (1) 160**](colorectal surgery) prior to your surgery on monday
for additional instructions.
|
[
"2875",
"2859",
"V1582"
] |
Admission Date: [**2140-4-30**] Discharge Date: [**2140-5-8**]
Date of Birth: [**2062-9-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Norvasc / Zestril / Coumadin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
unstable angina/ ACS
Major Surgical or Invasive Procedure:
[**2140-5-2**]
1. Redo sternotomy.
2. Coronary artery bypass grafting x3, with reversed
saphenous vein graft to the obtuse marginal artery and
reversed saphenous Y-graft to the left anterior
descending artery and diagonal artery.
History of Present Illness:
77 yo Male with known coronary artery disease s/p CABG x3 '[**31**],
hypertension, dyslipidemia, chronic AFib (not on Warfarin 2' hx
retroperitoneal bleed while on Coumadin '[**36**]), CRI, who underwent
repeat cath 2' unstable angina, STEMI.
EMTs in the field performed ECG=ST elevations in V1-V3 with TWI
V1-V4. NTG sl given x3 with resolution of CP/ST elevations. He
was admitted to MWMC with Acute Coronary Syndrome, positive
Troponins, and under went an urgent cath which revealed
significant multivessel coronary disease and restenosis of
bypass
grafts. He was placed on Heparin drip, pain free,
hemodynamically
stable and transferrd th [**Hospital1 18**] for csurg evaluation of
redo-sternotomy/CABG. Denies current CP,dyspnea, nausea or
diaphoresis.
Past Medical History:
per HPI,CAD s/p CABG x3'[**31**], Chronic AFib-
No Coumadin 2' retroperitoneal bleed '[**36**], HTN, dyslipidemia,
hiatal hernia-nonobstructive Schatzki ring, CRI baseline 1.68,
GERD
Social History:
Lives with:wife
Occupation:retired engineer
Tobacco:quit smoking 52 years ago
ETOH:denies
Family History:
non-contributory
Physical Exam:
Pulse: 50 Resp: 18 O2 sat: 96% nc @ 2LPM
B/P Right:111/62 Left:
Height: 5'7" Weight:95 KG
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
(L)LE varicosity -(R)LE SVG 2 segments taken for bypass '[**31**] None
[]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit -none Right: 2+ Left:2+
Pertinent Results:
Conclusions
PRE-CPB: Redo CABG
1. The left atrium is markedly dilated. The left atrium is
elongated. Mild spontaneous echo contrast is seen in the body of
the left atrium. No mass/thrombus is seen in the left atrium or
left atrial appendage. Mild spontaneous echo contrast is present
in the left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). No thrombus is seen in the left
atrial appendage.
2. 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. There is mild global left
ventricular hypokinesis (LVEF = 40 %). There is severe anterior
hypokinesis.
4. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
6. Mild to moderate ([**1-9**]+) mitral regurgitation is seen. There
is a very small pericardial effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results.
POST-CPB: On infusion of epinephrine, phenylephrine. V-pacing.
Preserved left ventricular systolic function on inotropic
support. LVEF = 55%, with improved anterior hypokinesis and MR
is now 1 +. RV systolic function is now moderately depressed. TR
is mild. Aortic contour is normal post decannulation. There is a
moderate left pleural effusion.
[**2140-5-7**] 08:17AM BLOOD WBC-10.9 RBC-3.40* Hgb-10.3* Hct-30.7*
MCV-90 MCH-30.3 MCHC-33.5 RDW-16.2* Plt Ct-142*#
[**2140-5-6**] 01:30AM BLOOD WBC-12.9* RBC-3.33* Hgb-10.1* Hct-30.0*
MCV-90 MCH-30.3 MCHC-33.6 RDW-15.6* Plt Ct-94*
[**2140-5-8**] 06:20AM BLOOD Glucose-96 UreaN-49* Creat-1.8* Na-137
K-4.0 Cl-94* HCO3-35* AnGap-12
[**2140-5-7**] 08:17AM BLOOD Glucose-122* UreaN-43* Creat-1.7* Na-137
K-3.6 Cl-92* HCO3-34* AnGap-15
[**2140-5-6**] 01:30AM BLOOD Glucose-102* UreaN-38* Creat-1.7* Na-140
K-3.8 Cl-95* HCO3-34* AnGap-15
Brief Hospital Course:
Transferred in from [**Hospital1 **] on [**4-30**] for pre-op workup. He was
continued on heparin drip until surgery. Underwent an urgent
redo CABG with Dr. [**Last Name (STitle) **] on [**5-2**] with a reverse saphenous vein
graft to the diagonal, Y graft to the left anterior descending
and reverse saphenous vein graft to the obtuse marginal. See
operative note for full details. He was transferred to the CVICU
in stable condition on titrated epinephrine and phenylephrine
and vasopressin drips. Milrinone was added postoperatively
secondary to a low cardiac index. A left chest tube was placed
postoperatively for a left hydropneumothorax. He was extubated
on the morning of POD #2. Vasoactive medications and inotropes
were weaned. He was kept in the intensive care unit for
pulmonary toilet issues. He was transferred to the floor on post
operative day 4 in stable condition. Chest tubes and pacing
wires were removed per cardiac surgery protocol. He was working
with physical therapy to increase strength and endurance. He
was not started on Coumadin for chronic atrial fibrillation due
to a history of retroperitoneal bleed. He had a preoperative
right groin hematoma which was stable with a stable hematocrit
at the time of discharge. Chest xrays showed a moderate right
pneumothorax, which was stable at the time of discharge with the
patient oxygenating at 100% on room air and asymptomatic. On
post operative day 6 he was ambulating in the halls with
assistance, tolerating a full oral diet and his incisions were
healing well. It was felt that he was safe for discharge home
with visiting nurse services at this time. He was instructed to
follow up with his PCP [**Last Name (NamePattern4) **] 1 week for chest x-ray to evaluate the
right pneumothorax. He was instructed to go to the emergency
room with any increase in shortness of breath or pain.
Medications on Admission:
Zocor 20(1),Toprol XL 100(1),Diovan 320(1),
Calcium 500(1), Allopurinol 300(1), Indapamide 2.591), Vit C
400(1), Glucosamine, ASA 81(1) M-W-F, Nexium 20(1)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Combivent 18-103 mcg/Actuation Aerosol Sig: [**1-9**] Inhalation
four times a day as needed for shortness of breath or wheezing.
Disp:*1 * Refills:*0*
8. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO every twenty-four(24)
hours for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*0*
11. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease, s/p coronary artery bypass
s/p CABG x3'[**31**],
Chronic AFib-No Coumadin 2' retroperitoneal bleed '[**36**], HTN,
dyslipidemia,
hiatal hernia-nonobstructive Schatzki ring, CRI baseline 1.68,
GERD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram
Incisions:
Sternal - no drainage or erythema, sternum stable
Leg Right-healing well, no erythema or drainage. Large area of
ecchymosis at medial thigh, soft, nontender, not warm
Edema 1+ bilateral lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] at MWMC(for Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 6256**] in [**2-10**]
weeks
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) 412**] A. [**Telephone/Fax (1) 20221**] in 1 weeks -
needs CXR at follow up to evaluate right pneumothorax
Cardiologist Dr. [**Last Name (STitle) 32255**] in 4 weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2140-5-8**]
|
[
"2762",
"5859",
"42731",
"40390",
"2724",
"53081"
] |
Admission Date: [**2124-6-8**] Discharge Date: [**2124-6-20**]
Date of Birth: [**2069-10-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Abdominal discomfort
Major Surgical or Invasive Procedure:
[**2124-6-12**] - Paracentesis
[**2124-6-20**]- Paracentesis
History of Present Illness:
This 55 Hispanic male arrived from [**Location 7196**] 2 months ago and is
s/p aortic valve replacement with a mechanical valve 10 years
ago. He has had increasing fatigue and shortness of breath over
the past year and has also developed
ascites and has had 2 paracenteses. He was admitted 1 month ago
with shortness of breath and had an outpatient echocardiogram 2
days ago which revealed a 6 centimeter ascending aortic
aneurysm. He had a subtheraputic INR at the time and his
cardiologist prescibed a Lovenox bridge. The patient could no
afford the prescription and presented to the emergency
department to receive the medication. He complained of
abdominal discomfort and had an abdominal CT which revealed an
aortic dissection. A chest CT was then performed and revealed a
Type A dissection.
Past Medical History:
-Aortic (mechanical) valve replacement 10 years ago
-Dilated cardiomyopathy LVEF 30%,
-Liver disease with unclear etiology.
-Right upper extremity aneurysm s/p surgical intervention 10
years ago
-? Resection clavicular mass? 2year ago
Social History:
Patient visting US from Guatamala. Arrived 3 weeks ago, seeing
medical care, plans to stay 6 months in the US. Patient quit
smoking 11 yrs ago, previously smoked 1 PPD for 10 years. Social
ETOH. Married, with five children.
Family History:
Father and Uncle with heart disease.
Physical Exam:
Physical Exam
Pulse: 72 Resp: 20 O2 sat: 98%
B/P Right: 94/59 Left: 88/69
Height: 59" Weight: 51.3 kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [] non-distended [] non-tender [x] bowel sounds +
[x]sl. abdominal distention
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []+ Venous stasis changes
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right:no Left:no
Pertinent Results:
[**2124-6-18**] 07:40AM BLOOD WBC-5.1 RBC-3.86* Hgb-12.5* Hct-38.0*
MCV-98 MCH-32.5* MCHC-33.0 RDW-15.9* Plt Ct-139*
[**2124-6-20**] 05:50AM BLOOD PT-22.1* PTT-83.3* INR(PT)-2.1*
[**2124-6-20**] 12:25AM BLOOD PT-20.8* PTT-114.7* INR(PT)-2.0*
[**2124-6-19**] 09:10AM BLOOD PT-16.6* PTT-50.8* INR(PT)-1.5*
[**2124-6-18**] 07:40AM BLOOD Glucose-85 UreaN-20 Creat-0.9 Na-137
K-4.7 Cl-102 HCO3-25 AnGap-15
[**2124-6-8**] CTA
1. Type A dissection involving the right internal carotid artery
and left
subclavian artery extending to the iliac bifurcation.
2. Superimposed Type B dissection arising from the distal
arch/descending
aorta extending just below the takeoff of the SMA.
3. Ascending aortic aneurysmal dilatation measuring 6.6 x 7.8
cm. Left
subclavian artery aneurysm measuring 3.0 x 2.3 cm. Abdominal
aortic aneurysm measuring 3.9 x 4.9 cm.
4. Large right pleural effusion and cardiomegaly. No pericardial
effusion.
5. Moderate amount of ascites, partially imaged.
6. Heterogenous appearance of liver with reflux of contrast from
IVC/hepatic veins.
Note that the true lumen is compressed but patent and feeds the
celiac and
SMA, each false lumen gives rise to one renal artery. Overall no
findings of ischemia however.
[**2124-6-9**] CT Scan Cardiac
1. Possibly obstructive mixed plaque in the mid LCX at the
origin of the
single OM branch.
2. Non-obstructive calcified plaque involving the distal left
main.
3. Nonobstructive mixed plaque involving the LAD and RCA.
4. Known thoracic aortic aneurysm with a type A dissection
[**2124-6-12**] ECHO
The left atrium is dilated. No mass/thrombus is seen in the left
atrium or left atrial appendage. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is dilated. Overall left ventricular systolic
function is depressed (LVEF= 40 %). The right ventricular cavity
is dilated with depressed free wall contractility. The aortic
root is markedly dilated at the sinus level. The ascending aorta
is markedly dilated. The descending thoracic aorta is moderately
dilated. A mobile density is seen in the ascending aorta, aortic
arch, and descending aorta, consistent with an intimal
flap/aortic dissection. The aortic wall is thickened consistent
with an intramural hematoma. Ther is predominant thrombosis of
the false lumen distal to the left subclavian (up to 40 cm from
the incisoirs) with a small channel of antegrade flow. A
mechanical aortic valve prosthesis is present. The aortic valve
prosthesis leaflets appear to move normally. The transaortic
gradient is normal for this prosthesis. The mitral valve
leaflets are structurally normal. The mitral valve leaflets do
not fully coapt. An eccentric, posteriorly directed jet of
moderate to severe (3+) mitral regurgitation is seen. There is
no pericardial effusion.
IMPRESSION: Markedly dilated ascending aorta with type A
dissection involving the ascending aorta, arch, and descending
aorta. Normal functioning mechanical aortic valve.
Moderate-severe mitral regurgitation. Biventricular dilatation
and hypokinesis.
[**2124-6-12**] Stress Test
No anginal symptoms or additional ST segment changes from
baseline. Nuclear report sent separately.
Gated Perfusion Study
1. Large, moderate to severe, fixed inferior wall defect as well
as a small,
moderate, fixed defect in the mid-lateral wall. A thallium study
could be
performed to evaluate for any viability in these regions, if
clinically
indicated.
2. Markedly dilated LV cavity with calculated EDV of 231 ml.
3. Reduced ejection fraction at 33%.
Brief Hospital Course:
Mr. [**Known lastname 68506**] was admitted to the [**Hospital1 18**] on [**2124-6-8**] for further
management of his abdominal pain. He underwent a CT scan which
showed a Type A dissection involving the right internal carotid
artery and left subclavian artery extending to the iliac
bifurcation, a superimposed Type B dissection arising from the
distal arch/descending aorta extending just below the takeoff of
the superior mesenteric artery, an ascending aortic aneurysmal
dilatation measuring 6.6 x 7.8 cm with the left subclavian
artery aneurysm measuring 3.0 x 2.3 cm, an Abdominal aortic
aneurysm
measuring 3.9 x 4.9 cm, a large right pleural effusion and
cardiomegaly, a moderate amount of ascites, partially imaged and
a heterogenous appearance of liver with reflux of contrast from
IVC/hepatic veins. The hepatology service was consulted given
his ascites. Paracentesis was performed with the fluid being
negative for malignant cells. The infectious disease service was
consulted for an infectiuos etiology of his liver disease. No
infectious process was identified during admission, however,
there are pending tests on discharge. ID will follow up on these
results. The patient's ascites reaccumulated and he did undergo
a second paracentesis on the day of discharge. A family meeting
was held to discuss the risks and benefits of surgery. The
patient and his family have decided to take some time to make a
decision regarding surgery. Coumadin was resumed for his
mechanical aortic valve. When INR was therapeutic, the patient
was discharged home with extensive follow up instructions.
Medications on Admission:
Carvedilol 6.25'', digoxin 250, lovenox 60'', lasix 40,
lisinopril 2.5, spironolactone 25, warfarin 5
Discharge Medications:
1. Outpatient Lab Work
Chem 7
results to Dr. [**Last Name (STitle) 171**], fax:[**Telephone/Fax (1) 19842**]
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day).
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
6. 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*
7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
dose will change daily for goal INR [**3-14**], Dr. [**Last Name (STitle) 23903**] to manage.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
serial PT/INR
dx: mechanical aortic valve
goal INR [**3-14**]
results to Dr. [**Last Name (STitle) 23903**] [**Telephone/Fax (1) 17826**]
Discharge Disposition:
Home
Discharge Diagnosis:
s/p mechanical AVR [**25**] years ago.
Dilated cardiomyopathy with LVEF 30%
Liver disease
Repair of right upper extremity aneurysm
Discharge Condition:
good
Discharge Instructions:
1) You are taking coumadin for a mechanical aortic valve. Your
goal INR is 2.0-3.0. You will need daily PT/INR testing until
otherwise instructed by Dr.[**Name (NI) 65892**] office. Please take daily
coumadin only as instructed. Please note that your daily dose
may change based on your blodd work (PT/INR).
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 23903**] for coumadin management and in
2 weeks for routine follow-up appointment. [**Telephone/Fax (1) 17826**] Please
call for appointment.
Please follow-up with Dr. [**Last Name (STitle) 914**] in [**3-14**] weeks ([**Telephone/Fax (1) 1504**]
Dr. [**Last Name (STitle) 171**] 1 week
Lab Draw in 1 week (lab slip included in prescriptions)
Completed by:[**2124-6-20**]
|
[
"4280",
"4240",
"42789",
"V5861",
"V1582"
] |
Admission Date: [**2104-10-3**] Discharge Date: [**2104-10-7**]
Date of Birth: [**2042-9-3**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
bright red blood per rectum s/p transrectal prostate biopsy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC:[**CC Contact Info 106943**].
HPI: 62M with h/o DM, HCV, and Parkinson's disease, s/p
transrectal prostate biopsy 9d ago, c/b several episodes of
BRBPR over the last week, who presents with orthostatic symptoms
x 1d. He has had multiple episodes of large amounts of BRBPR
daily for the past several days. He did not contact Dr.
[**Last Name (STitle) 106944**] because he thought this was an expected side
effect. He had RLQ pain associated with his first episode the
day after the biopsy and this morning. He denies chest pain,
palpitations, fevers, nausea/vomiting. He takes 2 Aleve daily.
In the ED, his VS on presentation were T 99.9, HR 95, BP 89/56,
RR 26, O2sat 97% RA. He had 2 large bore IVs placed, T&C for 8U
was sent. Hct 24, glucose 714, HCO3 24. He was given 16U SC
insulin after which his BG was still critically high (>500), and
he was given another 8U insulin. He was also given vitamin K 5mg
po for INR of 1.3. Urology was consulted and requested admission
to Medicine. His BP improved to 118/63 after 2L NS. However, it
subsequently dropped to 79/57 2h later. He was given 500cc NS
bolus x 2 and 2U PRBC with improvement in his BP to 108/74. He
was admitted to the MICU for further monitoring.
Pt feeling well and has been hemodynamically stable SBP 100-120,
last transfusion [**10-4**] RBCs and on [**10-6**] of PLT. No BM x 2 days.
Urology and liver following. Low plts most likely related to
liver disease.
ROS: denies HA, CP, SOB, N/V/D.
Past Medical History:
1. HCV- last VL 8,590,000 on [**9-22**], followed by Dr. [**Last Name (STitle) **], on
colchicine week 146 in the COPILOT study, last biopsy [**8-26**] with
gr 2 inflammation and stage 4 cirrhosis, gr I/II varices
2. DM- on NPH, last HgA1C 8.0 on [**9-22**]
3. Parkinson's disease- on Sinemet, followed by Dr. [**Last Name (STitle) **]
4. PTSD- followed by Dr. [**Last Name (STitle) 3704**]
5. Last colonoscopy [**7-25**] with adenomatous rectal polyp and
sigmoid diverticulosis
6. s/p cholecystectomy
7. s/p R inguinal hernia repair ([**2097**])
Social History:
Lives with wife and son, retired veteran, now volunteers at the
VA. Occasional tobacco, <1 cig/d. Denies EtOH and IVDU
Family History:
Father died of unknown cause at age [**Age over 90 **], brother died in 60s of
alcoholic liver disease, mother still alive, no cancer in the
family
Physical Exam:
PHYSICAL EXAM:
Vitals- T 97.8, HR 87, BP 118/66, RR 14, O2sat 100% RA
General- pleasant man in NAD, lying flat in bed
HEENT- NCAT, sclerae anicteric, moist MM
Neck- supple
Pulm- CTAB with good respiratory effort
CV- RRR with some ectopy, no murmur/rub/gallop
Abd- + BS throughout, mildly distended but soft, + RLQ and
epigastric tenderness to deep palpation, no rebound/guarding,
liver edge palpable 3cm below costal margin, no palpable spleen
tip, RUQ transverse scar, no fluid wave
Extrem- no peripheral edema, + clubbing
Rectal: deferred
Neuro/Psych- A&Ox3, bright affect, pressured speech, slightly
tangential thinking, + pill-rolling tremor b/
Pertinent Results:
[**2104-10-3**] 09:00PM COMMENTS-GREEN TOP
[**2104-10-3**] 09:00PM HGB-8.0* calcHCT-24
[**2104-10-3**] 08:15PM GLUCOSE-715 UREA N-17 CREAT-1.5* SODIUM-127*
POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-24 ANION GAP-12
[**2104-10-3**] 08:15PM CK(CPK)-199*
[**2104-10-3**] 08:15PM CK-MB-8 cTropnT-0.02*
[**2104-10-3**] 08:15PM CALCIUM-9.3 PHOSPHATE-2.8 MAGNESIUM-2.0
[**2104-10-3**] 08:15PM LITHIUM-1.2
[**2104-10-3**] 08:15PM WBC-6.6 RBC-2.39*# HGB-7.9*# HCT-23.9*#
MCV-100* MCH-32.8* MCHC-32.8 RDW-13.6
[**2104-10-3**] 08:15PM NEUTS-75.2* LYMPHS-19.9 MONOS-4.1 EOS-0.6
BASOS-0.2
[**2104-10-3**] 08:15PM HYPOCHROM-1+ MACROCYT-1+
[**2104-10-3**] 08:15PM PLT COUNT-149*
[**2104-10-3**] 08:15PM PT-14.5* PTT-30.6 INR(PT)-1.3*
Brief Hospital Course:
# BRBPR: With time frame and lack of other symptoms, BRBPR most
likely secondary to prostate biopsy. However, with abdominal
pain, may need to consider intraabdominal etiologies such as
diverticular bleed, variceal bleed (but no hematemesis), brisk
UGI bleed from other sources including PUD, Dieulafoy's,
gastritis/duodenitis. Further eval postponed since HCT stable
and no active bleeding. CT abd neg for retroperitoneal bleed.
Hct down to 24 from baseline of 42 now stable at 33. No stooling
x [**2-23**] day. On day of discharge, pt had one formed melanotic
stool. Although bleed has been blamed on rectal biopsy, pt may
need further eval for possible upper GIB. Pt hemodynamically
stable and will follow up with the liver clinic in 6 days.
- f/u with urology in 3 weeks
#abd pain: Now has left UQ pain but CT neg 2 days ago,
tolerating PO and afebrile. [**Month (only) 116**] be related to constipation x [**2-23**]
days. Pt is passing gas. Pt started on bowel treatment but will
make it more aggressive if need be today.
-adv bowel treatment to goal of stooling
# DM: Suboptimal control over last few months per HgA1C. On
NPH at home. Had marked hyperglycemia but no anion gap acidosis
on admission. No lethargy to suggest hyperosmolar coma.
Inciting factor is likely blood loss, no clear symptoms of
infection although has had difficulty urinating since the
biopsy. CXR with no infiltrate, no h/o cough. Pt started in
insulin drip in ICU which was stopped on [**10-5**]. UA and CXR neg
for infection. has been stable in floor with minimal RISS
requirements.
-discharge on same medications with PCP f/u to reeval glucose
control
-DM diet
.
# ARF: On admission, likely prerenal with significant GI bleed.
Baseline 1.1-1.2 On ACE-i, but has been on for long time.
Elevated to 1.5 on admisison now resolved and at baseline. We
held his lisinopril in setting of bleeding and nl BP
- d/c home on home lisinopril dose
.
# Elevated troponin: Asymptomatic but diabetic, likely
secondary to ARF. ECG with no new changes to suggest active
ischemia. However, with anemia and CAD equivalent of DM, pt was
ruled out for MI.
- will need to clarify ASA allergy with PCP
.
# Hyponatremia: Likely combination of pseudohyponatremia with
hyperglycemia and hypovolemia with bleed. Now appears euvolemic
after resuscitation.
