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Admission Date: [**2156-9-21**] Discharge Date: [**2156-9-25**]
Date of Birth: [**2071-4-21**] Sex: F
Service: MEDICINE
Allergies:
morphine
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hospitalist Admit Note
Patient Name:[**Name (NI) **] [**Name (NI) 4580**] [**Medical Record Number 90591**]
DOB: [**2071-4-21**]
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30878**]
Transferring Facility: [**Hospital3 **]
Transferring Physician:[**Last Name (NamePattern4) **]. [**Last Name (STitle) 69038**] Contact [**Name (NI) **]: [**Telephone/Fax (1) 90592**]
Transferring Floor: N3 3122 Contact [**Name (NI) **]:[**Telephone/Fax (1) 90593**]
.
CC:[**CC Contact Info 90594**]
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
85 yo F with HTN, skin melanoma in [**2153**] and skin squamous cell
cancer in [**2155**] who developed new onset jaundice and nausea. At
OSH, T bili 16 and direct bili 13. AST/ALT: 124/103; AP 303. INR
5.4. CT showed a 7x6x5 cm cystic lesion with calcification at
the head of pancreas. CBD and PD were dilated. She had mild
respiratory distress and CXR showed LLL infiltrate for which she
was started on ampicillin. She was given vitK and 4 unit of FFP
due to coagulopathy, INR improved to 1.3. She underwent ERCP
with Dr. [**Last Name (STitle) 69038**] yesterday under general anesthesia. Cannulation
of CBD was not successful. Only PD was cannulated. Patient with
increasing bili today, needing transfer for repeat ERCP. Per
report, vitals prior to transfer. Tx 101. Tc:99.8 BP:140-170/70
HR:70-80 RR: 15 O2 Sat: 89-93 4L/min O2-per transferring
physician patient with no respiratory symptoms after ERCP
despite O2 requirement.
.
Pt reports that that she developed 1 week of nausea, vomiting,
fever up to 102.7, abdominal distention and 1 day of dark urine
prior to admission to OSH. Reports that symptoms were
intermittent, but worsened on sat prior to admit. Pt reports she
was diagnosed with a UTI on fri and started on cipro. She
reports intermittent chills, weight loss of ~15-20lbs over [**2-26**]
months. In addition, pt reports intermittent diarrhea-non
bloody- over last few months. Pt denies new foods, travel, sick
contacts, abdominal pain, constipation, melena, brbpr, cp, sob,
palpitations, URI/cough, rash, paresthesias, weakness, dysuria,
headache, but does report chronic intermittent dizziness. PT
reports decreased appetite and pO intake x1 week.
Past Medical History:
appendectomy, hysterectomy, tonsillectomy, removal of skin
cancer and melanoma
-formerly had HTN
-formerly HL
-hypothyroidism
Social History:
PT lives at home alone, but multiple family members nearby to
help. Ambulates with a cane occasionally. Former smoker, quit
25yrs ago, former alcoholic quit 27 years ago. Denies drug use
Family History:
mother died at 86-arthritis, "cancer"
dad-alcoholic
Physical Exam:
GEN: lying in bed, jaundiced, NAD
vitals: T 97.2, BP 152/68, HR 75, RR 24, sat 93% on 4L
HEENT: nc/at, EOMI, +icterus, dry MM
neck: supple, +thyromegaly, +JVD to earlobe
chest: +b/l crackles
heart: rrr, m/r/g
abd: +bs, soft, mildly tender, softly