- resolved
.
# HCV: No ascites or encephalopathy. If decompensates, will
need evaluation of varices. AFP elevated x 2y but US with no
hepatoma.
- continue colchicine renally dosed
- Liver will see pt at next scheduled visit.
- CT Abd/Pelvis done on [**10-5**] and read without any evidence of
bleed
#thrombocytopenia: Unclear etiology, most likely related to hep
C liver disease/sequestration. Stable after transfusion [**10-6**].
.
# Bipolar disorder: Stable
- continue lithium, renally dosed
# Parkinson's:
- continue Sinemet
.
# FEN:
DM diet
.
# Code status: FULL CODE, confirmed with patient
.
# Communication: HCP is wife [**Name (NI) **] [**Name (NI) 106945**] ([**Telephone/Fax (1) 106946**]. PCP is
[**First Name8 (NamePattern2) **] [**Name9 (PRE) **] ([**Company 191**], [**Telephone/Fax (1) 99157**])
.
Dispo: home with urology, liver and pcp f/u
Medications on Admission:
Colchicine 0.6mg [**Hospital1 **]
Clonazepam 500mcg [**Hospital1 **]
Lithium 300mg tid
Humulin N 100 16units qam, 10units qpm [**Hospital1 **]
Neurontin 300mg tid
Lisinopril 5mg qd
Sinemet 25/100 mg 2 pills tid
Rhinocort 32mcg NS 2 sprays [**Hospital1 **]
Discharge Medications:
Colchicine 0.6mg [**Hospital1 **]
Clonazepam 500mcg [**Hospital1 **]
Lithium 300mg tid
Humulin N 100 16units qam, 10units qpm [**Hospital1 **]
Neurontin 300mg tid
Lisinopril 5mg qd
Sinemet 25/100 mg 2 pills tid
Rhinocort 32mcg NS 2 sprays [**Hospital1 **]
Discharge Disposition:
Home
Discharge Diagnosis:
rectal bleeding
Discharge Condition:
improved
Discharge Instructions:
Continue your medications from home.
Return to the ED or call your primary care for continued
bleeding from your bottom.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] on [**2104-11-5**] at 10:10am
Follow up with Dr. [**Last Name (STitle) **] on [**2104-10-29**] at 11:15am [**Telephone/Fax (1) 106947**]
Follow up with Dr. [**Last Name (STitle) **] on [**2104-10-13**] at 9:20am
|
[
"5849",
"2761",
"2875",
"25000",
"V5867"
] |
Admission Date: [**2174-11-28**] Discharge Date: [**2175-2-16**]
Date of Birth: [**2174-11-28**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname 64554**] is a 1370 gram product of a 29-
[**2-21**] week gestation born to a 31-year-old G1, P0 now 1 mother.
Prenatal labs: Blood type O positive, antibody negative, RPR
nonreactive, rubella immune, hepatitis surface antigen
negative. Pregnancy unremarkable until the morning of
delivery when mother awoke with vaginal bleeding and
contractions. She was found to be dilated, she was begun on
magnesium and betamethasone and Penicillin. Despite magnesium
labor progressed with continued intermittent vaginal
bleeding. Due to concerns for possible abruption in setting
of progressive labor, magnesium was discontinued and
membranes artificially ruptured. Infant was born vaginally
shortly thereafter with Apgar's of 7 and 8.
PHYSICAL EXAMINATION: On admission weight 1370 grams, head
circumference 28.5 cm, length 39.5 cm, all 50 to 75th
percentile. Warm dry premature infant. Active with
examination, moderate respiratory distress at rest. Overall
appearance consistent with gestational age. Skin warm, pink,
mildly pale. Capillary refill 1.5 to 2 seconds. Fontanel soft
and flat. Ears and nares patent. Palate intact. Neck supple.
Chest: Coarse with tight to moderate aeration, positive
retraction. Cardiovascular: Regular rate and rhythm. No
murmurs. Soft abdomen, no hepatosplenomegaly, no masses, 3
vessel cord. Quiet bowel sounds. GU: Normal premature female.
Anus patent. Extremities: Back normal, no lesions.
Neurological: Appropriate tone and activity.
HOSPITAL COURSE: Respiratory: [**Known lastname **] was admitted to the
newborn intensive care unit and was intubated. She received
one dose of Surfactant and was extubated to CPAP by 24 hours
of age. She transitioned to room air for approximately 24
hours and then required placement back on CPAP for 2 days.
She was in nasal cannula O2 briefly until [**2174-12-17**]
and has been stable in room air since that time. She was
treated with caffeine citrate for management of apnea and
bradycardia of prematurity. The caffeine citrate was
discontinued on [**2174-12-19**] with a marked increase in
apnea and bradycardia episodes. Caffeine was restarted on
[**2175-1-1**] with resolution of severity and frequency of
apnea and bradycardia spells. Caffeine was then discontinued
at 36 weeks gestation on [**2175-1-13**]. She continued to
have intermittent apnea and bradycardia episodes with the
last documented episode being on [**2175-2-8**]. A 24 hour
pneumogram was obtained on [**2175-2-15**] with no documented
central apnea. There were rare bradycardias of extremely short
duration. DIscussed with Dr [**First Name (STitle) **], pediatric pulmonologist, study
ersuilts felt to be consistent with normal premature inafnt not
requiring onitoring or therapy. The infant will be discharged
home without monitoring and without caffeine.
Cardiovascular: The infant was treated with Indomethacin on
[**2174-11-29**] following an echocardiogram that
demonstrated a large patent ductus arteriosus. No follow-up
echocardiogram was performed and the infant currently is
cardiovascular stable with no signs of murmur.
Fluid and electrolyte: Her birthweight was 13,070 grams. She
was initially started on 80 cc per kilo per day of D10-W.
Enteral feedings were initiated on day of life #3. She
achieved full enteral feedings. By day of life #17 maximum
enteral intake was 830 cc per kilo per day with premature
Enfamil 28 calorie with ProMod. She is currently ad lib
feeding Enfamil AR 20 calorie taking in adequate amounts,
demonstrating good weight gain. Her discharge weight is .
GI: Peak bilirubin was on day of life #10, it was 6.9/0.3.
She received phototherapy and the issue has since resolved.
The infant was noted to have excessive apnea and bradycardia.
Concerns were raised as infant was spitting, an abdominal
ultrasound was performed to rule out pyloric stenosis and the
ultrasound was within normal limits.
Hematology: Hematocrit on admission was 40.9, she has not
received any blood transfusions during this hospital course.
She is currently on Ferrous sulfate supplementation and her
most recent hematocrit was on [**2175-1-24**], it was 27.2
with a reticulocyte count of 3.7%.
Infectious Disease. CBC and blood culture were obtained on
admission. CBC was benign. Blood cultures were negative at 48
hours at which time antibiotics were discontinued. Infant has
had no further sepsis concerns during this hospital course.
Neurological: The patient has been appropriate for
gestational age. Head ultrasounds performed at day of life
10, day of life 30 and day of life 60 were all within normal
limits.
Sensory: Hearing screen was performed with automated auditory
brain stem responses and the infant passed both ears.
Ophthalmology: She was most recently seen on [**2175-1-30**] revealing normal mature retinal vessels and recommended
follow-up in 9 months with Dr.[**First Name9 (NamePattern2) **] [**Name (STitle) **], M.D., [**Telephone/Fax (1) 63493**].
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Home.
PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) 50736**], [**Telephone/Fax (1) 42047**].
FEEDS AT DISCHARGE: Continue ad lib feeding, Enfamil AR 20
calorie.
MEDICATIONS: Continue ferrous sulfate supplementation.
Car seat position screening was performed on the infant .
IMMUNIZATIONS: Infant has not received hepatitis B vaccine.
Parents would like it done with her 2 month immunization.
Infant received Synergist vaccine on [**2175-2-2**].
IMMUNIZATIONS RECOMMENDED: Synergist RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria. 1. Born at less than 32
weeks. 2. Born between 32 and 35 weeks with 2 of the
following day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings or 3. With chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the childs life
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOW UP: Recommended 9 month follow-up appointment with
ophthalmology, Dr. [**Last Name (STitle) **], [**Telephone/Fax (1) 50314**].
DISCHARGE DIAGNOSIS:
1. Premature infant product of 29-3/7 weeks gestation.
2. Respiratory distress syndrome.
3. Patent ductus arteriosus.
4. Rule out sepsis with antibiotics
5. Hyperbilirubinemia.
6. Anemia of prematurity
7. Apnea and bradycardia of prematurity
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 56160**]
MEDQUIST36
D: [**2175-2-16**] 21:25:35
T: [**2175-2-16**] 22:26:49
Job#: [**Job Number 64555**]
|
[
"7742",
"53081",
"V290"
] |
Admission Date: [**2150-9-8**] Discharge Date: [**2150-9-11**]
Date of Birth: [**2096-12-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
History taken with use of Spanish interpretor. The patient is a
53 y/o F with a PMH of fibromyalgia and hypertension presenting
with chest discomfort, shortness of breath and hypotension. The
patient reports that she began to feel increasingly unwell
yesterday when she noted increased fatigue and did not leave her
home. Today she noted dyspnea and dizziness while walking with
her daughter. She had to stop frequently to catch her breath
while walking home and had difficulty ambulating up stairs. She
also reports difficulty swallowing secondary to throat
tightness, with dysphagia to hard solid foods for one month. She
has had symptoms like this before, last time one week ago. She
sleeps on four pillows nightly due to difficulty breathing.
Denies PND. She called EMS for transport to the ED. On arrival
to the ED she complaints of [**10-24**] chest pain with associated
diaphoresis and shortness of breath.
.
In the ED, initial vitals: T 99.6, HR 89, BP 106/60, 98% RA. She
was given zofran 2mg IV, ntg sl, tylenol 1000 mg, ketorolac 30mg
IV. EMS had been concerned about ECG and code STEMI was called.
On arrival to ED, ECG was not felt to be consistent with acute
ischemia. She underwent a FAST scan which was negative for
pericardial effusion. CTA negative for PE or dissection. Her BP
dropped to 80s after reciept of SL NTG. She was given 2L NS
without response in BP. Her BP improved to 90s after 3rd L NS.
She reported continued chest discomfort [**7-24**], which was
reproducible upon palpation of the sternum.
.
On arrival to the MICU, the patient complains of continued
discomfort in her chest and throat.
Past Medical History:
GERD.
Bilateral carpal tunnel syndrome.
Hypertension
Lumbosacral radiculopathy.
Depression.
Fibromyalgia.
.
SURGICAL HISTORY
Carpal tunnel release.
Cholecystectomy.
Laser surgery on the right eye.
Social History:
She is a widow, her husband was alcoholic and committed suicide
three years ago. She lives with youngest daughter. The patient
is currently unemployed after being laid off from a foods
service job 6 weeks ago.
Habits: Current tobacco use with 5 cig/daily. No EtOH or IVDU.
Family History:
Mother died with liver disease. Father died at 45 with a heart
attack. One brother died with renal failure.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Vitals: T 97.3, BP 87/51, RR 16, O2 100% 2L
GEN: alert, oriented X3, NAD
HEENT: MMM, OP clear, patchy alopecia.
CV: RRR, nl s1/s2, no MRG, palpable, reproducible tenderness
along sternum, pulses palp 2+ radial, PT/DP
RESP: CTAB, no WRR
ABD: soft, NT/ND, NABS. Tendeness at epigastrium.
EXT: no edema
.
PHYSICAL EXAM AT DISCHARGE:
Vitals: T 97.9, BP 138/86, RR 18, pulse 77, O2 97%RA
GEN: alert, oriented X3, NAD
HEENT: MMM
CV: RRR, nl s1/s2, no MRG, pulses palp 2+ radial, PT/DP
RESP: CTAB, no WRR
ABD: soft, NT/ND, NABS
EXT: no edema
Pertinent Results:
LABORATORY RESULTS:
.
[**2150-9-8**] 12:00PM BLOOD WBC-6.0 RBC-3.81* Hgb-10.8* Hct-33.1*
MCV-87 MCH-28.4 MCHC-32.7 RDW-14.2 Plt Ct-306
[**2150-9-8**] 10:04PM BLOOD Hct-30.7*
[**2150-9-9**] 05:10AM BLOOD WBC-3.9* RBC-3.48* Hgb-9.4* Hct-30.8*
MCV-88 MCH-27.1 MCHC-30.7* RDW-13.5 Plt Ct-236
[**2150-9-10**] 05:00AM BLOOD WBC-4.2 RBC-3.67* Hgb-10.1* Hct-31.7*
MCV-87 MCH-27.6 MCHC-31.9 RDW-13.5 Plt Ct-250
[**2150-9-11**] 05:25AM BLOOD WBC-4.7 RBC-3.63* Hgb-10.0* Hct-31.1*
MCV-86 MCH-27.7 MCHC-32.3 RDW-13.6 Plt Ct-247
[**2150-9-8**] 12:00PM BLOOD PT-12.0 PTT-26.2 INR(PT)-1.0
[**2150-9-8**] 12:00PM BLOOD Fibrino-229
[**2150-9-8**] 12:00PM BLOOD UreaN-10 Creat-0.9
[**2150-9-9**] 05:10AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-136 K-4.7
Cl-107 HCO3-21* AnGap-13
[**2150-9-10**] 05:00AM BLOOD Glucose-129* UreaN-9 Creat-0.7 Na-140
K-4.2 Cl-106 HCO3-27 AnGap-11
[**2150-9-11**] 05:25AM BLOOD Glucose-124* UreaN-9 Creat-0.7 Na-141
K-3.7 Cl-103 HCO3-31 AnGap-11
[**2150-9-8**] 12:00PM BLOOD CK(CPK)-130
[**2150-9-8**] 07:12PM BLOOD ALT-29 AST-26 CK(CPK)-109 AlkPhos-52
TotBili-0.2
[**2150-9-9**] 05:10AM BLOOD ALT-32 AST-34 CK(CPK)-103 AlkPhos-52
TotBili-0.2
[**2150-9-8**] 12:00PM BLOOD Lipase-30
[**2150-9-8**] 07:12PM BLOOD CK-MB-3 cTropnT-<0.01
[**2150-9-9**] 05:10AM BLOOD CK-MB-3 cTropnT-<0.01
[**2150-9-10**] 05:00AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0
[**2150-9-11**] 05:25AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.9
[**2150-9-9**] 05:10AM BLOOD Cortsol-0.6*
[**2150-9-10**] 05:21AM BLOOD Cortsol-6.0
[**2150-9-10**] 05:58AM BLOOD Cortsol-13.9
[**2150-9-10**] 06:58AM BLOOD Cortsol-17.8
[**2150-9-11**] 05:25AM BLOOD Cortsol-5.1
[**2150-9-8**] 12:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2150-9-8**] 10:55PM BLOOD Type-[**Last Name (un) **] pO2-169* pCO2-41 pH-7.36
calTCO2-24 Base XS--1 Comment-GREEN TOP
[**2150-9-8**] 12:16PM BLOOD Glucose-113* Lactate-2.7* Na-136 K-4.3
Cl-101 calHCO3-24
[**2150-9-8**] 10:55PM BLOOD Lactate-1.2
[**2150-9-10**] 05:21AM BLOOD ACTH - FROZEN-PND
.
[**2150-9-8**] 2:20 pm URINE CULTURE (Final [**2150-9-9**]): NO GROWTH.
[**2150-9-8**]: Blood Culture: No growth
[**2150-9-9**]: Blood Culture: No growth
.
STUDIES:
.
EKG [**2150-9-8**]: Tracing #1: Sinus rhythm. ST-T wave configuration
suggests early repolarization pattern but clinical correlation
is suggested. Compared to the previous tracing of [**2150-4-29**] no
significant change.
EKG [**2150-9-8**]: Tracing #2: Sinus rhythm. ST-T wave configuration
suggests early repolarization pattern but clinical correlation
is suggested. Compared to the previous tracing of same date no
significant change.
EKG [**2150-9-8**]: Tracing #3: Sinus rhythm. ST-T wave configuration
suggests early repolarization pattern but clinical correlation
is suggested. Compared to the previous tracing of same date no
significant change.
EKG [**2150-9-8**]: Tracing #4: Sinus rhythm. ST-T wave configuration
suggests early repolarization pattern but clinical correlation
is suggested. Compared to the previous tracing of same date no
significant change.
CXR [**2150-9-8**]: IMPRESSION: There is no evidence of pneumonia or
CHF.
There is no pneumothorax or pleural effusion. The heart is
mildly enlarged. The aorta is tortuous. There is no definite
acute displaced fracture.
.
CTA [**2150-9-8**]: IMPRESSION: Limited study due to technique. No
definite pulmonary embolism within the main, primary, lobar or
large segmental branches of the pulmonary artery. Cardiomegaly.
Incidentally noted aberrant right subclavian artery.
.
CT HEAD [**2150-9-8**]: IMPRESSION: No definite acute intracranial
abnormality.
.
UGI AIR w/o KUB: [**2150-9-10**]: IMPRESSION: IMPRESSION: Small amount
of penetration into the vestibule. No aspiration into the
airway. Prominent cricopharyngeus impression with free passage
of a barium tablet.
Brief Hospital Course:
53 y/o F with a PMH of fibromyalgia and hypertension presenting
with chest discomfort, shortness of breath, admitted for
hypotension.
.
# HYPOTENSION: SBP 106 at ED triage, dropped to 80s after nitro
SL, and stable in 100-110s after 3L IVF. SBP in 100-110s is
likely relative hypotension given her h/o HTN. However, she
remains well-perfused on exam, with Cr and lactate within normal
limits.
.
Unclear etiology. Initial concern for ACS, aortic dissection, or
PE, but CE negative and stable, ECG unchanged from prior, and
CTA negative. Arm pain could represent atypical CP, but likely
MSK/fibromyalgia since it is exacerbated with movement and
consistent with past arm pain. Volume depletion is possible but
pt does not seem overtly volume down on exam or labs. Some
improvement in ED with 2.6L of IVF but little change with final
500cc in MICU followed by autodiuresis, which indicates adequate
fluid status but persistent relative hypotension. Minimal
evidence of significant infection-- no fever, tachycardia. WBC
down and lymphocytosis on [**9-9**], so viral infection is possible.
However, vasodilation due to infection is unlikely since she
does not meet SIRS criteria aside from WBC. BCx and UCx pending.
Abx held give lack of evidence of infection. Blood loss possible
given GERD symptoms and Hct down from 39.1 on [**6-23**] from 39.1 to
33 at admission and to 30.7 on [**9-9**]. Thus, GI bleed in setting
of gastritis is possible, but she denies changes to bowel
movement, guaiac was negative,and Hct has stabilized. Medication
effect from metoprolol and lisinopril less likely since patient
was adamant about adhering to the prescribed doses.
Nitroglycerin effect unlikely to cause prolonged hypotension.
Adrenal insufficiency is possible given hypotension and
borderline low sodium. Random cortisol level was low but pt
responded appropriately to cosyntropin stimulation test.
Outpatient hypertensives were held. Pt then became hypertensive
and her metoprolol was restarted at low dose and pt monitored.
Blood pressures remained stable and at discharge was 138/86.
.
# Chest Discomfort: Likely due to GERD given ascending
retrosternal burn, throat pain/tightness c/w prior experiences
with GERD. GI cocktail with some effect. +/-MSK or
costochondritis, especially given arm pain this AM. As noted,
cardiac etiology less likely given unchanged EKG and negative
CE. However, other cardiac etiologies including unstable angina,
coronary vasospasm. Should follow up with outpatient
cardiologist to see if catheterization is planned. A
pharmacologic sestamibi stress test or similar CVD work up may
be warranted given recent increase in health care
visits/hospitalizations associated with chest pain. Significant
anxiety given loss of job could exacerbate chest pain and cause
sensation of SOB, throat tightness, weakness. Dysphagia to hard
solids with history of GERD is suspicious for esophageal
stricture/adhesion or esophageal spasm. Barium swallow was
performed showing no obstruction or esophageal pathology. PPI
and GI cocktail prn started and patient discharged on famotidine
10mg tablet [**Hospital1 **].
.
# ANEMIA: Hct down from 39.1 on [**6-23**] to 33 at admission and to
30.7 on [**9-9**], then stable at 30.8. No clinical signs of poor
perfusion, Cr stable. However, history of GERD could be
associated with GI bleed in the setting of gastritis, although
guaiac was negative and she denies changes to BM per above.
Hemolysis less likely given normal tbili.
.
# ANXIETY/DEPRESSION: Worse in past 6 months following loss of
her job, with worsening insomnia, headaches and anxious mood
(per daughter, patient does not endorse) in the last month. No
outpatient anxiolytics. Will likely defer to outpatient care
providers, but would consider outpatient start of SSRI.
.
# FIBROMYALGIA: Continued gabapentin and nortriptyline
.
# FEN - regular diet, replete lytes PRN
.
# Ppx - heparin sc, pneumoboots
.
# ACCESS - PIV X2
.
# DISPO - Home
Medications on Admission:
Fluticasone 50 mcg Spray, 2 puff daily
Gabapentin 300 mg Capsule TID
Lisinopril 10 mg Tablet daily
Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]
Nitroglycerin 0.3 mg Tablet, Sublingual PRN
Nortriptyline 50 mg Capsule QHS
Tramadol 50 mg Tablet one or two Tablet(s) by mouth daily as
needed Aspirin 325 mg Tablet daily
Loratadine 10 mg Tablet daily
Nicotine 7 mg/24 hour Patch 24 hr
Discharge Medications:
1. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for pain.
4. Famotidine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Nortriptyline 50 mg Capsule Sig: One (1) Capsule PO at
bedtime.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
active GERD
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because of chest discomfort
and a low blood pressure. Your chest discomfort is most likely
due to your GERD and less likely due to a [**Last Name **] problem. It is
recommended that you follow up with your cardiologist to confirm
this. Your blood pressure normalized after we withheld your
medications and gave you fluids and can be restarted.
Famotidine was added to your home medications and is to be taken
twice a day. The rest of your home medications can be continued
as outpatient.
Please keep your scheduled appointments or contact the provider
[**Name9 (PRE) 67751**] you need to reschedule.
Please contact the hospital or your doctor if you should
experience a fever of greater than 101, shortness of breath or
chest pain.
Followup Instructions:
Please contact the provider if you should need to
reschedule/cancel any of your appointments.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2150-10-1**] 3:20
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4012**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2150-10-30**] 2:40
Provider: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2150-11-6**]
1:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 16624**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2150-10-12**] 2:00
Completed by:[**2150-9-11**]
|
[
"53081",
"4019",
"25000",
"2859",
"311"
] |
Admission Date: [**2188-3-22**] Discharge Date: [**2188-4-1**]
Date of Birth: [**2104-7-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
critical aortic stenosis, coronary artery disease
Major Surgical or Invasive Procedure:
[**2188-3-25**] AVR ( 23mm [**Company 1543**] Mosaic Ultra Porcine)/CABG x2 (LIMA
to LAD, SVG to ramus)
History of Present Illness:
The patient is an 83 year old male with known aortic stenosis
who has been followed by echo. He has had some exertional chest
discomfort, shortness of breath and a possible syncopal episode
this past summer. Echo reveals aortic valve area 0.8cm2, with a
peak gradient 80mmHg and mean gradient 53mmHg. Ejection
fraction is 60%. As well he had significant double vessel
coronary artery disease and was transferred for operation.
Past Medical History:
aortic stenosis
coronary artery disease
hypertension
hyperlipidemia
benign prostatic hyperplasia
s/p resection of left acoustic neuroma
s/p left tibial rodding
s/p bilateral total knee replacements
revision of left knee
bilateral cataract surgery
bilateral carpal tunnel release
tonsillectomy/adenoidectomy
excision of left upper extremity lipoma
Social History:
retired
lives with wife
tobacco: quit 40 yrs ago
EtOH: 1 drink per month
Family History:
brother with MI, RHD
father suffered MI
Physical Exam:
Admission:
VS: 48reg, 132/60, 124/64
ht: 5'[**89**]" Wt: 92.1kg
Gen: NAD, slightly unsteady
Skin: unremarkable, LUE scar
HEENT: unremarkable, PERRL, EOMI, sclera anicteric, dentition in
fair repair
Neck: supple, no JVD
Chest: lungs CTAB
Heart: RRR, [**3-3**] holosystolic murmur- with radiation to
precordium and carotids
Abd: soft, NT, ND, +BS, -HSM/CVA tenderness
Ext: warm, well-perfused, no edema, knee scars well-healed, mild
chronic venous stasis, mild swelling left knee
Neuro: grossly intact, MAE 5/5 strength, non-focal exam
Pulses:
femoral: R 1+ L 1+
DP: R NP L NP
PT: R 1+ L 1+
Radial: R 2+ L 2+
Pertinent Results:
PREBYPASS
1. The left atrium is markedly dilated.
2. No atrial septal defect or PFO is seen by 2D or color
Doppler.
3. There is moderate symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is critical
aortic valve stenosis (valve area <0.8cm2). Trace aortic
regurgitation is seen.
7. The mitral valve leaflets are mildly thickened.
8. Trivial mitral regurgitation is seen.
9. There is no pericardial effusion.
10. Dr. [**Last Name (STitle) **] was notified in person of the results during the
surgery on [**2188-3-25**] at 1214.
POSTBYPASS
1. Patient is on phenylephrine infusion
2. A well seated, well functioning bioprostetic valve is noted
in the aortic position. 10 mm Hg max gradient, 6 mm Hg mean
gradient, V max 1.58 m/sec
3. LV EF appears similar to prebypass but underfilled.
4. Mitral regurgitation initially appeared worse with a moderate
grade but improved after discontinuing v-pacing and allowing
time after bypass ending.
5. Aortic contour is smooth after decannulation
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician
?????? [**2181**] CareGroup IS. All rights reserved.
[**2188-3-31**] 05:50AM BLOOD WBC-5.5 RBC-3.11* Hgb-9.5* Hct-27.7*
MCV-89 MCH-30.5 MCHC-34.3 RDW-14.3 Plt Ct-195
[**2188-3-31**] 05:50AM BLOOD Plt Ct-195
[**2188-3-31**] 05:50AM BLOOD Glucose-102 UreaN-26* Creat-0.9 Na-140
K-3.8 Cl-107 HCO3-24 AnGap-13
Brief Hospital Course:
The patient was admitted to the hospital on [**2188-3-22**] for
completion of his pre-operative work-up after he had angina
during a dental visit. Non-invasive carotid exam revealed less
than 40% stenosis bilaterally. He was cleared by dental. The
patient underwent aortic valve replacement (25mm St. [**Male First Name (un) 923**]
tissue) and coronary artery bypass x 2 with Dr. [**Last Name (STitle) **] on [**3-25**].
He was transferred to the CVICU in stable condition on
phenylephrine and propofol drips.
He remained stable postoperatively and weaned from pressors. he
was somewhat slow to awaken but did so and was neurologically
intact. he was transferred to the floor, after pacing wires and
CTs had been removed according to protocol. He was diuresed
towards his preoperative weight. There was still some edema at
discharge and his Lasix was continued at transfer. He was sent
to rehabilitation for further recover recovery prior to return
home.
Wounds were clean and dry. He was voiding after the Foley was
removed. Discharge medications and instructions as well as
followup were given to the rehabilitation facility([**Hospital3 15644**]
Healthcare Center in [**Location (un) 47**], MA).
Medications on Admission:
terazosin 5'
metoprolol 25''
simvastatin 40''
asa 81'
lasix 20 prn
KCl 10 prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 2 weeks: after 2 weeks decrease to 200mg [**Hospital1 **] for 2
weeks then stop.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for PAIN.
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
aortic stenosis
coronary artery disease
hypertension
hyperlipidemia
benign prostatic hyperplasia
s/p resection left acoustic neuroma
s/p left tibial rodding
Discharge Condition:
good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 3 weeks at [**Hospital1 **] for wound check and post-op
follow-up : [**Telephone/Fax (1) 6256**]
Dr. [**First Name8 (NamePattern2) 7325**] [**Name (STitle) **] in 3 weeks (same day as Dr.
[**Telephone/Fax (1) 82678**]
Dr. [**Last Name (STitle) 1655**] in 2 weeks
please call for appointments
Completed by:[**2188-4-1**]
|
[
"4241",
"41401",
"42731",
"4019",
"2724"
] |
Admission Date: [**2160-10-28**] Discharge Date: [**2160-11-2**]
Date of Birth: [**2114-10-13**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: Patient is a 46-year-old male
with a complicated cardiac history including coronary artery
disease status post CABG x2 ([**2139**], [**2152**]), pericardial
constriction status post stripping, diastolic dysfunction,
stable angina (patient no longer an operative candidate per
Cardiothoracic Surgery). Patient also with history of
diabetes mellitus type 1, hypercholesterolemia, chronic renal
insufficiency, and chronic pleural effusion, who is admitted
to the [**Hospital Unit Name 196**] service on [**2160-10-28**] in decompensated heart
failure.
Patient complained of progressive shortness of breath and
pedal edema as well as an approximately 11 pound weight gain
over the past 2-3 weeks. While on the floor, diuresis was
attempted with Lasix and nesiritide, but patient's heart
failure was refractory to treatment, in addition he had
worsening renal failure and became hypotensive. He was
subsequently transferred to the CCU for PA catheterization
and further evaluation of hemodynamics/tailored CHF therapy.
Upon transfer, the patient denied complaints of chest pain,
shortness of breath, nausea, vomiting, abdominal pain,
lightheadedness, or dizziness, fever or chills.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG '[**39**] with SVG to
LAD and D1 and CABG in '[**52**] with SVG to RCA, and pericardial
stripping secondary to constrictive pericarditis.
Catheterization [**1-20**] reveals 100% LAD lesion with
unsuccessful PTCA attempt, patent D1 and a subtotal D2.
Small [**Last Name (LF) 8714**], [**First Name3 (LF) **]-2 subtotally occluded status post PTCA with no
stent, SVG to RCA patent, and SVG to LAD/D1 totally occluded
proximally. Patient with collateral perfusion of LAD
territory. Catheterization [**1-20**] also revealed constrictive
physiology with RA approximately equal to PCWP approximately
20 mm Hg.
2. Chronic renal insufficiency, baseline creatinine of
1.4-1.8.
3. Diabetes mellitus type 1 complicated by retinopathy and
nephropathy.
4. CVA secondary to prior CABG.
5. Seizure disorder secondary to CVA.
6. Hyperlipidemia.
7. Gastritis.
8. PVD status post right toe amputation and right fem bypass.
9. Stable angina.
10. Chronic anemia.
HOME MEDICATIONS:
1. Imdur 90 q.d.
2. Lasix 160 q.a.m., 80 q.p.m.
3. Tegretol 300 t.i.d.
4. Zestril 10 q.d.
5. Lopressor 100 b.i.d.
6. Aspirin 325.
7. Protonix 40 q.d.
8. Lantus 20 q.a.m., 18 units q.p.m.
9. Humalog sliding scale.
10. Fluvoxamine 12.5 b.i.d.
11. Lipitor 10 q.d.
12. NTGSL prn, patient takes approximately one q.o.d.
ALLERGIES: Penicillin results in hives.
SOCIAL HISTORY: Patient lives with parents. No tobacco,
EtOH, or drugs. Currently on disability secondary to stroke.
FAMILY HISTORY: Dad with "[**Last Name **] problem", diabetes mellitus.
PHYSICAL EXAMINATION: Temperature 97.7, heart rate 93, blood
pressure 88/60, breathing 18, and satting 97% on room air.
General: Patient is alert, comfortable, and pleasant in no
acute distress. HEENT: Moist mucous membranes. Oropharynx
clear. Cardiovascular: Regular, rate, and rhythm, positive
S3, JVD difficult to assess. Lungs: Trace rales bilaterally
at bases. Abdomen: Positive bowel sounds, soft, nontender,
obese. Extremities: 3+ pitting edema bilaterally. Dorsalis
pedis 1+ bilaterally.
DATA: Chem-7: Sodium 117, potassium 4.7, chloride 83,
bicarb 25, BUN 60, creatinine 2.0. CBC: 8.3/28.8/421.
ECG: Normal sinus rhythm, normal intervals, normal axis,
flat T waves, no ST changes.
Echocardiogram: [**10-28**] EF 60%, E/A ratio 1.57, no evidence of
effusion or constriction, trivial MR.
HOSPITAL COURSE:
1. CHF: Patient was transferred to the CCU and had a PA
catheter placed without complication. Initial Swan numbers
revealed the following: CVP 22, PA 64/33, PCWP 30, CO/CI
equals 6.4/2.8, CR 475.
Given patient's etiology for hypotensive on the floor was
unclear and he was found to have elevated wedge pressure. He
was started on nesiritide drip, which he initially tolerated
well. Dopamine was added to increase renal perfusion and
enhance diuresis, however, patient became tachycardic and
experienced anginal symptoms which resolved upon
discontinuing dopamine. Patient's blood pressure remained
stable and given that his heart failure was secondary to
diastolic dysfunction, his beta blocker was titrated back on
board and increased as tolerated, as it was felt that slowing
his heart rate, increasing his filling time would improve his
cardiac function. Additionally, Lasix drip was added for
further diuresis. Patient's dry weight per family was noted
to be 205 pounds.
2. Coronary artery disease: Patient remained chest pain free
throughout stay except for episode of chest pain associated
with dopamine drip. He is known to have native LAD and SVG
to LAD occlusion with perfusion via collaterals. He is not
an operative candidate for CT surgery given substantial
mortality associated with third redo CABG, and patient with
longstanding diabetes. He was continued on aspirin, beta
blocker, and statin, Imdur, and prn NPG.
3. Hyponatremia: Etiology felt related to either SIADH
secondary to his SSRI or Tegretol or CHF. Urine electrolytes
were more consistent with SIADH picture, however, patient was
hypervolemic and urine electrolytes can be confounded in the
setting of diuretic therapy. Tegretol was felt to be an
unlikely etiology as this patient had been on this medication
for many years with no prior history of hyponatremia. His
SSRI was felt to be more a likely potential etiology. Thus a
psych consult was obtained for help with an appropriate
alternative if any.
Patient's sodium improved slowly over the course of his stay
with 1000 cc fluid restriction.
4. Renal: Patient with chronic renal insufficiency and
initially elevated creatinine. Once transferred to the CCU,
the patient's creatinine initially declined and then remained
stable at prior baseline value of even in the setting of
continued diuresis. Urinalysis was sent which was negative
for any evidence of ATN contributing to his renal disease.
5. Anemia: Patient required several transfusions while
in-house. He had no evidence of active bleeding, was guaiac
negative, and additionally had no evidence of hemolysis.
Iron studies were consistent with anemia of chronic disease
most likely secondary to longstanding renal failure.
6. Diabetes mellitus: Patient was initially maintained on
his home insulin regimen, however, his p.m. lantus had to be
decreased while in-house secondary to low fingersticks in the
a.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2160-11-2**] 16:51
T: [**2160-11-4**] 13:49
JOB#: [**Job Number 19055**]
|
[
"4280",
"5119"
] |
Admission Date: [**2179-5-5**] Discharge Date: [**2179-5-6**]
Date of Birth: [**2134-6-11**] Sex: F
Service: NEUROLOGY
Allergies:
Valium / Penicillins / Percocet / Benzodiazepines
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Intubation
Lumbar puncture
History of Present Illness:
44 F with hx RR-MS with recent admission for MS flare [**4-8**], s/p
5 days IV solumedrol, was found at home by family around 6 pm
dressed in towels and drying to dress self with plastic bags.
Shortly prior to her daughter arriving home, other family
members
(who live above and below her) had heard a variety of banging
noises coming from the pt's apt, but thought it might have been
the daughter coming home. The daughter found behaving very
bizarrely, not following commands, and was becoming agitated and
beligerent. She was brought to the ER where she was noted to be
very agitated and uncooperative with examination. She was given
ativan and haldol. At one point she became very somnolent with
shallow breathing, but as [**Name8 (MD) **] RN tried to apply face mask, she
resisted and stated she didn't need it. She also had an episode
where she was repeatedly sitting up and down in bed and was
breathing in a staccato manner. Over the course of several hours
she was given a total of 8 mg ativan and 15 mg haldol. She was
also given ceftriaxone, vancomycin, and acyclovir to cover for
meningitis. She also received 100 mg hydrocortisone in case of
adrenal insufficiency [**2-1**] her recent solumedrol infusions.
Finally she received 1000 mg Dilantin. Family states that
nothing
like this has happened before. She has not been ill otherwise,
and there have been no new meds added to her regimen recently.
They do note that her PO intake has been poor lately.
Past Medical History:
MS - as above.
Gluacoma in the left eye.
Supercervical hysterectomy for 20 pound fibroid.
Hypercholesterolemia
Social History:
Lives on the [**Location (un) 1773**] of her family home. Her mother lives
on the [**Location (un) 448**] and she lives on the [**Location (un) 1773**]. She is
currently on disability allowance.
She has worked as recently as [**10-6**] for the [**Location (un) **] Theater
Company selling tickets.
She reports smoing for at least 25 years about 1 PPD.
Sh denied ETOH and illicit drug use.
Family History:
Father passed away form lung CA at the age of 54.
No history of the mother's medical history or family history of
neurological diseases was elicited.
Physical Exam:
T- [**Age over 90 **] F BP- 124/70 HR- 82 RR- 18 O2Sat 100%RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa; some blood noted in nostrils
and
on tip of tongue, but no clear lac.
Neck: supple
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no c/c/e
Neurologic examination:
Mental status: sleeping, unarousable to verbal or tactile stim.
No eye opening.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. (+) VOR. No obvious facial asymmetries. (-) BTT
B/L, (+) corneals B/L
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
spont mvmt of the RLE and RUE noted. withdraws to noxious in the
LE B/L and the LLE, but not LUE.
Sensation: withdraws in all ext except the LUE
Reflexes:
0 and symmetric throughout.
Toes downgoing bilaterally
Pertinent Results:
[**2179-5-5**] 08:00AM GLUCOSE-135* UREA N-19 CREAT-0.8 SODIUM-143
POTASSIUM-2.9* CHLORIDE-112* TOTAL CO2-22 ANION GAP-12
[**2179-5-5**] 08:00AM WBC-4.3 RBC-3.79* HGB-10.7*# HCT-32.3* MCV-85
MCH-28.2 MCHC-33.0 RDW-13.1
[**2179-5-5**] 08:00AM NEUTS-79.8* LYMPHS-18.3 MONOS-1.8* EOS-0.1
BASOS-0
[**2179-5-5**] 04:45AM CEREBROSPINAL FLUID (CSF) PROTEIN-37
GLUCOSE-87
[**2179-5-5**] 04:45AM CEREBROSPINAL FLUID (CSF) WBC-11 RBC-4*
POLYS-0 LYMPHS-83 MONOS-16 ATYPS-1
[**2179-5-5**] 04:45AM CEREBROSPINAL FLUID (CSF) WBC-10 RBC-118*
POLYS-1 LYMPHS-96 MONOS-3
[**2179-5-5**] 03:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2179-5-5**] 02:15AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2179-5-5**] 12:41AM GLUCOSE-122* LACTATE-3.9* NA+-143 K+-3.0*
CL--95* TCO2-26
[**2179-5-5**] 12:41AM HGB-15.9 calcHCT-48 O2 SAT-96 CARBOXYHB-3
[**2179-5-5**] 12:30AM GLUCOSE-124* UREA N-32* CREAT-1.5* SODIUM-140
POTASSIUM-3.0* CHLORIDE-95* TOTAL CO2-26 ANION GAP-22*
[**2179-5-5**] 12:30AM ALT(SGPT)-20 AST(SGOT)-28 ALK PHOS-64 TOT
BILI-0.3
[**2179-5-5**] 12:30AM ALBUMIN-4.7 CALCIUM-10.5* PHOSPHATE-2.7
MAGNESIUM-2.2
[**2179-5-5**] 12:30AM TSH-0.89
[**2179-5-5**] 12:30AM OSMOLAL-301
[**2179-5-5**] 12:30AM LITHIUM-0.2*
[**2179-5-5**] 12:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
EEG [**2179-5-5**] - burst suppression seen (patient was on propofol)
MRI of the brain
In comparison with the prior examination dated [**2176-3-27**],
there is no
evidence of new lesions, persistent areas of hyperintensity
signal in the
subcortical and periventricular white matter and also in the
reflection of the callosal septal region likely consistent with
areas of demyelination and possibly representing lesions related
with multiple sclerosis. There is no evidence of abnormal
enhancement or new lesions. No diffusion abnormalities are
detected.
Brief Hospital Course:
44 yo RHW with relapsing remitting multiple sclerosis, recently
discharged from hospital after a 5 day course of IV solumedrol
presents with bizarre, and uncharacteristic behavior. Her family
mentioned that she is prone to agitation in the hospital
setting, which is exacerbated with benzodiazepines. Family
discussion with [**Known firstname **] [**Known lastname 17113**] health care proxy and mother,
[**Name (NI) 110032**] [**Name (NI) **] indicated that she was unclear regarding the
necessity for intubation and the lumbar puncture. As
evidenced from Dr[**Name (NI) 110033**] note from yesterday, Ms [**Known lastname 17113**]
bizarre behavior continued in the ER, and it was felt that she
was having seizures. In the ER when she received Dilantin, she
became hypotensive. She was then intubated in the ER.
According to the patient's daughter, her mother kept wanting to
go to the bathroom, rubbing her legs in the ER and not making
much sense. Prior to the ER incident, when her daughter returned
from college late at night, she found her mother in an
uncharacteristic mess or paraphernalia, which was
uncharacteristic of her, in addition, she had not gone to bed,
which she normally does. The patient's mother had described loud
banging noises in her daughter's portion of the family house
which is the [**Location (un) 1773**]. Dr [**Last Name (STitle) **] [**Last Name (NamePattern4) **] note from [**2179-2-28**]
described the patient as having a pervasive sleep disorder for
which she used baclofen and vicodin as Mirapex had not been
useful for her.
In the neuro ICU service she was maintained on droplet
precautions due to the concern of a viral encephalitis. She was
switched from Midazolam to Propofol, due to her issue of
agitation on benzodiazepines, which may have posed a problem
while attempting to wean her.
On [**2179-5-6**] she was extubated. After extubation, despite attempts
to convince her to stay in hospital, she self-discharged herself
from hospital. She was found to be competent (please refer to Dr
[**Last Name (STitle) **] note in OMR).
Medications on Admission:
Copaxone 20mg injections daily
Mirapex PRN yet not used in quite some time
Timolol 0.05% 1 drop in left eye [**Hospital1 **]
HCTZ 25mg PO qdaily
Baclofen 40 mg QHS and 20 mg TID PRN
Lorcet PRN
Ranitidine 150 mg [**Hospital1 **]
Tramadol 50 mg PO TID PRN
Discharge Medications:
Copaxone 20mg injections daily
Mirapex PRN yet not used in quite some time
Timolol 0.05% 1 drop in left eye [**Hospital1 **]
HCTZ 25mg PO qdaily
Baclofen 40 mg QHS and 20 mg TID PRN
Lorcet PRN
Ranitidine 150 mg [**Hospital1 **]
Tramadol 50 mg PO TID PRN
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Seizures
Discharge Condition:
Self discharged against medical advice
Discharge Instructions:
You have discharged yourself from hospital against medical
advice.
Followup Instructions:
Neurology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD Phone:[**Telephone/Fax (1) 5434**]
Date/Time:[**2179-5-31**] 9:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2179-5-6**]
|
[
"2720"
] |
Admission Date: [**2129-9-21**] Discharge Date: [**2129-9-21**]
Date of Birth: [**2059-3-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypothermia, hypotension, lactic acidosis
Major Surgical or Invasive Procedure:
Intubation, femoral CVL, femoral arterial line
History of Present Illness:
Patient is a 70 year old female with past medical history of
coronary artery disease, hypertension, CVA, and breast cancer
who was recently discharged from [**Hospital1 18**] on [**9-16**]. Per report from
the emergency room physicians, her daughter went to visit the
patient today and noted the patient was cold, breathing fast,
and felt unwell. EMS was called, and upon arrival the patient
was noted to be tachypneic with a respiratory rate to the 40's,
cold, sweaty, and hypotensive with a blood pressure of 70/palp.
EMS was unable to obtain a temperature or start an IV in the
field.
.
Upon arrival to [**Hospital1 18**] ED, patient was noted to be tachypneic,
and was placed on a non-rebreather. The ED staff had a difficult
time obtaining a blood pressure (erratic and felt to be
erroneous readings of 190's obtained), and ultimately a mannual
cuff provided [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1131**] of systolic of 85. Again it was
difficult to place a peripheral IV, so a left EJ was placed.
Ultimately a femoral central line was placed, as with her
persistent tachypnea a neck line was felt unsafe. Her breathing
improved to a rate in the 20's, and she was placed on nasal
cannula oxygen with a saturation in the 90's. She received three
liters of intravenous fluid. A chest x-ray was felt to possibly
be consistent with pneumonia, so she was given levofloxacin,
zosyn, and vancomycin to cover for possible aspiration and
hospital-acquired pathogens given her recent stay. Of note, she
remained hypothermic and a rectal probe was unable to read a
temperature. With warm blankets, her temperature improved to 92
rectally at time of transfer. Her labs were notable for a
lactate of 9.5, troponin at her baseline (0.06), and a bump in
her creatinine to 2.3 (previously 1.4).
.
Upon arrival to the floor, patient denies any discomfort or
pain, but states she feels cold. She cannot provide any details
regarding the events leading to hospitalization.
Past Medical History:
Dyslipidemia
Hypertension
Recent Inferior STEMI ([**6-/2129**])
Left breast cancer s/p modified radical mastectomy [**2125**]; also
received Taxol and Herceptin.
h/o subacute infarct L temporal lobe found in [**2125**]
s/p excision of ganglion cyst in hand
s/p right deep inferior epigastric perforator ([**Last Name (un) 5884**]) flap breast
reconstruction to fix breast asymmetry
Social History:
The pt is divorced and has been living with daughter following
discharge from hospitalization in 8/[**2128**]. Homemaker. Emigrated
from [**Country 2045**].
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
Noncontributory
Physical Exam:
General: Sleeping, arousable, answers some questions, but
difficult to understand. In NAD
HEENT: NC/AT. Dry mucous membranes. No scleral icterus or
conjunctival pallor. PERRL. EOMI.
Neck: Supple, flat JVP.
Lungs: Occasional rales at bases, good air movement, no wheezes.
Cardiac: Regular, soft diastolic murmur at apex, no rubs or
gallops appreciated.
Abdomen: Soft, NT, ND, +BS
Extr: Cool, no cyanosis, no clubbing or edema. Radial, PT/DP 2+.
Neuro: Awake, oriented to self only. CNs appear symmetric, but
patient unable to cooperate with fomral testing. Moves all
extremities when requested.
Pertinent Results:
[**2129-9-21**] 11:34AM BLOOD WBC-12.4* RBC-2.52* Hgb-7.5* Hct-25.5*
MCV-101* MCH-29.8 MCHC-29.5* RDW-15.0 Plt Ct-151
[**2129-9-20**] 10:20PM BLOOD WBC-11.2*# RBC-3.39* Hgb-10.1* Hct-32.3*
MCV-96 MCH-29.9 MCHC-31.3 RDW-15.5 Plt Ct-237
[**2129-9-20**] 10:20PM BLOOD Neuts-80.4* Lymphs-17.1* Monos-2.1
Eos-0.2 Baso-0.1
[**2129-9-21**] 11:34AM BLOOD Glucose-91 UreaN-31* Creat-2.2* Na-146*
K-4.3 Cl-118* HCO3-10* AnGap-22*
[**2129-9-20**] 10:20PM BLOOD Glucose-115* UreaN-30* Creat-2.3* Na-141
K-4.6 Cl-102 HCO3-14* AnGap-30*
[**2129-9-21**] 10:43AM BLOOD CK(CPK)-81
[**2129-9-20**] 10:20PM BLOOD CK(CPK)-73
[**2129-9-21**] 10:43AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2129-9-21**] 04:31AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2129-9-21**] 11:34AM BLOOD Calcium-6.3* Phos-5.7* Mg-1.7
[**2129-9-21**] 04:31AM BLOOD Albumin-3.4 Calcium-8.7 Phos-6.7*# Mg-2.1
[**2129-9-21**] 04:31AM BLOOD TSH-6.4*
[**2129-9-21**] 04:31AM BLOOD Cortsol-110.8*
[**2129-9-21**] 11:47AM TYPE-ART TEMP-35 PO2-23* PCO2-38 PH-6.99*
TOTAL CO2-10* BASE XS--24
[**2129-9-21**] 11:47AM LACTATE-8.5*
[**2129-9-21**] 11:47AM freeCa-0.88*
[**2129-9-21**] 11:34AM GLUCOSE-91 UREA N-31* CREAT-2.2* SODIUM-146*
POTASSIUM-4.3 CHLORIDE-118* TOTAL CO2-10* ANION GAP-22*
[**2129-9-21**] 11:34AM CALCIUM-6.3* PHOSPHATE-5.7* MAGNESIUM-1.7
[**2129-9-21**] 11:34AM WBC-12.4* RBC-2.52* HGB-7.5* HCT-25.5*
MCV-101* MCH-29.8 MCHC-29.5* RDW-15.0
[**2129-9-21**] 11:34AM PLT COUNT-151
[**2129-9-21**] 11:09AM TYPE-ART PO2-196* PCO2-15* PH-7.34* TOTAL
CO2-8* BASE XS--14
[**2129-9-21**] 11:09AM LACTATE-8.8*
[**2129-9-21**] 10:43AM CK(CPK)-81
[**2129-9-21**] 10:43AM CK-MB-NotDone cTropnT-0.07*
[**2129-9-21**] 05:14AM TYPE-ART PO2-109* PCO2-19* PH-7.29* TOTAL
CO2-10* BASE XS--14
[**2129-9-21**] 05:14AM LACTATE-8.2*
[**2129-9-21**] 04:31AM GLUCOSE-132* UREA N-31* CREAT-2.3* SODIUM-140
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-11* ANION GAP-27*
[**2129-9-21**] 04:31AM ALT(SGPT)-350* AST(SGOT)-518* LD(LDH)-824*
CK(CPK)-75 ALK PHOS-114 AMYLASE-76 TOT BILI-1.0
[**2129-9-21**] 04:31AM LIPASE-52
[**2129-9-21**] 04:31AM CK-MB-NotDone cTropnT-0.06*
[**2129-9-21**] 04:31AM ALBUMIN-3.4 CALCIUM-8.7 PHOSPHATE-6.7*#
MAGNESIUM-2.1
[**2129-9-21**] 04:31AM TSH-6.4*
[**2129-9-21**] 04:31AM CORTISOL-110.8*
[**2129-9-21**] 04:31AM WBC-12.9* RBC-3.05* HGB-9.0* HCT-29.8* MCV-98
MCH-29.4 MCHC-30.1* RDW-15.5
[**2129-9-21**] 04:31AM PLT COUNT-191
[**2129-9-21**] 03:02AM TYPE-ART PO2-96 PCO2-22* PH-7.21* TOTAL
CO2-9* BASE XS--17
[**2129-9-21**] 03:02AM GLUCOSE-128* LACTATE-9.8* NA+-140 K+-3.9
CL--112
[**2129-9-21**] 03:02AM freeCa-1.07*
[**2129-9-20**] 11:05PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2129-9-20**] 11:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2129-9-20**] 11:05PM URINE RBC-0 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-[**6-7**]
[**2129-9-20**] 11:05PM URINE HYALINE-0-2
[**2129-9-20**] 10:50PM GLUCOSE-110* LACTATE-9.5* K+-4.4
[**2129-9-20**] 10:20PM GLUCOSE-115* UREA N-30* CREAT-2.3* SODIUM-141
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-14* ANION GAP-30*
[**2129-9-20**] 10:20PM CK(CPK)-73
[**2129-9-20**] 10:20PM CK-MB-NotDone cTropnT-0.06*
[**2129-9-20**] 10:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2129-9-20**] 10:20PM WBC-11.2*# RBC-3.39* HGB-10.1* HCT-32.3*
MCV-96 MCH-29.9 MCHC-31.3 RDW-15.5
[**2129-9-20**] 10:20PM NEUTS-80.4* LYMPHS-17.1* MONOS-2.1 EOS-0.2
BASOS-0.1
[**2129-9-20**] 10:20PM PLT COUNT-237
[**2129-9-20**] 10:20PM PT-14.1* PTT-29.4 INR(PT)-1.2*
Brief Hospital Course:
Patient is a 70 year old female with past medical history of
breast cancer, coronary artery disease, stroke, and hypertension
who presents with hypothermia, hypotension, and elevated lactic
acid. Pt was admitted to the MICU for continued resuscitation.
.
#) Hypothermia: Unclear etiology. Differential includes sepsis,
environmental, adrenal insufficiency, hypothyroidism, secondary
to toxic/metabolic etiology (leading to inability to seek
warmth) among other possibilities. Likely contributing to lactic
acidosis. Most likely is volume depletion +/- sepsis.
- Bair-hugger to raise core temperature
- Infectious work-up as discussed below including blood, urine,
sputum cultures.
- AM cortisol and TSH, if cortisol abnormal will consider
cortisone stress
.
#) Hypotension: Patient noted to be hypotensive with systolic to
80's, suspect pre-renal state, possibly inconjunction with
taking usual home medications such as lasix, with possible poor
PO intake since discharge. As noted above, sepsis is strong
possibily. Given recent STEMI, cardiogenic shock also
consideration.
- Hold all BP medications.
- Patient is status-post 3 liters of IVFs, will continue
bolusing as needed to maintain MAP >60 and urine output
>30cc/hr.
- Cycle cardiac enzymes
- Infectious work-up as noted.
- Checking AM cortisol.
- Pressors if needed if fluids cannot bring up pressure.
.
#) Hypoxia: Patient required non-rebreather in ED initially, as
team was unable to obtain oxygen saturation. Suspect that at
least some degree of the hypoxia may have been related to
inability to obtain good pleth in setting of marked hypothermia.
She may also have a developing pneuomia that is contributing.
Less likely to be PE in setting of hypothermia and other
findings that have improved with hydration.
- Repeat PA/lateral chest x-ray after hydration completed if
stable.
- Oxygen probe to forehead or other central part of body.
- Sputum culture to work up possible pneumonia.
- ABG to assess oxygenation.
- Continuing levofloxacin, vancomycin, zosyn for broad coverage
of atypical, MRSA (given recent hospital stay), and aspiration
(given prior CVA).
- Consider CT to r/o PE if hypoxic once warmed, but ABG
demonstrated adequate pO2.
.
#) Acute renal failure: Baseline for last month was 1.4, prior
to [**Month (only) **] baseline appears to be 0.9-1.0. She is currently
making small amount of urine. This may be due to intravascularly
depleted state with continued administration of lasix and poor
PO intake.
- Holding lasix.
- Sending off urine lytes
- Bolusing fluids to help urine output pick-up for goal >30cc
.
#) Metabolic acidosis:
Patient's bicarbonate noted to be low at time of admission.
Suspect this is multifactorial, secondary to elevated lactate
and ARF.
- Toxin screen
- CK was checked, not elevated (patient possibily was down for
some time, also was on statin)
- Will trend lactate, continue to hydrate
- Renal electrolytes to evaluate for RTA
.
#) Coronary artery disease: Continue ASA, holding BB given
hypotension, continue statin once LFTs come back.
- Will continue to be mindful of possible cardiogenic shock.
.
#) Mitral regurgitation: Noted on prior echo from last week. No
evidence of volume overload at present.
.
#) History of CVA: Neurologic examination difficult to assess
given patient appears to have somewhat altered mental status
(per neurology notes from a few days ago, she was A&Ox3 and
although slow to respond, appropriate in conversation). CT head
negative.
- Continue to monitor neurologic exam as patient is warmed and
resuscitated (reversible factors that are likely contributing).
.
Pt was resuscitated in the MICU overnight with improvement in
mentation, achievement of normothermia, with warm extremities
and good peripheral pulses; however, lactate still remained
elevated. Pt denied any complaints, stated she felt much
improved from the evening prior. Pt continued to be tachypneic.
Approximately an hour later, patient became acutely diaphoretic
and agitated, and was intubated emergently. The blood pressure,
which had been in the low 100s systolic, then dropped to 80s,
with bradycardia. EKG demonstrated no ST elevations but
non-specific changes and TWI and ST depressions. Pressors were
initiated. The patient lost a pulse, found to be in PEA, CPR was
initiated, a femoral a-line was placed. Pt received epinephrine,
atropine, with return of pulse, followed by subsequent loss of
pulse approximately 10 minutes later. CPR was continued, ACLS
meds given. A bedside ultrasound of the heart revealed no
significant pericardial effusion. The cardiology fellow arrived
and reviewed the EKGs, no evidence of STEMI, bedside ultarsound
without cardiac activity. Empiric tPA given in case of massive
PE, CPR continued, no return of pulses, no cardiac acivity on
ultrasound. Pt pronounced dead. Daughter [**Name (NI) 653**]. ME declined
case; family has consented to autopsy.
Medications on Admission:
(per discharge summary from [**2129-9-18**])
1. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain.
7. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiac arrest
Hypothermia
Sepsis
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
"0389",
"486",
"5849",
"2762",
"99592",
"4240",
"4019",
"2724"
] |
Admission Date: [**2187-12-2**] Discharge Date: [**2187-12-12**]
Service: MEDICINE
Allergies:
Penicillins / Lasix / Erythromycin Base
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
L-anterior CP; hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89F from [**Hospital3 **] with L ant CP [**4-2**] worse w/ deep
inspiration, + nausea/emesis, no diaphoresis. Duration of CP x1
hour. Brought in per EMS, EKG difficult to interpret, LBBB HR
80s-paced, initial CE negative x1. Was unable to give any
Nitrates or morphine due to low SBP. CP resolved w/o any
medications or interventions. She was given ASA 325x1, CTA done
to r/o PE, which was negative. Pt stated that she has been
having trouble swallowing x1-2 weeks due to nausea and inability
to swallow. She's had poor PO intake since then, with some fluid
intake and weight loss. She has no idea why she can't swallow
and is frustrated by this. Of note, she had a recent admission
to [**Hospital6 4287**] where she was found to have oral thrush
and was presumed to have oropharyngeal [**Female First Name (un) **]; a barium swallow
was normal. Has also had diarrhea for several days.
.
ED course: Initial VS T 100.8 Rectally, HR 80-paced, BP 95/56
then dropped to 88/44 MAP 60; RR 13 95%RA. Received 1.7 LNS
w/improvement in her SBP. Attempt at placing R and L-IJ
unsuccessful, unable to pass guidewire. Successfully placed
R-femoral line. Pt also noted to be guaiac + w/brown stools,
also noted to have Bright Red Blood in vaginal vault. ?
prolapsed uterus. Given increased INR did not proceed w/vaginal
exam w/speculum due to ?friable bleeding tissue. CT
chest/abd/pelvis done. She received Levo/Vanco/Flagyl.
.
Of note this is her 3rd hospitalization in 1month. 1st
hospitalization at [**Hospital3 2568**] Hosp-Kidney stones s/p stent. 2nd
hospitalization at [**Hospital1 96085**], Bacteremia, unclear about [**Name (NI) **] and
duration. At her baseline A&Ox3, bed bound per [**Hospital3 **]
staff. Uses diapers not due to incontinence but b/c bedbound.
Staff at [**Hospital3 **] denied documentation of BRBPR or blood
in stool or vagina. She's had a swallow study/barium
study-->report not in record at [**Location (un) **].
.
On review of systems, the pt. denied recent fever or chills.
+HA, No vision changes. Hard of hearing R-ear. Denied cough,
shortness of breath. Chest pain-resolved, no palpitations. +N/V
x1-2 weeks, no abdominal pain. No dysuria. She's unsure whether
she's had blood from below-rectally or vaginally. Denied
arthralgias or myalgias. Per niece has had ~50pound weight loss
this year.
Past Medical History:
-shingles w/post herpetic neuralgia CN V involvement on R side
of face
-R hearing loss
-dementia
-arthritis
-gallstones
-pneumonia
-chronic eosinophilia
-CAD s/p MI
-CHF ?EF
-s/p pacemaker
-atrial fibrillation on coumadin
-history of varicose veins
-bilateral cataracts
-PVD w/peripheral venous stasis skin changes
Family History:
Notable for brothers with atrial fibrillation and a father who
died at age 60 secondary to rectal carcinoma.
Physical Exam:
Vitals: T: 98.8 HR 80-paced BP: 89/51 SaO2: 100%RA
General: Awake, alert, speaking in full sentences, NAD.
HEENT: PERRL, EOMI without nystagmus, no scleral icterus noted,
dry MM, Cracked tongue w/white exudates on posterior palate,
significant tenderness on R side of face-midline from
forehead/chin/neck and R shoulder-CN V distribution, no erythema
or lesions on face
Pulmonary: Lungs CTA bilaterally anteriorly
Cardiac: regular, Nml S1,S2, 2/6 SEM at LUSB
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, [**12-25**]+ DP pulses b/l, chronic
vascular venous stasis changes
Skin: no rashes or lesions noted, mild skin breakdown in rectal
area
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact, CNV noted above
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
Pertinent Results:
GLUCOSE-72 UREA N-27* CREAT-1.1 SODIUM-137 POTASSIUM-4.3
CHLORIDE-108 TOTAL CO2-19* ANION GAP-14
CK(CPK)-45
CK-MB-NotDone cTropnT-<0.01
CALCIUM-7.4* PHOSPHATE-2.8 MAGNESIUM-1.7
HCT-29.5*
LACTATE-1.0 K+-4.4
URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD; URINE RBC-[**2-25**]*
WBC-21-50* BACTERIA-OCC YEAST-NONE EPI-0-2
GLUCOSE-85 UREA N-32* CREAT-1.4* SODIUM-135 POTASSIUM-5.2*
CHLORIDE-102 TOTAL CO2-22 ANION GAP-16
CK(CPK)-51, cTropnT-<0.01, CK-MB-NotDone, WBC-11.0# RBC-3.79*
HGB-11.3* HCT-33.7* MCV-89 MCH-29.9 MCHC-33.6 RDW-15.1,
NEUTS-84.6* LYMPHS-6.5* MONOS-4.4 EOS-4.3* BASOS-0.2, PLT
COUNT-392, PT-20.9* PTT-35.2* INR(PT)-2.0*
.
CT chest/abdomen/pelvis [**2187-12-3**]:
1. No evidence of pulmonary embolism.
2. Bilateral small pleural effusion and associated atelectasis.
3. Severe coronary artery calcifications.
4. Multiple hypoattenuating lesions in both kidneys, too small
to characterize.
5. Dilatation of main pulmonary arteries suggestive of pulmonary
hypertension.
6. Right ureteral stent.
7. Multiple prominent mesenteric lymph nodes, which do not meet
size criteria for pathologic enlargement.
8. Large calcified uterine fibroids.
.
CXR [**2187-12-4**]:
Mild pulmonary edema and small bilateral pleural effusions new
since [**12-2**] are unchanged over two hours. There is no
pneumothorax. No central venous line or drainage tube projects
over the chest. A transvenous right ventricular pacer lead is
unchanged in position and at least one nephrostomy tube is seen
in the right upper quadrant. No pneumothorax.
.
ECHO [**2187-12-3**]:
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is dilated. Right ventricular systolic
function is normal. The aortic root is moderately dilated. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**12-25**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is severe pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
KUB [**2187-12-9**]: The right double-J stent is again visualized.
Calcified fibroids in the pelvis are again seen. Contrast is
seen in nondistended colon. Small bowel loops are mildly dilated
up to 3.5 cm. No air-fluid levels are seen. This most likely
represents an ileus. Small bilateral effusions are present.
Brief Hospital Course:
Assessment and Plan: 89 yo F w/ h/o CAD s/p MI, pacer, CHF, AF,
p/w hypotension, N/V and poor PO intake, improved with aggresive
IVF, with likely candidal esophagitis contributing to poor PO
contributing to hypotension, with clostridium difficile colitis.
.
1 Hypotension: Pt has had poor PO intake x1-2 weeks (likely
longer), nausea, vomitting, diarrhea as well. Hypotension most
likely hypovolemic in nature. Pt w/some note of bright red blood
in vaginal area in ED, however this may have been secondary to
attempted line placement and her HCT remained stable. Cardiac
etiology less likely despite chest pain, ECG unchanged here,
cardiac enzymes negative x3 on admission. Sepsis was possible
given elevated WBC on admission (now normal), source possible
UTI though culture did not grow anything except yeast (not
present in UA), no tachycardia but paced, lactate normal, blood
cultures [**2187-12-2**] no growth x4. She was mentating normally, with
good urine output. Diarrhea was noted prior to admission, no BM
from admission thru [**12-7**], then diarrhea, c.difficile positive,
may have been contributing to initial presentation. She was
treated with 7 days of ciprofloxacin for potential urinary tract
infection. She was started on oral flagyl for clostridium
difficile infection and will need to complete a 14 day course.
She was restarted on metoprololXL on [**12-11**] at 25mg by mouth
which she is tolerating. This will need to be titrated up as she
tolerates as an outpatient.
.
2 Acidosis: Noted during her hosptial course, improved, non-gap,
hyperchloremic ? secondary to IVF, will monitor.
.
3 Dysphagia: Pt w/difficulty swallowing of unclear etiology,
poor PO intake, possibley due to thrush, negative barium swallow
at OSH. Has had intermittent improvement but now with
nausea/vomitting. Suspected secondary to esophageal [**Female First Name (un) **]
though possibly also due to ulceration. GI consulted on this
hospitalization and recommended if no improvement with empiric
therapy with fluconazole and pantoprazole would consider
endoscopy but would favor trying to hold off on this in this
medically complicated woman. Speech and swallow evaluation was
done and they recommended her for thin liquids, pureed solids.
Given low albumin (2.3) likley poor PO for months, c/w weight
loss, cont. ensure TID.
.
4 Vomitting: This has been present intermittantly during her
hospital course. To further assess a KUB was done [**2187-12-9**] which
showed small bowel dilation consistent with ileus. This improved
on [**12-11**] though she may require further antiemetic therapy.
.
5 C.difficile colitis: stool + for c.diff [**2187-12-9**] so she was
placed on contact [**Name (NI) 39962**], she was started on 14 day course
of po flagyl and diarrhea improved, at this time she was noted
to have trace guaiac + stool, so was started on pantoprazole
40mg twice daily.
.
6 Elevated INR: on coumadin for a.fib, started on
cipro/fluconazole with significant elevation in INR, up to 7.3,
s/p 1mg vitamin k IV, held coumadin [**12-5**], INR to 1.4, restarted
coumadin [**12-6**], then held again [**12-8**] for potential EGD, now
refusing EGD but INR 2.0 despite holding coumadin, will cont. to
hold as 2.0 on flagyl, monitor INR closely.
.
7 Anasarca: likely combined aggresive IVF (initially she
recieved 14L IVF for hypotension) with low albumin, this has
improved slowly since tranfer from the ICU to general medicine.
She was restarted ethacrynic acid and tolerated that well.
.
8 CAD s/p MI: She initially presented with chest pain that
resolved with no recurrance, ECG unchanged, CE's neg x3. Aspirin
held on admission out of concern for elevated INR but was
restarted without incident. ECHO done [**12-3**] shows EF >55%.
.
9 Atrial fibrillation: s/p pacer, on coumadin on admission, now
subtheraputic, coumadin stopped [**2187-12-8**] in anticipation of
procedure, yet INR up to 2.0 through [**2187-12-8**], possibly [**1-25**]
flagyl, so this was held but should be restarted on 1mg po qhs
and have this titrated to INR 2.0-3.0.
.
10 Post herpetic neuralgia: controlled with topamax, oxycodone
5mg as needed, scheduled 2gm/24h tylenol with prn not to exceed
4gm/24h.
.
12 Ppx: PPI, heparin sc pending increased inr, bowel regimen,
first step mattress, no diapers, miconazole, OOB to chair.
.
13 FEN: full liquids, soft (dysphagia), nutrition consult,
replete lytes as needed
.
14 Code Status: DNR/DNI, per HCP [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 96086**];
[**Hospital3 2558**] [**Telephone/Fax (1) 7233**] [**Location (un) **]
Medications on Admission:
-Tylenol 650mg PO prn
-ASA 81mg daily
-Calcium Carbonate 1500mg PO BID
-Colace 100mg PO BID prn constipation
-Toprol XL 50mg daily
-Remeron 22.5mg PO qhs
-Prilosec 20mg PO qAM
-Oxycodone 5mg PO q6hr
-MVI daily
-Topamax 25mg PO qhs
-viscous lidocaine2% TID prn
-Vitamin D 400U po daily
-Coumadin 3 mg qhs
-Florastor
-Ethacrynic acid
-fluconozole 200MG POx4 days (day 1=[**12-1**])
-home O2--PM
Discharge Medications:
1. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
2. Florastor 250 mg Capsule Sig: One (1) Capsule PO twice a day.
3. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
4. Lidocaine Viscous 2 % Solution Sig: [**12-25**] units Mucous membrane
at bedtime as needed for pain.
5. Calcium 600 600 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Maalox 200-200-20 mg/5 mL Suspension Sig: One (1) ML PO QID
(4 times a day) as needed for heartburn. ML(s)
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-25**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
13. Topiramate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
14. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
15. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
16. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain: not to exceed 4
grams daily.
17. Ethacrynic Acid 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
19. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 days.
20. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
21. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
22. Prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea.
23. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
24. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime:
please adjust dose to INR 2.0-3.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Dysphagia, c.difficile colitis.
.
Shingles, post-herpetic neuralgia, R hearing loss, dementia,
arthritis, gallstones, CAD s/p MI, s/p pacemaker, atrial
fibrillation on coumadin, varicose veins, bilateral cataracts,
PVD w/peripheral venous stasis skin changes
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed and follow-up with
your primary care physician. [**Name10 (NameIs) 357**] call your primary care
doctor or return to the Emergency Department if you have fevers,
chills, worsening of nausea, vomitting, abdominal pain,
diarrhea, constipation, chest pain, shortness of breath or any
symptoms that concern you.
Followup Instructions:
Please follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] of
your coumadin to INR 2.0-3.0. Please also follow with your
primary care doctor for your c.difficile colitis and dysphagia.
|
[
"0389",
"78552",
"4280",
"42731",
"5849",
"4240",
"99592",
"V5861",
"40390"
] |
Admission Date: [**2184-6-25**] Discharge Date: [**2184-7-2**]
Date of Birth: [**2124-3-19**] Sex: F
Service: CCU
CHIEF COMPLAINT: Acute anterior ST-elevation myocardial
infarction; status post primary percutaneous coronary
intervention.
HISTORY OF PRESENT ILLNESS: This is a 60-year-old female
with a prior inferior myocardial infarction in [**2170**],
persistent tobacco use, question of family history for
coronary artery disease, and hypercholesterolemia who
presents with the acute onset of chest pain radiating to the
left arm, neck, and jaw since about 5 p.m. on the night of
admission.
The patient does also report shortness of breath,
diaphoresis, nausea, and vomiting times three. She is a
vague tangential historian. The patient called a friend to
call 911. The patient had mild relief with sublingual
nitroglycerin.
Electrocardiogram showed ST elevations in leads V2 through
V4. ST depressions in leads II, III, and aVF. Q waves in V1
through V3.
Cardiac catheterization revealed a right-dominant system with
a short left main coronary artery with dual ostia, left
anterior descending artery with midsegment 90% stenotic
lesion with a small thrombosis evident. The left circumflex
had a 50% proximal stenosis and an 80% stenosis in the distal
segment of the proximal vessel. The right coronary artery
was dominant with a 50% midsegment stenosis and a 50% PLD
ostial stenosis. The mid left anterior descending artery
lesion was stented. There was plaque into the second
diagonal which was treated with angioplasty. There was no
residual stenosis in the left anterior descending artery and
20% residual stenosis in the diagonal branch. TIMI-III was
obtained, and no dissections. Pulmonary capillary wedge
pressure was noted to be 22 with a cardiac index of 2.2.
After intervention the electrocardiogram revealed showed
residual ST elevations in V3 and Q waves in V1 through V4.
No recurrent chest pain after the procedure.
PAST MEDICAL HISTORY:
1. Inferior myocardial infarction in [**2170**]. The patient
underwent cardiac catheterization and rescue percutaneous
transluminal coronary angioplasty of the right coronary
artery.
2. She has poor dentition with gingivitis.
3. Hypothyroidism; status post iodine radioblation.
4. Positive tobacco use.
5. Hypercholesterolemia.
6. Medication noncompliance.
7. History of diabetes mellitus; questionable.
MEDICATIONS ON ADMISSION: (Medications at home included)
1. Aspirin 81 mg p.o. once per day.
2. Atenolol 50 mg p.o. once per day.
3. Lipitor 10 mg p.o. once per day.
4. Levoxyl 50 mcg p.o. once per day.
MEDICATIONS ON TRANSFER: (Medications on transfer included)
1. Aspirin 325 mg p.o. once per day.
2. Eptifibatide 2 mcg.
3. Plavix 75 mg p.o. once per day.
ALLERGIES: SULFA DRUGS (cause a rash). The patient gets
nauseous with CODEINE or PERCOCET.
SOCIAL HISTORY: Tobacco use, and the patient gets very
defensive and tangential when questioned about smoking.
FAMILY HISTORY: Brother died of unknown causes at the age
of 54.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed temperature was 98.4, heart rate was 84, blood
pressure was 141/82, respiratory rate was 18, and oxygen
saturation was 99% on 2 liters. Pulmonary diastolic was
36/22 with a mean of 28. Neurologic examination revealed no
focal neurologic deficits. Alert and oriented times three.
Cardiovascular examination revealed a regular rate and
rhythm. No murmurs, gallops, or rubs. No jugular venous
distention. No peripheral edema. Pulmonary examination
revealed the lungs were clear to auscultation. The abdomen
was soft, nontender, and nondistended. Bowel sounds were
normal. Extremity examination revealed the groin was
covered. Clean, dry, and intact. No bruits. Head, eyes,
ears, nose, and throat examination revealed no icterus. No
pallor. Extremity examination revealed distal pulses were
intact and symmetric. The bilateral lower extremities were
warm with good capillary refill.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 13.1 and hematocrit was 36.8. INR was 1.1.
Creatinine was 0.9. Creatine kinase was 95. Troponin was
less than 0.3.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed left
basilar atelectasis.
HOSPITAL COURSE: Ms. [**Known lastname **] had no further chest pain or
shortness of breath while in house. Her Swan-Ganz catheter
was pulled the day after catheterization. She was started on
aspirin, Plavix, and Lipitor.
She was noted to have a persistent heart rate of about 100
and a blood pressure on the low side (between 90 and 100
systolic). For this reason, a beta blocker and ACE inhibitor
were started cautiously. She was kept on telemetry, and
there were no arrhythmias while in house.
A post myocardial infarction echocardiogram was obtained and
showed an ejection fraction of 30% with apical akinesis. For
this reason, she was started on six months of
anticoagulation. Heparin and Coumadin were started. After
three days of 5 mg p.o. q.h.s. of Coumadin and one day of 10
mg of Coumadin, her INR was still 1.3.
After a discussion with the patient, and after her expressing
her desire to go home, the decision was made to transition
her Lovenox and Coumadin as an outpatient. She was to follow
up early next week for an INR check and anticoagulation
medication adjustments.
It should be noted that the patient did have minor gingival
bleeding when placed on heparin, but hemostasis was
spontaneously achieved. Anticoagulation did not have to be
held.
A significant amount of time was spent with the patient by
all members of the team from intern through attending. A
sudden death risk stratification was discussed as was
modification of lifestyle and risk factors. The patient did
not express an interest in pursuing a discussion of these
matters at this time. It should also be noted that when the
subject of smoking tobacco was brought up, the patient became
explosive and very tangential. She preferred to end the
discussion when the subject turns to tobacco smoking.
It was noted in the medical record that the patient has a
history of medication noncompliance. From statements that
she made while in house, it would not be surprising if she
continued to be noncompliant with her medications. For this
reason, as stated above, a significant amount of time was
spent with her discussing the importance of taking her
medications to minimize the risk of another myocardial
infarction; especially since her ejection fraction had
significantly decreased. She was to have followup with a
visiting nurse to try to aid with medication compliance.
DISCHARGE STATUS: The patient was stable for discharge to
home with a visiting nurse.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient had a follow-up appointment with her new
primary care provider (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]) on [**2184-7-7**]
at 2:30 p.m. in the [**Last Name (un) 469**] Building.
2. The importance of followup and adherence to the advice of
her physicians again was stressed.
3. The patient was advised to follow up at the [**Hospital Ward Name 517**]
[**Hospital Unit Name **] Cardiology Clinic given that she did not
currently have a cardiologist.
MEDICATIONS ON DISCHARGE:
1. Lovenox 60 mg subcutaneously twice per day (until INR
therapeutic).
2. Coumadin 5 mg p.o. q.h.s. (INR to be reassessed on [**2184-7-7**] and Coumadin dose adjustment will be made at this
time).
3. Atenolol 12.5 mg p.o. q.h.s.
4. Lisinopril 5 mg p.o. q.h.s.
5. Lipitor 20 mg p.o. once per day.
6. Plavix 75 mg p.o. once per day.
7. Aspirin 325 mg p.o. once per day.
8. Levoxyl 50 mcg p.o. once per day.
DISCHARGE DIAGNOSES:
1. Anterior myocardial infarction with resultant apical
akinesis and decreased ejection fraction.
2. Status post left anterior descending artery stent and
diagonal percutaneous transluminal coronary angioplasty.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 2582**]
MEDQUIST36
D: [**2184-7-2**] 13:55
T: [**2184-7-2**] 15:21
JOB#: [**Job Number 104693**]
|
[
"41401",
"2720",
"3051",
"412"
] |
Admission Date: [**2194-12-11**] Discharge Date: [**2194-12-17**]
Date of Birth: [**2171-6-8**] Sex: F
Service: MEDICINE
Allergies:
Egg [**Location (un) 76704**] Dust
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
"DOE with dry cough and n/v."
Major Surgical or Invasive Procedure:
1. CT-guided lung biopsy of the 1.9cm lesion in the RUL.
History of Present Illness:
23 year old homeless female presents to the ED with temp 100.3,
dyspnea on exertion and dry cough.
.
Patient has had intermittent dry cough since [**2194-7-24**]. At
the end of [**Month (only) **] she was treated with azithromycin x 5 days
for an atypical pneumonia. Patient was subsequently
hospitalized at [**Hospital1 18**] from [**2194-10-25**] - [**2194-10-28**] with persistent
cough, nightsweats and chills. Her CXR showed a RUL infiltrate
which was thought to be an old pneumonia, not treated with any
antibiotics. Initial concern for active TB, she had two
negative AFB sputums however samples were noted to be
concentrated with upper respiratory secretions. PPD was
negative. Follow-up chest film on [**2194-12-4**] showed progression of
lung lesion, now identified as two discrete lung lesions, in
right upper vs lower lobe and lingula. Differential includes
fungus, mycobacterial and nocardia infection. Patient was
referred to pulmonary, per phone note from [**2194-12-8**], and
scheduled for a CT chest without contrast tomorrow ([**2194-12-12**]).
Patient complained of worsening chest tightness, sob and
nightsweats. She was advised to go to the ED if symptoms
persisted.
.
Patient reports Temp to 100.3 several days ago. She reports
that she had been feeling better until Sunday when she had a
episode of nausea and NB NB vomitting. She also reports
worsening NS, chills and decreased activity tolerance. She
reports that she is usually able to go for 15 minute walks
without difficulty. Now she gets sob with about 5 minutes of
walking. She says that she had infections fairly frequently in
the past, but unsure of exact duration or location. She has a
h/o pna at age 12 yo but no other pulmonary issues. Her ROS is
also positive for vaginal discharge that she feels is from an
untreated BV infection. She denies CP per say but says she has
occasional parathesias in her chest. ROS is otherwise negative.
.
Had a negative HIV test in [**Month (only) 359**]. Attempting to relocate to a
new shelter, reports high levels of mold.
.
ED: 98.6 108 120/60 16 100% RA; CTA Chest: neg for pe,
multifocal nodules in both lungs, cavitation in 2 nodules, ddx
includes multifocal infection, fungal vs septic emboli; patient
given unasyn, nafcillin, gent and ambisome - to cover
endocarditis and fungal etiologies
.
ROS:negative.
Past Medical History:
-Fibromyalgia and chronic pain
-Iron deficiency
-Depression, anxiety, PTSD
-Gonorrhea/chlamydia [**2188**] and Gonorrhea [**6-/2194**]
-Abnormal Pap in [**2187**]
-Bed bug bites
-h/o PNA
Social History:
-Living in a shelter with her 3 year old son.
-Recently spent some time at grandparents house because she had
bed bug bites from the shelter.
-5 py hx of smoking, quit 1 month PTA.
-No known TB exposure.
-denies IVDU
-denies ETOH
-on depo for birth control, has unprotected sex with father of
child
Family History:
No family h/o lung pathology. Son with asthma.
Physical Exam:
Exam on admission:
VS: 98.2 117/69 94 18 100 RA
General: AAOX3 in NAD
HEENT: CN 2-12 grossly intact, MMM, oropharynx clear
Endo/Lymph: no obvious thyroid nodules, no LAd
CV: RRR, no RMG
Lungs: mild bibasilar crackles, left greater then right, equal
lung expansion
Abdomen: flat, not TTP, no HSM, active BS
Extremities:
UE: WWP, pulses equal, sensation intact, strength wnl
LE: WWP, pulses euqal, sensation intact, strenght wnl
Derm: no obvious rashes, no stigmata of IE
Psych: mood and affect wnl
Exam at discharge:
T 97.6 BP 112/60 P 70s-80s RR 16 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, [**11-28**] blowing
systolic murmur best heard at LUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
Labs upon admission:
[**2194-12-11**] 02:58AM LACTATE-1.3
[**2194-12-11**] 02:43AM GLUCOSE-116* UREA N-14 CREAT-0.6 SODIUM-140
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-26 ANION GAP-12
[**2194-12-11**] 02:43AM WBC-6.7 RBC-4.05* HGB-13.3 HCT-38.2 MCV-95
MCH-32.8* MCHC-34.7 RDW-12.6
[**2194-12-11**] 02:43AM NEUTS-41.9* LYMPHS-45.7* MONOS-7.2 EOS-4.1*
BASOS-1.2
[**2194-12-11**] 02:43AM PLT COUNT-208
[**2194-12-11**] 02:20AM URINE HOURS-RANDOM
[**2194-12-11**] 02:20AM URINE UCG-NEGATIVE
[**2194-12-11**] 02:20AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2194-12-11**] 02:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
[**2194-12-11**] 02:20AM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-1
[**2194-12-11**] 02:20AM URINE MUCOUS-RARE
Pregnancy test negative
Labs prior to discharge:
[**2194-12-12**] 06:35AM BLOOD ESR-7
[**2194-12-12**] 06:00PM BLOOD PT-15.7* PTT-32.8 INR(PT)-1.5*
[**2194-12-13**] 03:05AM BLOOD PT-14.5* PTT-29.0 INR(PT)-1.4*
[**2194-12-12**] 06:00PM BLOOD Albumin-4.3 Calcium-9.2 Phos-3.5 Mg-2.1
[**2194-12-11**] 02:43AM BLOOD RheuFac-5
[**2194-12-11**] 02:43AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2194-12-12**] 06:35AM BLOOD CRP-2.0
[**2194-12-11**] 02:43AM BLOOD ANCA-NEGATIVE B
Aspergillus Galactomannin: Negative
Beta Glucan: Negative
ACE, serum: Negative
Micro:
Blood culture x4 negative, included fungal and AFB culture
.
Cryptococcal antigen: negative
.
TISSUE RUL NODULE.
GRAM STAIN (Final [**2194-12-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2194-12-15**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2194-12-18**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2194-12-15**]):
NO FUNGAL ELEMENTS SEEN.
ACID FAST SMEAR (Final [**2194-12-13**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2194-12-14**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
.
AFB smear x3 negative
.
Reports:
[**2194-12-11**] CTA Chest: 1. No evidence of acute pulmonary embolism or
thoracic aortic pathology. 2. Multiple nodules in both lungs,
with suggestion of cavitation in a single nodule. The
differential considerations include multifocal infections, with
etiologies including fungal and Nocardia infection and
malignancy such as lymphoma. Septic emboli is considered
unlikely given the time course of progression. Recommended
biopsy for further evaluation.
[**2194-12-11**] CXR: Three nodules in the right upper lobe and left mid
lung, are
concerning for an infectious process including fungal and
nocardia infection. Malignancy is also in the differential.
Please refer to the CT chest performed on the same day for
further evaluation.
Biopsy results from Right lung lesion:
Lung nodule, needle core biopsy:
Pulmonary parenchyma with non-necrotizing granulomatous
inflammation, see note.
Note: AFB and GMS (fungal) stains are negative for organisms.
No polarizable material seen. The differential diagnosis
includes an infectious process and other causes of granulomatous
lung disease (sarcoidosis, etc...).
.
Cytology of right lung lesion:
NEGATIVE FOR MALIGNANT CELLS.
Bronchial cells, abundant macrophages, and structures
suggestive of granulomas.
.
[**12-12**] TTE:
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 regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
Brief Hospital Course:
23 year old woman with history of pneumonia and bronchitis as a
child, recent history of presumed right upper lobe pneumonia
treated with subsequent improvement but persistence of symptoms
(dry cough, fatigue, night sweats, chills, shortness of breath
on exertion), found to have progressive pulmonary nodules
(increasing in size and number), now s/p CT guided biopsy with
significant hemoptysis transferred to ICU for monitoring.
.
# Hemoptysis: [**1-25**] cups of hemoptysis acutely during CT guided
biopsy of the right lung. Patient remained hemodynamically
stable, transferred to the [**Hospital Unit Name 153**] with continued intermittent
scant hemoptysis. 2 large PIVs were maintained and patient was
T&S'd. Hct stable at 39, satting 100% on RA. Patient was kept on
her right side (the side of the biopsy) and kept NPO. IP and IR
were consulted and requested her transfer to the [**Hospital Ward Name **] for
monitoring, should she need intervention. Repeat CXR showed new
right pleural effusion, right upper nodule now hazier,
consistent with post-biopsy state, no pneumothorax identified.
Patient was trasnferred west for further monitoring. She was
hemodynamically stable throughout the rest of her hospital
course with resolution of hemoptysis.
.
# Non-necrotizing granulomatous lung nodules: No fever or
leukocytosis. Biopsy and cytology results revealed
non-necrotizing granulomatous disease. Tissue culture was
negative, Staining for fungi and AFB were negative, serum fungal
markers negative, AFBx3 negative, Normal ESR, CRP, and
Rheumatoid factor, and [**Doctor First Name **] and ANCA negative. Based on these
findings in conjunction with imaging studies, infectious
etiologies, connective tissue disease/vasculidities, and
lymphoma were considered highly unlikely. The exact disease is
unclear at this time, but consideration was given to nodular
sarcoid, which although typically presents with hilar
lymphadenopathy and interstitial infiltrates can also present as
nodular lesions with minimal hilar lymphadenopathy.
.
# Pain: Patient is having post procedural pain which was
controlled initially with IV fentanyl, however was transtioned
to IV morphine and then oxycodone with good control.
.
# Anxiety: Managed with ativan prn.
.
# Fibromyalgia and chronic pain: Patient does not appear to be
managed with an SSRI at home.
.
# Iron deficiency anemia: not on iron supplements at home, no
evidence of iron deficiency on OMR. MCV is 95-98.
.
# Depression, anxiety, PTSD: not on outpatient meds.
.
.
Code: Full
TRANSITIONAL: Follow up on lesions. Given worsening of symptoms
at homeless shelter likely some component of allergies and
reactive airway disease. Recommend consideration of allergy
testing.
Medications on Admission:
MEDROXYPROGESTERONE
PNV WITH CA,NO.71-IRON-FA [NATALCARE PLUS] - 27 mg-1 mg Tablet
daily
ACETAMINOPHEN - 325 mg Tablet - 2 Tablet(s) by mouth q6h prn
pain
NICOTINE - 14 mg/24 hour Patch 24 hr - apply 1 patch daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
3. Depo-Provera Intramuscular
4. cyanocobalamin (vitamin B-12) 50 mcg Tablet Sig: One (1)
Tablet PO once a day.
5. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
6. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO twice a day.
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
8. fluticasone 250 mcg/Actuation Disk with Device Sig: One (1)
Inhalation twice a day.
Disp:*1 disk* Refills:*1*
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Non-necrotizing granulmatous pneumonitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname 51795**],
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted for worsening of your dry cough, shortness of
breath, fever, and nightsweats. You had imaging of your lungs
done which demonstrated progression of your lung nodules
including cavitation in one of them. Because it was unclear
what was causing these lesions to progress, a biopsy was
performed of a right upper lobe nodule. This caused you to
cough up significant amounts of blood due to injury of a lung
vessel. As a result, you went to the intensive care unit. Your
coughing up blood resolved.
Your sputums revealed no evidence of active tuberculosis and
results of the biopsy showed no evidence of cancer,
tuberculosis, or fungal infection. You did have a significant
amount of inflammation on your biopsy in which certain cells
have "walled off" a harmful substance that your immune system
cannot clear; however, at this time, it is unclear what is
causing this.
The following changes were made to your medication:
Increase dose of fluticasone
Started oxycodone for chest pain just for the next few days
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2194-12-18**] at 2:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: THURSDAY [**2194-12-18**] at 2:30 PM
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2194-12-18**] at 2:30 PM
With: DR. [**Last Name (STitle) **]/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
Completed by:[**2194-12-18**]
|
[
"486",
"5119",
"49390"
] |
Admission Date: [**2153-5-8**] Discharge Date: [**2153-5-11**]
Date of Birth: [**2100-12-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
chest pain, inferior/posterior MI
Major Surgical or Invasive Procedure:
Cardiac Catheterization with stenting of right coronary artery
History of Present Illness:
52 yo female, with no significant PMH, presented to OSH with a
few hours of chest pain. She states that the pain was [**11-12**],
associated with SOB, and feeling of bilateral arm heaviness.
Thinking it was acid reflux/indigestion, she took tums which
provided no relief. She reports associated nausea, but denies
vomiting, diaphoresis, abdominal pain. She denied every having
pain like this in the past. She denies PND/orthopnea, states
that she gets intermittent swelling of her LE. She went to OSH
where EKG showed STE in inferior leads. She was given retevase
x 2 for thrombolysis, (7pm, 7:40 pm), loaded with [**Last Name (LF) **], [**First Name3 (LF) **],
started on heparin gtt, and transferred here for further
management. On arrival here, she was pain free, and EKG was
without ST elevations.
Past Medical History:
Hypercholesteremia
Depression
Psoriasis
Social History:
Lives alone, has grown son
Social EtOH
1 ppd x 20 yrs
Family History:
Father with CABG in 70's, DM
Mother [**Name (NI) 19477**] DM, MI in her 70's
Physical Exam:
VS: afebrile 115/43 64 20 97% RA
Gen: very pleasant female, NAD
HEENT: PERRL, OP clear, no bruits or JVD
Lungs: CTA bilaterally, no w/r/r
CV: RRR, nl s1/s2, no m/r/g
Abd: soft, nt/nd, nabs
Extr: no c/c/e, PT 2+ bilaterally
Neuro: grossly intact
Pertinent Results:
[**2153-5-8**] 08:00PM cTropnT-<0.01
[**2153-5-8**] 08:00PM WBC-11.6* RBC-4.30 HGB-14.1 HCT-40.5 MCV-94
MCH-32.7* MCHC-34.8 RDW-12.6
[**2153-5-8**] 08:00PM NEUTS-74.3* LYMPHS-21.0 MONOS-3.5 EOS-0.9
BASOS-0.3
[**2153-5-8**] 08:00PM PLT COUNT-435
[**2153-5-8**] 08:00PM PT-13.5 PTT-56.0* INR(PT)-1.1
CK peak=216, Tnt peak=0.84
EKG from OSH: STE in II, III, AVF with reciprocal ST depressions
in V2
EKG on arrival: resolution of above changes
Cardiac Catheterization:
90% ulcerated plaque of proximal RCA, Cypher Drug eluting stent
placed
LVEDP=28mm Hg
TTE post catheterization: EF=55%, mild LA enlargement, mild
focal inferior hypokinesis, no pericardial effusion, no valvular
abnormalities
Brief Hospital Course:
1. CAD: Evidence of inferior posterior MI on EKG, s/p
thrombolysis at OSH (2 doses of retavase). EKG on arrival here
was without any ST elevations, and she was pain free. She
likely had a MI that was aborted by thrombolytic therapy. On
admission, she was maintained on a heparin drip, aspirin, and
[**Year/Month/Day 4532**]. She was taken to catheterization the next morning, and
she was found to have a 90% proximal, ulcerated right coronary
artery lesion. A cypher drug eluting stent was placed.
Post-procedure, she was started on Metoprolol and Lisinopril
(titrated up as blood pressure allowed. She was pain free after
intervention and discharged to continue on [**Year/Month/Day **], [**Year/Month/Day **] (for 9
months), Lisinopril, Toprol, and Lipitor. Her peak CK was 216
with a peak tnt=0.84 (were trending down at time of discharge).
Her fasting lipid profile was checked revealing a total
cholesterol of 246, TG of 152, LDL of 167, and HDL of 49. Liver
function tests were also checked and were within normal limits.
HbA1C was checked and was pending at time of discharge (glucose
was within normal limits on daily labs). She was also
encouraged to stop smoking upon discharged. She was discharged
to follow up with her Cardiologist. She will need cardiac
rehabilitation and further lifestyle modification.
2. Pump/CHF: TTE was checked after catheterization showing
EF=55% with mild LA enlargement, mild focal inferior
hypokinesis, and no valvular abnormalities. She had a small
amount of peripheral edema at time of discharge but was
auto-diuresing (negative by Ins/Outs recorded).
3. Rhythm: No arrhythmias were noted on telemetry.
4. Hypercholesterolemia: as above, fasting lipids were checked,
and she was started on 80 mg of lipitor (LFT's were within
normal limits). She will need monitoring of her liver function,
and she was advised of the possible side effect of
myalgias/myositis with this medication.
5. Tobacco abuse: she was directed to stop smoking at time of
discharge. She may need tobacco replacement (nicotine patch) to
facilitate this. This can be addressed with her PCP.
6. Disposition: She was discharged in good condition, and she
will follow up with her cardiologist, Dr. [**Last Name (STitle) 47242**]. She will
need Cardiac Rehabilitation as well as ongoing lifestyle
modification. She will need Liver function monitoring (given
initiation of Lipitor) and Creatinine checks (given initiation
of her lisinopril).
Medications on Admission:
Multivitamin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*8*
3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
5. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Cardiac Rehabilitation
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Acute Inferior-posterior MI
Secondary Diagnoses:
1. Hypercholesterolemia
2. Tobacco use
Discharge Condition:
Good
Discharge Instructions:
1. Please take all your medications exactly as described in
this discharge paperwork. We made the following changes to your
medication regimen:
- We added Toprol XL 50 mg daily, a medication to help with
your heart and blood pressure
- Lisinopril 2.5 mg daily, a medication to help with your
heart and blood pressure
- Lipitor 80 mg daily, a medication to help lower your
cholesterol. You must get your liver function tested regularly
while on this medication. In addition, you should let your
doctor know if you are experiencing muscle aches/pains while on
this medication.
- We added [**Last Name (STitle) **] 75 mg daily (to be taken for 9 months) and
Aspirin 325 mg (to be taken indefinitely). These medications
help to thin your blood and prevent clots from forming in your
new cardiac stents. You must take these every day, or you risk
death/recurrent hear attack.
2. Please follow up with your cardiologist as described below.
3. Please call your doctor if you are experiencing chest pain,
shortness of breath, fever, chills, dizziness, lightheadedness,
or with any other concerns.
Followup Instructions:
Please call your Cardiologist, Dr. [**Last Name (STitle) 47242**] ([**Telephone/Fax (1) 60485**]) to
schedule an appointment within 1-2 weeks of discharge. She will
need to monitor your Liver function tests while you are on
Lipitor. In addition, she may want to increase your doses of
Toprol and Lisinopril. Finally, your creatinine and potassium
should be checked while on this medication.
You need to stop smoking, and strategies for this can be
discussed with your primary cardiologist.
You will need to undergo cardiac rehabilitation, and this can be
arranged via your cardiologist as well.
Do not return to work until you follow up with Dr. [**Last Name (STitle) 47242**]
(likely not for at least 1 month). Avoid heavy lifting or
strenous exertion.
|
[
"41401",
"2720",
"3051"
] |
Admission Date: [**2164-9-15**] Discharge Date: [**2164-9-20**]
Date of Birth: [**2119-10-8**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
Ultrasound-guided cholecystostomy tube placement
History of Present Illness:
This is a 44 year-old male with multiple sclerosis who presented
to his PCP with [**Name Initial (PRE) **] [**1-9**] week history of dark urine and abdominal
pain. His liver function studies were found to be elevated and
he underwent an abdominal ultrasound which showed an inflamed
gallbladder. He was then sent to [**Hospital6 6640**] on
[**2164-9-15**] for further evaluation. Because he is followed by the
neurology service at [**Hospital1 18**] he was transferred here for
treatment.
Past Medical History:
Multiple Sclerosis
Hypertension
Depression
Social History:
Retired. No ETOH. No Tobacco.
Family History:
Non-contributory
Physical Exam:
Initial Physical Exam - Emergency Department- [**2164-9-15**]
100.8 106 112/74 26 93%RA
NAD
Head/Eyes:PERRLA
ENT/Neck: Supple
Chest: CTAB
Cardio: RRR
GI: tender RUQ, +[**Doctor Last Name **]
Pertinent Results:
Admission Labs:
[**2164-9-15**] 03:15PM BLOOD WBC-18.0*# RBC-4.52* Hgb-14.1 Hct-39.9*
MCV-88 MCH-31.3 MCHC-35.5* RDW-12.9 Plt Ct-300
[**2164-9-15**] 03:15PM BLOOD Neuts-85.9* Lymphs-9.1* Monos-4.4 Eos-0.4
Baso-0.2
[**2164-9-15**] 03:15PM BLOOD PT-14.0* PTT-26.1 INR(PT)-1.2*
[**2164-9-15**] 03:15PM BLOOD Glucose-97 UreaN-12 Creat-0.9 Na-140
K-4.0 Cl-102 HCO3-26 AnGap-16
[**2164-9-15**] 03:15PM BLOOD ALT-353* AST-65* AlkPhos-395* Amylase-32
TotBili-0.9
[**2164-9-15**] 03:15PM BLOOD Lipase-23
[**2164-9-16**] 02:36AM BLOOD Albumin-3.6 Calcium-9.0 Phos-3.7 Mg-1.8
[**2164-9-15**] 03:35PM BLOOD Lactate-1.0
Discharge Labs:
[**2164-9-19**] 05:18AM BLOOD WBC-7.8 RBC-4.03* Hgb-12.4* Hct-36.2*
MCV-90 MCH-30.7 MCHC-34.2 RDW-12.8 Plt Ct-420
[**2164-9-15**] 03:15PM BLOOD Neuts-85.9* Lymphs-9.1* Monos-4.4 Eos-0.4
Baso-0.2
[**2164-9-19**] 05:18AM BLOOD Plt Ct-420
[**2164-9-19**] 05:18AM BLOOD Glucose-107* UreaN-9 Creat-0.9 Na-141
K-4.0 Cl-101 HCO3-33* AnGap-11
[**2164-9-19**] 05:18AM BLOOD ALT-87* AST-19 AlkPhos-169* Amylase-28
TotBili-0.4
[**2164-9-19**] 05:18AM BLOOD Lipase-28
[**2164-9-19**] 05:18AM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.6 Mg-2.0
Procedure (Please see OP note for details):
US guided cholecytostomy
CLINICAL INDICATION: Acute cholecystitis, patient with severe
multiple sclerosis, unable to tolerate general anesthesia.
IMPRESSION: Uncomplicated ultrasound-guided cholecystostomy tube
placement.
Brief Hospital Course:
Mr. [**Known lastname 50416**] was evaluated in the emergency department at [**Hospital1 18**]
after transfer from [**Hospital3 8544**] on [**2164-9-15**]. His liver enzymes
were elevated, and his WBC count was 18. He was seen and
admitted by the surgery service under the care of Dr. [**Last Name (STitle) **]
for cholecystitis.
He was started on Levofloxacin and Flagyl; IV fluids were
initiated; and he was placed NPO. An abdominal ultrasound was
performed which was concerning for cholecystitis. There was no
evidence of common duct obstruction. His total bilirubin was
slightly decreased from 0.9 on admission to 0.8, suggesting a
passed stone. ERCP was postponed and it was decided that a
percutaneous cholecystostomy tube would be placed with interval
laparascopic cholecystectomy to minimize the surgical impact to
his multiple sclerosis.
On HD 2 an ultrasound guided cholecystostomy tube was placed
without problems. 30ml of purulent material was drained and sent
for culture. The gram stain was negative. Please see OP note for
details. On HD 3 he spiked a temperature of 102.8. His IV
antibiotics were changed to Zosyn. By HD 4 his WBC count and
liver enzymes were trending down. His bile fluid culture was
negative for growth. He was afebrile and his diet was advanced.
Neurology saw him and felt that his current therapy was
satisfactory and that he should continue his present medication
regimen with baclofen for spatiscity.
During hospitalization he was evaluated and treated by physical
therapy to increase strength and functional mobility. It was
recommended that he be discharged home with continued physical
therapy.
On [**2164-9-20**] he was discharged home in good condition. He was to
follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 8760**] in [**1-9**] weeks. He was
to receive VNA visits for drain care and home physical therapy.
Medications on Admission:
Neurontin 300 TID
Baclofen 20 TID + 40 qhs
Lisinopril 30 qd
Paxil 20 [**Hospital1 **]
Flomax 0.4 qd
Provigil 200 at 8am and 12
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Baclofen 10 mg Tablet Sig: Six (6) Tablet PO HS (at bedtime).
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
5. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
7. 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*
8. Provigil 200 mg Tablet Sig: One (1) Tablet PO twice a day:
give @ 0800 and 1200 .
9. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 10 days.
Disp:*90 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain or persistent pain that is not relieved by
pain
medications
* Inability to urinate
* Fever (>101 F)
* Persistent nausea or vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you
Please continue your previous medications.
Followup Instructions:
Please follow up in surgery clinic with Dr. [**Last Name (STitle) **] in [**1-9**]
weeks. Please call for an appointment. The number is ([**Telephone/Fax (1) 4336**].
Completed by:[**2164-9-20**]
|
[
"4019"
] |
Admission Date: [**2199-10-19**] Discharge Date: [**2199-10-21**]
Date of Birth: [**2199-10-19**] Sex: F
Service: NB
HISTORY: Baby Girl ([**Name2 (NI) **]) [**Known lastname 66444**] #1 is a former 34 [**2-18**]
week female triplet #1 admitted to the NICU because of
prematurity.
OBSTETRICIAN: Perinatologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
HISTORY: Mother is a 37-year-old G4, P0 now 3 white female.
Prenatal screens: O positive, antibody negative, hepatitis B
surface antigen negative, RPR nonreactive.
Past OB history is remarkable for 3 SABs. This pregnancy was
achieved with the assistance of IVF and was complicated by
maternal cholestasis, treated with Actigal, and abdominal
lymphedema. Both of these conditions were stable.
Mother was noted to have elevated blood pressures and
proteinuria on [**10-15**] and was admitted to the [**Hospital1 18**] for
bed rest and treatment with betamethasone.
Delivery was on [**10-19**] by cesarean section. It was
uncomplicated. This baby triplet #1, appeared vigorous at
birth. Apgars 8 at 1 minute, 9 at 5 minutes.
PHYSICAL EXAM ON ADMISSION: [**Month (only) **], AGA preterm female,
breathing comfortably in room air. Vital signs: Temperature
98.6, heart rate 156, respiratory rate 72, O2 saturation 92%
on room air, birth weight 2,360 grams which is 50-75th
percentile, length 44 cm, 25th-50th percentile, head
circumference 33.5 cm, 75th-90th percentile. Discharge weight
on [**10-21**]: 2,250 grams down 110 grams. HEENT: Head is
asymmetric, appears to be deformational from in utero
positioning with head tilted to the left with flattening of
the right parietal-occipital skull. Anterior fontanel is soft
and flat. Palate: Intact. Normal red reflexes. Respiratory:
Breath sounds clear and equal, no retractions. CV: S1, S2
normal intensity, no murmur. Abdomen: Soft with normal bowel
sounds, no organomegaly. GU: Normal female. Neuro: Tone good,
symmetrical exam except for described head tilt to the left.
Hips: Stable.
Admission D-stick 43. Baby fed with improvement.
REVIEW OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Infant has remained in room air. Baseline
respiratory rate 40s-70s. No apnea or bradycardia noted. No
issues.
Cardiovascular: No murmur. Baseline heart rate 130s-150s.
Blood pressures systolic 60s-70s, diastolic 29-45, means in
the 40s-60s. No issues.
Fluid, electrolytes, and nutrition: Baby initially had some
hypoglycemia. She was fed with improvement to greater than 60.
She has continued to have some D-sticks in the 40s to low 50s
which have improved to greater than 50 with feeding of PE 20
every 3 hours. Baby continues to feed every 3 hours. Today
feeds were increased to PE 24. She continues with stable
D-sticks greater than 60. Plan would be to assess her ability
to tolerate PE 24 and consider ad-lib feedings with a maximum
interval of 4 hours while following Dextrostix.
Baby is voiding and stooling and as stated above, discharge
weight 2,250 grams. Currently on a minimum intake of total
fluids of 80 ml per kilogram per day would consider increasing
per routine.
GI: Plan to check bilirubin on [**10-21**] with state screen.
Hematology: No blood type is available. Baby has not required
any transfusions during this admission. Has not required a
CBC to determine red blood cell count. Baby appears [**Name2 (NI) **] and
well perfused.
Infectious disease: No issues. Delivery was for maternal
indications.
Neurology: Baby is appropriate for gestational age. No
issues.
Sensory: Audiology screening has not been performed. Would
recommend test prior to discharge. Ophthalmology exam: Not
indicated as gestational age is greater than 32 weeks.
Psychosocial: Mom looks forward to the children transitioning
closer to home. Is quite pleased with the triplets. Parents
are doing well with the delivery of their new babies.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: [**Hospital3 **]. Undecided on
primary pediatrician. Has requested assistance in choosing
pediatrician locally.
CARE AND RECOMMENDATIONS: Continue PE 24 and/or breast milk.
Mom has begun pumping and will need assistance transitioning.
Plans to do some breast feeding and some bottle feeding.
MEDICATIONS: None at time of transfer.
STATE NEWBORN SCREEN: Initial screen sent on [**10-21**]
prior to discharge.
IMMUNIZATIONS RECEIVED: None at time of discharge. Would
recommend hepatitis B prior to discharge.
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following 3 criteria: 1. Born at less than 32 weeks; 2.
Born between 32 and 35 weeks with 2 of the following:
Daycare during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school-
age siblings; or 3. With chronic lung disease.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out-of-home
caregivers.
FOLLOW-UP APPOINTMENTS: With primary care pediatrician per
routine. Consider VNA referral.
DISCHARGE DIAGNOSIS LIST:
1. 34-3/7 weeks premature female
2. Triplet #1
3. Hypoglycemia, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2199-10-21**] 12:10:35
T: [**2199-10-21**] 12:36:02
Job#: [**Job Number 66445**]
|
[
"7742"
] |
Admission Date: [**2158-11-9**] Discharge Date: [**2158-11-9**]
Date of Birth: [**2089-2-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 8404**]
Chief Complaint:
CC:[**Last Name (NamePattern1) 41182**]
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
69yoM with h/o prostate ca s/p radiation and hormonal therapy
and radiation induced proctitis who presents with sudden onset
of 20 episodes of BRBPR/clots and watery stool starting around
530pm and occuring q 15-30 mins, for which he called EMS and was
brought to [**Hospital1 18**] ED. Denies melena.
Initial ED vitals: 96.9 67 86/55 16 100%. He had c/o
lightheadedness, but no SOB, CP, abd pain. DRE showed BRBPR on
the glove. Hct was stable at 31.0. Had an NG lavage which was
completely clear for coffee grounds, blood and was so negative
that the tube was removed for presumed LGIB, and not given IV
Protonix. GI was consulted and reportedly will see pt in the am
for ? scope. He had no further bleeding episodes in the ED and
his systolics were 89 to 107 in the ED without any reflex
tachycardia. 2 18g PIV's were placed. He was given 3L NS, now
getting 4th.
Vitals before transfer: 59 98/56 13 98% 2L NC
Review of OMR notes shows normal systolics run in the 120's and
Hct had a noticeable drop from 40 in [**2-/2158**] to mid-high 20's in
[**8-/2158**], which was associated with symptoms), for which he was
evaluated by his PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 679**]. He was offered admission for
blood transfusions but the pt refused and started TID ferrous
sulfate.
He was then seen in the ED early [**9-/2158**] for chest pain,
SOB/DOE, chronic rectal bleeding with admission for transfusions
(4u with Hct increase from 23.7 --> 33.8) with symptomatic
improvement. Due to CP, he was stressed which was positive for L
elbow/subscapular pain, 0.5mm inferolateral depressions on the
treadmill, and reversible inferobasilar perfusion defect with
enlarged left ventricle and transient ischemic dilation (LVEF
46%) on nuclear. Per Dr.[**Name (NI) 16937**] notes, it appears pt had a
stress test 2 yrs ago which showed "previous inferior MI." Plan
was apparently medical management, and pt was only symptomatic
with the anemia. He is on a beta blocker, statin, baby ASA.
ROS: Pt currently endorsing lower back pain from straining while
working in his warehouse, and feeling the need to defecate, but
otherwise feels well and ROS is completely negative otherwise.
Past Medical History:
- depression
- hypertension
- hypercholesterolemia
- prostate cancer s/p radiation treatment (completed [**9-/2156**])
and hormone shots (last [**12/2156**] per OMR notes)
- diarrhea and abdominal pain responsive to pancreatic extracts
- rectal bleeding with colonoscopy [**4-3**] showing radiation
proctitis; acute anemia in [**8-/2158**] with repeat colonoscopy again
showing radiation proctitis s/p Argon therapy of proctitis
[**2158-10-27**]
- Stress test/echo [**2156-3-29**] resting inferior wall abnormality c/w
old
MI. Exercise induced ischemia in distal LAD distribution.
- Nuclear perfusion [**9-/2158**] depressions on
treadmill and reversible inferobasilar perfusion defect on
nuclear
Social History:
Lives at home with his wife and has 2 sons, 2 daughters. [**Name (NI) **]
working in a warehouse that he runs and apparently is still
doing very physical labor with a lot of lifting. Is easily
ambulatory and able to do his ADL's. No cigarettes ever, drinks
2-3 bottles of wine per week, no drugs/herbal medications
Family History:
Father - deceased from AMI and had tuberculosis
Mother - deceased from AMI
Brother - emphysema
Sister - DM
Sister - deceased recently from "many medical problems"
Physical Exam:
96 67 115/61 13 100% 2L NC
Well appearing gentleman in no distress, doesn't look ill, clear
historian. Appears euvolemic to mildly hypovolemic.
EOMI, no scleral icterus
No JVD
CTAB no w/c/r/r
RRR with clear S1 and S2, no murmurs or gallops. Radial pulses
are easily palpable
Abd obese NT ND, BS+, benign
Extrems are without edema, 2 well placed 18 g PIV in bilateral
AC's, warm and well perfused, no palmar cyanosis and good cap
refill
CN2-12 intact, no focal neuro deficits noted, moving all
extremities, mental status lucid and conversant
Pertinent Results:
139 104 46
-------------- 184
4.3 26 1.6
WBC 8.6 N75 L15.6 E4.2 o/w normal
Hct 31 MCV 82
Plts 311
Coags 14.3 / 31.7 / 1.2
UA pending
Imaging:
[**2158-10-27**] Coloscopy and EGD showing diffuse increase in
vascularity in distal rectum from 2 cm above dentate line to 10
cm, consistent with the appearance of radiation induced
proctitis. An Argon-Plasma Coagulator was applied for hemostasis
successfully. Grade 1 internal hemorrhoids. Otherwise normal
colonoscopy to cecum. Congestion and erythema in the antrum
compatible with gastritis (biopsy within normal limits).
Otherwise normal EGD to third part of the duodenum
EKG: NSR 64bpm, normal axis and intervals, prominent inferior
Q's and suggestive Q's in V5-6 which correlate to known recent
stress results. No acute ischemic appearing changes.
Brief Hospital Course:
69yoM with h/o radiation proctitis who presents with BRBPR from
likely lower GI source, hypotension resolved with IVF's and ARF
also resolved with IVF's.
1. Lower GI bleed: With BRBPR seen on digital rectal exam,
negative NGL in ED, increased vascularity of distal rectum
consistent with known radiation proctitis (also seen in [**3-/2158**]
colonoscopy) and also grade 1 internal hemorrhoids seen on
colonoscopy 2 wks ago, most likely source is lower GI
tract/rectum. Likely exacerbated by straining while working at
his warehouse to the point of hurting his lower back, and thus
raising intra-abdominal pressure and rupturing his superficial
rectal vasculature.
Hct initially dropped from 31 on admission which was stable from
prior to 24, but in the setting of having received ~4L NS. Hct
was transfused one unit of packed red blood cells and the
hematocrit bumped appropriately to 25 at time of discharge.
GI was consulted and felt that the bleeding was likely due to
scar tissue breaking off from the rectum after the recent
argon-plasma beam coagulation treatment for the radiation
proctitis. They did not feel that repeat endoscopy was
necessary.
2. Hypotension: Was not tachycardic and no evidence of end organ
ischemia other than Cr 1.6 from normal baseline, which responded
to IVF's back to normal. Hypotension also resolved quickly with
IVF resuscitation. Home beta blocker and ACEi held but were held
initially but can be restarted after discharge.
3. Acute renal failure: With Cr 1.6 up from baseline Cr 1.1.
Suspect pre-renal etiology in face of volume loss and elevated
BUN/Cr (however BUN may be elevated due to GIB). Responded well
to IVF's and back to baseline by discharge.
FEN: NPO initially. Diet was advanced on the first hospital day
without complication.
Access: 18g PIV's x2
PPx: Pneumoboots.
Comm: With patient and wife.
[**Name (NI) 7092**]: Full, confirmed with patient.
Medications on Admission:
reconciled with pt
Simvastatin 80 mg daily
Coreg 6.25 mg twice daily
aspirin 81 mg daily
B12 1000 mg daily
fish oil
Lipase-protease-amylase (pancrelipase 5000) 5000-[**Numeric Identifier 6085**]-[**Numeric Identifier **]
unit capsules --> pt takes [**11-28**] as needed for diarrhea
ocuvite
Celexa 40 mg daily
ambien 10 mg prn
Vitamin D 3000 units
Tamsulosin 0.4 mg daily
Iron 325 mg twice daily
Lisinopril unclear dosage, pt is unsure
Discharge Medications:
1. simvastatin Oral
2. Coreg 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
4. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO three times a day as needed for diarrhea.
7. Ocuvite Oral
8. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed
for insomnia.
10. Vitamin D Oral
11. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
12. iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once
a day.
13. lisinopril Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Radiation proctitis
Secondary Diagnoses:
Depression
Hypertension
Hypercholesterolemia
Prostate cancer s/p radiation treatment and hormonal therapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for bleeding from the
gastrointestinal tract. The bleeding was felt to be secondary to
recent argon-plasma coagulation and scar tissue that developed
around the sites of this therapy. You received one transfusion
of red blood cells. Throughout the admission your heart rate and
blood pressure were stable. You were seen by the
gastroenterologists who felt that you were stable to be
discharged to home.
There were no changes to your medicines during this admission.
Followup Instructions:
None.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 8405**]
Completed by:[**2158-11-9**]
|
[
"5849",
"4019",
"2720",
"311"
] |
Admission Date: [**2200-7-11**] Discharge Date: [**2200-8-5**]
Date of Birth: [**2121-5-6**] Sex: M
Service: MEDICINE
Allergies:
Azulfidine / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 663**]
Chief Complaint:
? stroke
Major Surgical or Invasive Procedure:
Right Internal Carotid Artery Stent
History of Present Illness:
Mr. [**Known lastname 4223**] is well known to the stroke service from a
prior consult on [**7-12**]. Please see Dr.[**Name (NI) 26235**] note for
full
details on his PMH.
Briefly, he 79 year-old right-handed man with multiple medical
problems including paroxysmal a fib not on Coumadin and a prior
right CEA. He initially presented last week with complaints of
transient R arm weakness and aphasia as well as possible
amaurosis in the left
eye 2 days prior. His exam at the time was remarkable for a
peripheral neuropathy and a R upgoing toe. He was imaged and
found to have complete occlusion of the L ICA at the
bifurcation
as well as R ICA stenosis in the cavernous portion. Dr. [**Last Name (STitle) **],
the stroke attending who initially evaluated him, felt that he
was using both Opthalmic collaterals for perfusion and that the
left MCA might be supplied also by the right ACom. Additionally,
the L PCA was not well visualized and felt to be perhaps of
fetal
origin. Given his bilateral vasculopathies, they recommended a
CTA and CTP.
These images where obtained and the CTA showed complete
occlusion
of the left internal carotid artery with persistent patency of
the circle of [**Location (un) 431**]. His CTP showed a "large area of ischemia
involving the left MCA and left PCA vascular territories.
Symmetric cerebral blood volume is evidence that ischemia is not
irreversible." Neurosurgery was consulted and he was taken for
conventional diagnostic angiogram followed by repeat angiography
yesterday during which the R ICA was stented. In the interim, he
was treated with heparin GGT which was discontinued on [**7-22**] at
21:25. He has also been on Aspirin 325, Plavix, and Lipitor
40mg.
He is also being treated for a UTI with Cipro.
In regards to his other stroke risk factors, he is currently off
anticoagulation. His last A1c was 5.7 in [**2196**] at which time his
LDL was 96, the TG were 159 and his HDL was 60. His last TTE was
a stress echo in [**Month (only) 116**] of this year which showed an LVEF 50% and
"mild inferolateral hypokinesis with preservation of systolic
function of other segments."
This afternoon he was seen in PACU around 7pm without deficits
and treated with analgesics (percocet) per report. He was then
transferred to the SICU and was evaluated by the RN at 9:20pm.
She noted no deficits, however the SICU resident re-assessed him
at 9:30 and noted impaired productive language. Neurology was
consulted at 10pm.
Of note, his blood pressure had required a nicardipine drip
after
the angiogram. After his symptoms had started, his SBP drooped
to
the 110s and the drip was stopped. Per report, he has not had
afib during the procedure or afterwards.
On exam, he is awake, alert and attentive, he has limited
productive speech saying "I can't" and "I don't know". His
longest phrase was "I want to call my mother". He was able to
answer Y/N questions reliably but was unable to name, read,
write
or repeat. The remainder of his exam was remarkable for a RUQ
visual field deficit, subtle R facial droop and drift. His lower
extremity strength exam was limited due to pain on the L and the
R side in a cast, however both extremities were antigravity. His
NIH SS was 6 (2 for LOC; 1 for visual field deficit; 1 for
facial
palsy; 1 for aphasia; 1 for dysarthria).
As he had received a large bolus of contrast from his prior
angiogram, a CTA was felt to be a poor choice especially given
his history of renal insufficiency. He was therefore referred
for
stat MRI.
ROS: deferred given aphasia
Past Medical History:
-Prostate Cancer diagnosed [**2185**], treated with XRT
-Colorectal cancer, diagnosed [**2198**], had been planned for a
follow-up colonoscopy next week. He has not had a recurrence of
the colon cancer
-IDDM
-HTN
-Paroxysmal A Fib, not on Coumadin but on ASA 81 qod, apparently
because it was diagnosed very recently and an ablation was being
considered.
-Hyperlipidemia
-PVD
-GERD
-Gout
-prostate Ca
-CRI
-back surgery > 10 yrs ago
Social History:
Quit smoking 40 years ago. Rare EtOH. Formerly worked
for the federal government as the Director of Refugee
Resettlement.
Lives with wife in [**Name (NI) 620**]. Four children (3 live locally) and 3
grandchildren.
Family History:
Mother died at age 84 from Leukemia; father died in an
industrial accident at a young age.
Physical Exam:
Vitals: T: 98.6 P: 88 R: 16 BP: 132/76 SaO2: 96% 2L NC
General: Awake, cooperative, NAD.
Pulmonary: Lungs CTA bilaterally
Cardiac: nl S1S2
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: R leg in brace, L leg painful to movement and with
erythema and edema of the knee
Neurologic:
-Mental Status: as described above, awake, alert, mild
dysarthria
with intermittent preserved phrases, unable to name, read, write
or repeat. no able to say name, place, date or age. There was no
evidence of apraxia or neglect.
CN
I: not tested
II,III: RUQ visual field cut; pupils 2mm->1mm bilaterally
III,IV,V: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead
wrinkling
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**6-9**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone; mild R pronator drift; no
asterixis or myoclonus.
Delt [**Hospital1 **] Tri WE FE Grip
C5 C6 C7 C6 C7 C8/T1
L 5 5 5 5 5- 5
R 5 5 5 5 5- 5
Unable to formally test LE, but both legs are antigravity and
ankle extensors and flexors are full bilaterally
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0 tr 0 0 0 mute
R 0 tr 0 0 0 up
-Sensory: No deficits to light touch and no extinction to DSS.
-Coordination: No intention tremor. No dysmetria on FNF but
perseverates on task, pulling my fingers to his nose on the L.
Unable to perform HKS bilaterally due to brace on R and pain on
L.
-Gait: deferred
Pertinent Results:
139 101 27
-------------/ 153 AGap=15
3.5 27 1.8 \
Ca: 7.8 Mg: 1.9 P: 3.2
8.8 \10.0 / 306
29.6
PT: 16.0 PTT: 150 INR: 1.4
UA:
Leuk Lg Bld Lg Nitr Neg Prot Tr Glu Neg Ket Neg
RBC 415 WBC 12 Bact None Yeast None Epi 1
Radiologic Data:
CT/CTA head, CTA neck [**2200-7-12**]
IMPRESSION:
1. Assessment for acute infarction is somewhat limited without
CT perfusion,
although no evidence of acute infarction on the available
images.
2. CT angiogram is somewhat limited by technical delay in
creation of 3D
reconstructions which are not available currently for review.
Evaluation
of the source axial and coronal and sagittal reformatted images
shows complete occlusion of the left internal carotid artery.
Despite this, the circle of [**Location (un) 431**] opacifies well and is patent.
3. Mucocele of the right ethmoid sinus.
CT perfusion [**2200-7-14**]:
IMPRESSION: Large area of ischemia involving the left MCA and
left PCA
vascular territories. Symmetric cerebral blood volume is
evidence that
ischemia is not irreversible.
Stenting of right internal carotid artery [**2200-7-22**]:
FINDINGS: Right internal carotid artery arteriogram demonstrates
a 90%
stenosis of the lacaro segment of the internal carotid artery.
Post-angioplasty post-stent, right internal carotid artery
arteriogram
demonstrates a 50% residual stenosis of the right internal
carotid artery at the lacaro segment. The patient was extubated
and found to be neurologically unchanged.
Transthoracic ECHO [**2200-7-23**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded.
Overall left ventricular systolic function is normal (LVEF>55%).
There is no ventricular septal defect. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2200-6-24**],
the LVEF appears normal.
MRI/MRA [**2200-7-23**]:
IMPRESSION:
1. Complete occlusion of the left ICA.
2. Atherosclerotic tight narrowing of the right ICA in the
cavernous portion.
3. Likely subacute foci of ischemia in the distribution of the
left MCA and
right ECA, which is most likely related to thromboembolic
disease.
4. Prominence of the ventricles and sulci due to age-related
parenchymal
atrophy.
Left knee plain film [**2200-7-21**]
There is no fracture or dislocation. The soft tissues
demonstrate mild soft swelling around the medial knee, without
evidence of radiopaque foreign body. Incidental note is made of
spurring along the anterior surface of the patella. Asside from
minimal spurring, no other evidence of degenerative change is
identified. No gross effusion is identified. Calcifications are
noted within the vascular system. IMPRESSION:
No fracture, dislocation, effusion, or gross degenerative
change. If symptoms persist, consider further evaluation with
MRI.
LEFT LOWER EXTREMITY ULTRASOUND [**2200-7-26**]:
IMPRESSION: No evidence of left lower extremity deep vein
thrombosis.
Chest X-rays:
[**2200-7-11**]:
FINDINGS: Compared to the prior study, there has been no
significant interval change in the cardiac and mediastinal
silhouette. There is some patchy areas of volume loss in the
left base, and an early infiltrate cannot be totally excluded.
Otherwise, the lungs are clear.
[**2200-7-15**]:
FINDINGS: A bedside frontal chest radiograph is compared to [**7-11**], [**2200**].
There is a vague opacity in the left retrocardiac region that is
relatively unchanged from [**2200-7-11**], but new from [**2199-2-11**]. The right lung is clear. The cardiac and mediastinal
contours are notable for a tortuous aorta. The pulmonary
vasculature is normal.
IMPRESSION: Left lower lobe opacity, likely pneumonia given
history,
atelectasis also possible.
[**2200-7-26**]:
Cardiac silhouette is mildly enlarged, and pulmonary vascularity
appears
engorged, accompanied by vascular indistinctness, peribronchial
cuffing, and bilateral interstitial opacities. These findings
favor interstitial pulmonary edema and are less likely due to an
atypical pneumonia. Additionally, hazy increased opacity has
developed along the periphery of the left mid and lower lung,
likely due to a partially loculated pleural effusion. Bibasilar
retrocardiac opacities may be due to a combination of
atelectasis and effusion, but underlying infection is not
excluded. Further evaluation with followup radiographs after
diuresis may be helpful.
[**2200-7-27**]:
Interstitial opacities, presumably representing pulmonary edema
have improved. Bibasilar opacities, left greater than right,
appear unchanged, as well as an apparent moderate loculated left
pleural effusion. PA and lateral chest radiographs may be
helpful to confirm and characterize the suspected loculated left
pleural effusion.
EKGs:
[**2200-7-11**]:
Sinus bradycardia. Possible left atrial abnormality. Poor R wave
progression. Compared to the previous tracing of [**2200-6-16**] atrial
flutter is absent.
[**2200-7-15**]:
Sinus rhythm. Slight non-specific ST segment sagging. Compared
to the
previous tracing of [**2200-7-11**] ST segment sagging is new.
Bradycardia is absent.
Brief Hospital Course:
Stroke/neurologic issues - the patient presented [**7-11**] with
transient R weakness and aphasia. CTP showed a large area of
increased MTT on the left as well as some decrease in CBV
especially in the striatocapsular region, indicating the
presence of a large area of hypoperfused but viable cortex.
Vascular imaging revealed a complete occlusion of L-ICA,
significant tandem stenosis of R-ICA including siphon, and
possible L-PCA stenosis. Based on these results, he underwent a
PCI on the R ICA on [**7-22**] and developed a post-op stroke with
bilateral multiple small infarcts as shown on DWI MRI. He was
placed on pressors to prevent hypoperfusion and a heparin drip
with change to coumadin. TTE was done r/o embolic origin. INR
has overshot goal and has been held. The patient has apashia and
weakness on the right side as a result of the stroke. In
addition, the patient will continue plavix antiplatlet tx as
required by stent.
.
A flutter- Patient developed persistent atrial flutter in house.
TTE was done which showed no embolus. EP/cardio consult obtained
and recommended continuing rate control with anticoagulation
with outpatient follow up for further evaluation.
Patient was well controlled on dual nodal therapy, this may need
to be adjusted as his systemic inflammation improves.
At time of discharge, INR was therpeutic on 1mg of Coumadin.
Patient will need close monitoring of INR with adjustments per
rehab physician [**Name Initial (PRE) 26236**].
.
Pulmonary edema- was treated with lasix, the patient was placed
on NC, sats <95% on RA, patitent developed [**Last Name (LF) **], [**First Name3 (LF) **] lasix d/c'ed.
No longer an active issue despite overall body water retention.
.
Acute Kidney Injury- as a result of poor perfusion and lasix
administration. Lasix d/c'ed and UA's have been monitored and
BUN/Cr.
.
# Diarrhhea- suspected c dif, being treated with 14d course of
MetRONIDAZOLE (FLagyl) 500 mg PO TID and placed on contact
precautions. At time of discharge, patient had improved
significantly.
.
# Chronic well-controlled DM Type 2- monitor FS, RISS
.
#. Cellulitis- resolved as per daily physical exam, vancomycin,
completed 7d course on [**8-2**].
.
#. CODE: Confirmed DNR/DNI status, Dr. [**First Name (STitle) **], and discussed
with the family on [**7-30**].
Medications on Admission:
Medications: (Per Prior OMR records)
- Insulin SC Sliding Scale
- Acetaminophen 325-650 mg PO Q6H:PRN
- Levothyroxine Sodium 100 mcg PO DAILY
- Acetylcysteine 20% 1200 mg PO BID
- Morphine Sulfate 1-5 mg IV PRN PAIN Q5MIN (PACU Only)
- Aspirin 325 mg PO DAILY
- NiCARdipine 1-3 mcg/kg/min IV DRIP INFUSION
- Atorvastatin 40 mg PO DAILY
- Ondansetron 4 mg IV Q8H:PRN
- Ciprofloxacin HCl 500 mg PO Q12H
- Oxycodone-Acetaminophen 1 TAB PO Q6H:PRN
- Clopidogrel 75 mg PO DAILY
- Promethazine HCl 6.25-12.5 mg IV MRX1:PRN (PACU Only)
- Colchicine 0.6 mg PO DAILY
- Prochlorperazine 2.5-5 mg IV MRX1:PRN nausea/vomiting (PACU
Only)
- Docusate Sodium 100 mg PO BID:PRN
- Ranitidine 150 mg PO BID
- Furosemide 120 mg PO DAILY
- Senna 1 TAB PO BID:PRN
- Dilaudid 0.2-0.6 mg IV Q5MIN:PRN PAIN
- Haloperidol 0.25-0.5 mg IV MRX1:PRN nausea/vomiting (PACU
Only)
- HydrALAzine 10 mg IV Q6H:PRN SBP > 170
Allergies: (Per Prior OMR records)
-Azulfidine / Sulfa (Sulfonamides)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed. Tablet(s)
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
8. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
14. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for cdif for 10 days.
16. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for anxiety.
18. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO Q
8H (Every 8 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Right Internal Carotid Artery Stenosis
Discharge Condition:
Neurologically Stable, Tolerating a regular diet, Pain
controlled on oral pain medications
Discharge Instructions:
You were admitted to the hospital because you had blockages of
the main arteries that supply your brain. You underwent a
procedure to help open these vessels, and your hospitalization
was complicated by a stroke. You have been closely monitored and
you have improved significantly. You will need to continue
getting stronger and will require rehabilitation.
Discharge Instructions:
-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
-Continue taking ASPIRIN & PLAVIX that you were started on in
the hospital postoperatively
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 DOES STOP, call our office.
- If bleeding DOES NOT STOP, call 911 for transfer to closest
Emergency Room
Followup Instructions:
Follow-Up Appointments
-Please call ([**Telephone/Fax (1) 88**] 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 for this
appointment.
Follow-up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] in 1
week
OTHER APPOINTMENTS:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2200-7-28**] 4:30
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2200-8-13**] 10:20
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 6197**]
Date/Time:[**2200-9-18**] 11:40
Completed by:[**2200-8-21**]
|
[
"9971",
"5990",
"42731",
"25000",
"4019"
] |
Admission Date: [**2121-12-5**] Discharge Date: [**2121-12-9**]
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is an 86 year old
male with a history of coronary artery disease, status post
myocardial infarction times two, remote percutaneous
transluminal coronary angioplasty on medical regimen, who
presented to the hospital with chest pain and shortness of
breath which was progressively worsened over the past two
months.
The patient describes increasing dyspnea on exertion but
denied any orthopnea or paroxysmal nocturnal dyspnea. An
electrocardiogram at the outside hospital demonstrated atrial
fibrillation with a ventricular rate in the 100s which was a
new rhythm for this patient.
The patient was admitted for congestive heart failure
exacerbation and new atrial fibrillation. Catheterization at
the outside hospital demonstrated 75% left main disease with
diffuse three vessel disease including diffuse left anterior
descending, nonsignificant circumflex, 70% medial, ejection
fraction 20%, 3+ mitral regurgitation, wedge increased at 29,
cardiac output 3.5. The patient was then transferred to [**Hospital1 1444**] for further catheterization
intervention.
Catheterization results at [**Hospital1 188**] demonstrated 75% left main disease with diffuse three
vessel disease. The right coronary artery was 80% occluded
with a stent placed to the proximal right coronary artery
with percutaneous transluminal coronary angioplasty and
Rotablator distally. There was a 50% residual.
The patient experienced hypotension episode with percutaneous
transluminal coronary angioplasty requiring transient
Dopamine which was further complicated by prolonged bleeding
of the left groin site. The patient received a total of 320
ccs of nonionic dye.
The patient was admitted to the CCU for observation and
medical therapy for significant left main disease and severe
systolic left ventricular dysfunction.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction times two with remote percutaneous transluminal
coronary angioplasty on medical regimen.
2. Congestive heart failure with an ejection fraction of 15
to 20%.
3. Hypertension.
4. Arthritis.
5. Benign prostatic hypertrophy.
6. Urticaria.
7. History of urinary tract infection.
8. Herniorrhaphy.
9. Status post laminectomy.
ALLERGIES: Erythromycin, Penicillin.
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg p.o. q.d.
2. Lipitor 5 mg p.o. q.d.
3. Imdur 30 mg p.o. q.d.
4. Atenolol 50 mg p.o. q.d.
5. Prilosec 20 mg p.o. q.d.
6. Altace.
7. DDAVP.
8. Aspirin 325 mg p.o. q.d.
9. Vioxx 25 mg p.o. q.d.
10. Benadryl 25 mg p.o. q6hours p.r.n.
SOCIAL HISTORY: The patient has a remote tobacco history but
quit in [**2082**].
PHYSICAL EXAMINATION: Heart rate 84, blood pressure 136/64,
respiratory rate 18, oxygen saturation 99% on four liters
nasal cannula. In general, the patient is comfortable in no
acute distress. Head, eyes, ears, nose and throat
examination - The oropharynx is clear. Extraocular movements
are intact. The neck is supple, brisk carotid upstroke, no
jugular venous pressure could be visualized. Cardiovascular
- normal S1 and S2, no S3 or S4, soft systolic murmur at the
left upper sternal border. Lungs -good aeration anteriorly.
Abdomen - positive bowel sounds, soft, nontender,
nondistended. Extremities - no edema, 1+ dorsalis pedis and
posterior tibial bilateral lower extremities. Groin - no
bruit on auscultation, femoral line placed on the left.
LABORATORY DATA: At outside hospital, white blood cell count
6.5, hematocrit 34.8, platelets 226,000. Sodium 135,
potassium 4.9, chloride 98, bicarbonate 27, blood urea
nitrogen 25, creatinine 1.2. Calcium 8.7.
At [**Hospital1 69**], white blood cell
count 10.7, hematocrit 29.2, platelets 190,000. Prothrombin
time 14.3, partial thromboplastin time 60.0, INR 1.4. Sodium
133, potassium 4.4, chloride 101, bicarbonate 23, blood urea
nitrogen 18, creatinine 1.1, glucose 187, ALT 13, AST 11, CK
33, alkaline phosphatase 79, total bilirubin 0.9, albumin
3.7, calcium 8.1, magnesium 1.7, phosphorus 3.0.
Postcatheterization electrocardiogram revealed frequent
premature ventricular contractions, question of normal sinus
rhythm, normal axis, minimal ST depressions laterally with T
wave inversions in aVL.
HOSPITAL COURSE: The patient is an 86 year old white male
with a history of coronary artery disease, status post
catheterization with 75% left main and three vessel disease,
increased wedge at 29, ejection fraction 20%, cardiac output
of 35, transferred to [**Hospital1 69**]
for intervention to right coronary artery.
1. Cardiovascular - The patient had his right coronary
artery stented with distal right coronary artery with
rotablation with a 50% residual. A decision was made for
further medical management of the patient's diffuse coronary
artery disease. He was continued on Aspirin, Lipitor and
Pravachol and was started on Plavix.
Chest x-ray demonstrated evidence of left sided failure
although the patient felt comfortable as this was most likely
secondary to compensated chronic heart failure. The patient
was continued on Metoprolol and his Captopril was increased
to 25 mg t.i.d. The patient was diuresed approximately two
liters over the first hospital day with significant increase
in his oxygen saturation and comfort level.
Over the next few hospital days, further gentle diuresis
resulted in decrease of the patient's jugular venous
distention and pulmonary edema until the patient was titrated
back down to his usual daily dose of Lasix.
The patient was noted to remain in atrial fibrillation over
the course of the hospital stay. Therefore, he was started
on a Heparin drip and Coumadin once his femoral bleeding site
had coagulated appropriately. The plan at this point is to
anticoagulate the patient over the next few weeks and
readdress the issue of cardioversion as an outpatient.
The patient remained hemodynamically stable over the course
of the hospital stay and was transferred to the floor without
complications. He ruled out for myocardial infarction with
negative CKs. The patient is to follow-up with his primary
care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2912**], for further management of his
atrial fibrillation.
2. Pulmonary - The patient had significant crackles on
pulmonary examination and chest x-ray evidence of heart
failure at the time of admission. The patient was diuresed
over the course of the hospital with significant improvement
in his symptoms and decreased oxygen needs. The patient's
Lasix was titrated back down to his usual daily dose of 40 mg
p.o. q.d.
3. Renal - The patient had a mildly elevated blood urea
nitrogen and creatinine at the time of admission of 25 and
1.2. He demonstrated excellent urine output over the course
of the hospital stay and his creatinine remained stable at
1.0. The patient had no further renal issues.
4. Hematology - The patient had an initial groin bleed on
his left side secondary to catheterization. This eventually
halted with significant pressure applied to the site for long
periods of time. The patient did experience a decrease in
his hematocrit and was therefore transfused one unit of
packed red blood cells in order to maintain his hematocrit
over 30.0.
Once adequate coagulation had been obtained at the site, the
patient was started on Heparin drip and was started on
Coumadin therapy for appropriate anticoagulation given his
new diagnosis of atrial fibrillation.
The plan is to anticoagulate the patient with an INR of 2.0
to 3.0 for the next few weeks and then consideration of
cardioversion. The patient left femoral site remained
without bruit and with good peripheral pulses and his
ecchymosis began to resolve over the course of his hospital
stay.
5. Prophylaxis - The patient was maintained on Protonix and
Heparin drip as prophylaxis during the hospital stay.
CONDITION ON DISCHARGE: The patient was discharged to
rehabilitation in stable condition.
MEDICATIONS ON DISCHARGE:
1. Aspirin 325 mg p.o. q.d.
2. Plavix 75 mg p.o. q.d. times thirty days.
3. Protonix 40 mg p.o. q.d.
4. Lipitor 5 mg p.o. q.d.
5. Lasix 40 mg p.o. q.d.
6. Zestril 10 mg p.o. q.d.
7. Tylenol 650 mg p.o. q6hours p.r.n.
8. Metoprolol 50 mg p.o. b.i.d.
9. Coumadin 5 mg p.o. q.h.s. (with INR checks daily over the
next few days).
10. Heparin drip at 1150 units per hour (with partial
thromboplastin time checks q6hours over the next few hours,
to be discontinued when therapeutic INR of 2.0 to 3.0 is
obtained).
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post myocardial infarction.
3. Congestive heart failure with an ejection fraction of
15%.
4. Hypertension.
5. Arthritis.
6. Benign prostatic hypertrophy.
7. History of urinary tract infection.
8. Herniorrhaphy.
9. New atrial fibrillation.
[**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) 2052**], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2121-12-8**] 13:43
T: [**2121-12-8**] 13:51
JOB#: [**Job Number 31519**]
|
[
"41401",
"4280",
"42731",
"4240",
"412"
] |
Admission Date: [**2158-8-28**] Discharge Date: [**2158-9-1**]
Date of Birth: [**2098-7-29**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides) / Mold/Yeast/Dust
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Presyncope
Major Surgical or Invasive Procedure:
[**2158-8-28**] Aortic Valve Replacement(21mm [**Doctor Last Name **] Pericardial Valve)
and Two Vessel Coronary Artery Bypass Grafting utilizing vein
graft to obtuse marginal and vein graft to right coronary
artery.
History of Present Illness:
This is a 60 year old female with known aortic stenosis. She
presented with presyncope in [**2158-5-28**]. Echocardiogram at that
time showed progression of her aortic valve disease - [**Location (un) 109**] of 0.5
cm2, mean 82mmHg, mild AI. She subsequently underwent cardiac
catheterization which showed a right dominant coronary system
with two vessel coronary artery disease - 50% lesion in the RCA,
70% lesion in the obtuse marginal. Based upon the above results,
she was referred for cardiac surgical intervention.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
Hypertension
Hypercholesterolemia
Type II Diabetes Mellitus
Carotid Disease
Morbid Obesity
B12 Anemia
Diabetic Retinopathy
Asthma
Nephrolithiasis - ?Lithotripsy in past
Cataracts
Gastric Bypass [**2153**]
Cesarean Section [**2130**]
Social History:
The patient is an ex-smoker, quit approximately 30 years ago;
smoked 1ppd before that. She denies any significant alcohol use.
No illicit drug abuse. She lives with her husband and her 27 yo
son. [**Name (NI) **] a daughter in [**Name (NI) 108**].
Family History:
Strong family history of DM. Mother also had stroke in her 60's.
Uncle died at 35 from blood clot and MI. Sister had breast ca.
Grandmother had angina in her 80's.
Physical Exam:
Vitals: 120-140/57-60, 60-70, 14, 100% RA
General: Obese female in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD, transmitted murmurs noted
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, harsh systolic murmur radiating
to carotid region
Abdomen: Soft, nontender with normoactive bowel sounds, obese
Ext: Warm, tr edema. Superficial varicosities noted
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**8-28**] Echo: PREBYPASS: Due to patient's previous history of
gastric bypass TEE probe inserted into esophagous only. No
gastric views obtained.-limited study. No atrial septal defect
is seen by 2D or color Doppler. There is symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets are
moderately thickened. There is moderate to severe aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. MV leaflet opening is limited but
not stenotic (MVA~2.4cm2) There is moderate thickening of the
mitral valve chordae. Mild (1+) mitral regurgitation is seen.
POSTBYPASS: Preserved biventricular systolic function. There is
a well seated well functioning bioprosthesis in the aortic
position. No AI is visualized in the esophageal views but AI
cannot be ruled out secojndary to shadowing of the valve ring.
Study is otherwise unchanged from prebypass exam.
[**8-31**] CXR: PA and lateral upright chest radiographs compared to
[**2158-8-29**]. The heart size is moderately enlarged but
stable. The sternal sutures are intact. Aortic valve is in a
standard location. The bilateral pleural effusions and bibasal
atelectasis are unchanged. No pneumothorax is demonstrated.
[**2158-8-28**] 12:07PM BLOOD WBC-11.6*# RBC-2.86*# Hgb-8.0* Hct-23.5*#
MCV-82 MCH-27.9 MCHC-34.0 RDW-14.6 Plt Ct-141*
[**2158-9-1**] 06:30AM BLOOD WBC-10.1 RBC-2.80* Hgb-7.8* Hct-23.4*
MCV-84 MCH-28.0 MCHC-33.5 RDW-15.5 Plt Ct-160
[**2158-8-28**] 12:07PM BLOOD PT-14.1* PTT-45.3* INR(PT)-1.2*
[**2158-8-28**] 01:20PM BLOOD UreaN-33* Creat-0.8 Cl-115* HCO3-22
[**2158-9-1**] 06:30AM BLOOD Glucose-119* UreaN-49* Creat-1.1 Na-139
K-4.6 Cl-103 HCO3-28 AnGap-13
[**2158-8-30**] 06:00AM BLOOD Mg-2.8*
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit after undergoing pre-operative
work-up as an outpatient. On day of admission she was brought to
the operating room and underwent an aortic valve replacement and
coronary artery bypass grafting by Dr. [**Last Name (STitle) 1290**]. For surgical
details, please see separate dictated operative note. Following
the operation, she was brought to the CVICU for invasive
monitoring in stable condition. Within 24 hours, she awoke
neurologically intact and was extubated without incident. She
maintained stable hemodynamics and transferred to the SDU on
postoperative day one. Beta blockers and diuretics were started
and she was gently diuresed towards her pre-op weight. Chest
tubes and epicardial pacing wires were removed per protocol. She
gradually improved and worked with physical therapy for strength
and mobility. On post-op day five she appeared to be doing well
and was discharged home with VNA services and the appropriate
follow-up appointments.
Medications on Admission:
Januvia 100 qd, Amaryl 4 qd, Diovan 160 qd, HCTZ 25 qd, Zocor 40
qd, Aspirin 81 qd, B12 shots monthly, Voltaren eye gtts
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. 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*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. JANUVIA 100 mg Tablet Sig: One (1) Tablet PO daily ().
Disp:*30 Tablet(s)* Refills:*0*
5. Glimepiride 2 mg Tablet Sig: Two (2) Tablet PO daily ().
Disp:*60 Tablet(s)* Refills:*0*
6. Diclofenac Sodium 0.1 % Drops Sig: One (1) Ophthalmic QID
().
Disp:*QS 1 month* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Niferex 60 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
12. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic Stenosis, Coronary Artery Disease - s/p Aortic Vavlve
Replacement and Coronary Artery Bypass Graft x 2
PMH: Hypertension, Hypercholesterolemia, Type II Diabetes
Mellitus, Carotid Disease, Morbid Obesity s/p Gastric Bypass,
B12 Anemia, Asthma, Cataracts, s/p c-section [**2130**],
Nephrolithiasis s/p lithotripsy
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in [**3-2**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**12-31**] weeks, call for appt
Dr. [**Last Name (STitle) **] in [**12-31**] weeks, call for appt
Completed by:[**2158-9-1**]
|
[
"4241",
"41401",
"4019",
"2720",
"49390"
] |
Admission Date: [**2140-6-13**] Discharge Date: [**2140-6-25**]
Date of Birth: [**2074-1-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
ibuprofen / Lipitor / deer tick
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x four (Left internal mammary
artery > left anterior descending, saphenous vein graft >
diagonal, saphenous vein graft > obtuse marginal, saphenous vein
graft > posterior descending artery) [**2140-6-13**]
History of Present Illness:
Mr. [**Known lastname 88571**] is a 66 year old male has a history of
dyslipidemia and prior tobacco abuse. He reports that over the
past six to eight weeks he has noticed "heartburn" or chest
pressure type symptoms when exerting himself after a meal or
walking up and down inclines. These symptoms always resolve
quickly with rest. He has also noticed occasional dyspnea on
exertion. For this reason, he underwent non imaging stress
testing where he was noted to have 3mm ST depression in the
inferoapical/anterior leads along with a fall in blood pressure.
He was referred for left heart catheterization. He was found to
have three vessel coronary artery disease and was referred to
cardiac surgery for revascularization.
Past Medical History:
Dyslipidemia
Lower back pain with spinal stenosis
GIB in the setting of high dose ibuprofen use (approximately 5-6
years ago)
Occasional hematuria on low dose aspirin (no prior workup)
BPH
Mild arthritis
Bilateral arthroscopic knee surgery
Hernia repair bilaterally
teeth extraction in [**2-/2140**]
Social History:
He lives with his wife. Mr. [**Known lastname 88571**] works four days a week in
maintenance at [**Hospital1 **]. He quit
smoking in [**2132**] and has a history of [**1-4**] cigars per week for 40
years. He rarely drinks alcohol.
Family History:
Mr. [**Known lastname 88572**] father had angina in his 80's. His mother had a
pacemaker.
Physical Exam:
Pulse:59 Resp:18 O2 sat:95/RA
B/P Right:111/66 Left:100/72
Height:5'[**39**].5" Weight:187 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] B groin hernia incisions
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: cath site Left: +2
DP Right: +2 Left: +2
PT [**Name (NI) 167**]: +2 Left: +2
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Discharge:
VS: T: 98.2 HR: 70 SR BP: 122/80 18 Sats: 100% RA
General: 66 year-old male in no apparent distress
HEENT; normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1.S2 no murmur
Resp: clear breath sounds throught out
GI: benign
Extr: warm no edema
Incision: sternal & LLE clean, dry intact
Neuro: awake, alert, oriented walking in halls
Pertinent Results:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
LV wall thickness, cavity size, and global systolic function
(LVEF>55%). Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque. Normal diameter of aorta
at the sinus, ascending and arch levels.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
PREBYPASS:
ESSENTIALLY NORMAL exam. He has a small PFO with left to right
flow. Normal function, normal valves.
The left atrium is normal in size. A patent foramen ovale is
present. Left ventricular wall thicknesses and cavity size are
normal. Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). 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 ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque . The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
POSTBYPASS: Unchanged. No segmental wall motion abnormalities.
LVEF 50-55%, No dissection seen after removal of aortic cannula.
[**2140-6-20**] 06:25AM BLOOD WBC-8.9 RBC-3.52* Hgb-10.4* Hct-31.4*
MCV-89 MCH-29.7 MCHC-33.3 RDW-13.1 Plt Ct-334
[**2140-6-21**] 05:50AM BLOOD Glucose-126* UreaN-76* Creat-6.7* Na-136
K-4.2 Cl-103 HCO3-22 AnGap-15
[**2140-6-23**] 08:51AM BLOOD UreaN-64* Creat-5.4*
[**2140-6-22**] 10:00PM BLOOD UreaN-70* Creat-5.9*# Na-138 K-3.7 Cl-106
[**2140-6-22**] 05:55AM BLOOD Glucose-114* UreaN-77* Creat-7.0* Na-137
K-4.4 Cl-104 HCO3-23 AnGap-14
Brief Hospital Course:
On [**6-13**] he was brought to the operating room for coronary artery
bypass graft surgery. Please see the operative note for
details. He received cefazolin for perioperative antibiotics
and was transferred to the intensive care unit for post
operative management. That evening he was weaned from sedation,
awoke neurologically intact and was extubated without
complications. On post operative day one he was started on
Lasix and beta blockers, additionally chest tubes were removed
and was noted for bilateral apical pneumothorax. He had serial
chest xrays that revealed continued improvement over the next
few days without further intervention. His chest xray at the
time of discharge showed stable pneumothoraces. On post
operative day two his epicardial wires were removed and
transferred to the floor.
Respiratory: aggressive incentive spirometer, ambulation and
good pain control he titrated off oxygen with room saturations
of 98%
Cardiac: hemodynamically stable sinus rhythm 80's without
ectopy. Beta-blockers were titrated. Blood pressure 110-130's
stable. Statins and aspirin continued.
GI: Proton Pump Inhibitor & bowel regimen. Tolerated a regular
diet
Renal: POD 3 developed ATN with peak Cre of 7.0 (baseline 0.9).
Furosemide and toradol was discontinued. He continued to make
adequate urine. Electrolytes were replete as needed. He was
seen by renal who recommended chem 10 labs daily
keeping SBP>100 and dose meds for eGFR<15. He was given 1 liter
of LR on POD 9 and 10 and his cratinine and BUN had decreased
after stopping all diuretics and IVF was given. His creatinine
had decreased to 4.1 at the time of discharge.
Endocrine: insulin sliding scale with blood sugars < 150.
Pain: Toradol discontinued with rising creatinine, Oxycodone and
acetaminophen were continued with good pain control.
Disposition: he was seen by physical therapy for strength and
mobility. He continued to make steady progress and was
discharged to home on [**2140-6-25**]. He will need his electrolytes,
BUN and Creatinine checked on [**2140-6-27**]. All follow-up
appointments were advised.
Medications on Admission:
BISOPROLOL FUMARATE 5 QHS
ASCORBIC ACID 1000 [**Hospital1 **]
ASA 81 daily
ERGOCALCIFEROL 1,000u daily
FLAXSEED 1,000 [**Hospital1 **]
VITAMIN E 400u daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for loose stools.
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for fever or pain.
Disp:*40 Tablet(s)* Refills:*0*
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
6. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Outpatient Lab Work
BUN/CRE Monday [**2140-6-27**] and call results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3142**]
[**Telephone/Fax (1) 58707**]
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Pneumothorax
Dyslipidemia
Lower back pain with spinal stenosis
Gastrointestinal bleeding
Hematuria
Benign prostatic hypertrophy
Mild arthritis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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:
Date/Time:[**2140-6-27**] BUN/creatinine check call results to [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3142**]
[**Telephone/Fax (1) 170**]
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2140-7-7**] 1:30 [**Hospital Unit Name **] [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Cardiologist:[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7756**]/ [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7526**] [**2140-7-18**] 1:00 pm
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) 59917**] [**Telephone/Fax (1) 21640**] in [**4-5**] weeks [**Telephone/Fax (1) 21640**]
**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:[**2140-6-25**]
|
[
"41401",
"5845",
"2724"
] |
Admission Date: [**2190-5-4**] Discharge Date: [**2190-5-6**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
Tracheobronchomalacia
Major Surgical or Invasive Procedure:
bronchoscopy
History of Present Illness:
[**Age over 90 **]F apparently in good health until mid-[**Month (only) 547**] when she had a
pneumonia with respiratory distress and presented to [**Hospital **] [**Hospital **]
hospital where an emergency trach was performed due to difficult
intubation, the cause of which is unclear - pt unable to wean
from vent and ENT tracheoscopy found severe TBM yesterday. They
would like us to consider airway stenting, but stent not placed
due to supraglottic edema and subglottic stenosis/granulation
tissue. Will return to CT thurs. 10am, thoracics aware. When
edema decreased, may return to get stent. Aneurysm old per
cards. Atenolol decreased to 50qd per cards rec. TF restarted
and KVO'd.
Past Medical History:
HTN
atrial fibrillation
mild dementia
s/p trach and PEG [**3-20**]
Social History:
Social History: no tob/etoh/drugs, lives alone
Physical Exam:
Afebrile
HR 81
BP 99/37
on CPAP 40% 5PEEP/14PS taking 380x21
NAD
coarse BS bilaterally
RRR
Pertinent Results:
[**2190-5-4**] 09:21PM proBNP-3291*
[**2190-5-4**] 09:21PM PT-12.8 PTT-23.6 INR(PT)-1.1
Brief Hospital Course:
Had newly diagnosed TBM and was sent here to see if there was
any intervention we could offer. Broncospy demonstrated severe,
disease, and swelling; the hope was that treating the
inflammation with steroids would allow stent placement.
On the day prior to d/c she under went a second bronchoscopy
that showed no significnat change in he condition. The IP team
decided there was no possibility of placing a stent in her. She
was having a difficult time weaning her vent dependency.
At the time of this discharge summary, she was about to be
transferred back to her vented rehab.
Medications on Admission:
Atenolol 100', norvasc 5', seroquel, prevacid
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day/Year **]: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day) as needed for dvt.
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Four
(4) Puff Inhalation Q6H (every 6 hours) as needed for
bronchospasm.
3. Amlodipine 2.5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily)
as needed for htn.
4. Donepezil 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime)
as needed for dementia.
5. Quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
6. Fluticasone 50 mcg/Actuation Aerosol, Spray [**Hospital1 **]: One (1)
Spray Nasal DAILY (Daily) as needed for Post-nasal drip.
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day) as needed for
pud.
8. Atenolol 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily) as
needed for htn.
9. Dexamethasone Sodium Phosphate 4 mg/mL Solution [**Last Name (STitle) **]: Four (4)
mg Injection Q8H (every 8 hours) as needed for supraglotic edema
for 2 days.
Discharge Disposition:
Extended Care
Facility:
Hospital for Special Care
Discharge Diagnosis:
tracheobronchomalacia
Discharge Condition:
fair
Discharge Instructions:
call your local PCP in [**Name9 (PRE) 7349**] if you develop chest pain, fever,
chills. Call if you have difficulty swallowing, nausea, vomiting
or diarrhea.
Followup Instructions:
follow up with your local pulmonologist in [**Location (un) 7349**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
|
[
"42731",
"5859",
"40390"
] |
Admission Date: [**2159-4-22**] Discharge Date: [**2159-4-26**]
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
82F h/o CVA presented to OSH for crescendoing SSCP [**10-15**] without
accompanying sx and was found to have anteroseptal MI. She
describes having chest pain with 'colds' over the past [**1-7**]
monhts with no other associated symptoms. She presented to OSH
where EKG was concerning for MI. She was given nitro, morphine,
plavix, integrillin, ASA, and heparin. ECG w/1mm STE in V1-V4.
CK 75 MB 3.3 TnT 0.07. Pt was tx to [**Hospital1 18**] for urgent cath were
she received DES x2 to 90% RCA and 90% LAD. Due to low CO 2.59
and CI 1.52, pt was tx to CCU for close monitoring.
Past Medical History:
1. CVA w/residual mild aphasia and R facial droop ([**2152**])
2. HTN
3. Hypercholesterolemia
Social History:
Married, no smoking history
Family History:
Brother died [**Name (NI) 5290**] in 50's
Physical Exam:
VS: Afebrile 90/48 62 20 95% RA
Gen: very pleasant female, lying in bed, NAD
HEENT: PERRL, OP clear, with right sided facial droop
Neck: no JVD
Lungs: CTA bilat, no w/r/r
CV: RRR, nl s1/s2, no m/r/g
Abd: soft, nt/nd, nabs
Extr: no groin bruits, sheath in right groin; no c/c/e, 2+ PT
bilaterally
Pertinent Results:
[**2159-4-22**] 11:33AM POTASSIUM-3.5
[**2159-4-22**] 11:33AM CK(CPK)-[**2129**]*
[**2159-4-22**] 11:33AM CK-MB-177* MB INDX-9.0*
[**2159-4-22**] 05:18AM GLUCOSE-118* UREA N-27* CREAT-1.0 SODIUM-137
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-29 ANION GAP-15
[**2159-4-22**] 05:18AM CK(CPK)-3013*
[**2159-4-22**] 05:18AM CK-MB-316* MB INDX-10.5* cTropnT-16.12*
[**2159-4-22**] 05:18AM CALCIUM-8.4 PHOSPHATE-3.2 MAGNESIUM-1.8
Brief Hospital Course:
1. CAD: cardiac catheterization revealed RCA with 90% mid
stenosis and LAD wiwht 90% proximal stenosis. Cypher DES were
placed in both vessels with good post-procedure flow. Her CO/CI
were 2.59/1.52 (venous saturation taken from RV, however), and
she was transferred to CCU for observation. She received 18
hours of integrillin post-procedure and was continued on Plavix
and Aspirin. She was started on metoprolol, and ACEI was started
as blood pressure allowed. Heparin gtt was started after
integrillin empirically given the extent of her infarct (large
CK leak, ?LV aneurysm/HK). She was also discharged on coumadin
as described below. TTE post procedure showed EF=35-40% with
anterior, distal septal, and apical hypokinesis
2. Pump: F/u echo post MI showed EF=35-40% as above. She was
started on an ACEI and kept euvolemic.
3. Rhythm-Mg and K repleted as necessary, and she was kept on
telemetry post-MI (NSR). She developed atrial fibrillation
post-MI and was started on amiodarone and coumadin. She will
follow up with a cardiologist in her area and with Dr. [**Last Name (STitle) **]
in EP.
4. Neuro: Stable prior residual abnormalities after past CVA.
5. Disposition: She was discharged in good condition and will
follow up with cardiology and EP. She will start cardiac rehab
2-4 weeks after discharge.
Medications on Admission:
Home Meds: ?ASA, diazide, atenolol
All: Lipitor (hives)
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: 1 half Tablet PO twice
a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Warfarin Sodium 2 mg Tablet Sig: 2 and 1/2 Tablets PO once a
day.
Disp:*75 Tablet(s)* Refills:*2*
4. Travoprost 0.004 % Drops Sig: One (1) drop Ophthalmic qhs ()
as needed for glaucoma.
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): Continue for six months.
Disp:*30 Tablet(s)* Refills:*6*
8. Oxazepam 10 mg Capsule Sig: [**1-7**] Capsules PO HS (at bedtime)
as needed.
9. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Continue taking 2 tablets daily for 1 week (until [**5-3**])
and take 1 tablet thereafter.
Disp:*35 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
Please check INR [**4-27**] and [**4-30**]. Fax results to Dr. [**Last Name (STitle) 7962**]
[**Name (STitle) **]: [**Telephone/Fax (1) 25562**] / fax [**Telephone/Fax (1) 60763**]
Discharge Disposition:
Home With Service
Facility:
caritas
Discharge Diagnosis:
acute myocardial infarction
Discharge Condition:
Stable
Discharge Instructions:
Please seek medical attention for fevers>101.4, chest pain, or
for anything else medically concerning.
Please take your medications as directed.
Followup Instructions:
1) Please see Dr. [**Last Name (STitle) 7962**] [**Telephone/Fax (1) 25562**] within 1 week for
followup. He will arrange for you to see a cardiologist in your
local area.
2) Visiting nurse service will come to draw your blood on
Friday, [**2159-4-27**] and Monday, [**2159-4-30**]. Dr.[**Name (NI) 60764**] office
will contact you with adjustments to your Coumadin dose.
3) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2159-5-30**] 3:00 for
your atrial fibrillation
4) Your should start cardiac rehab to start in two weeks
|
[
"42731",
"41401",
"2859"
] |
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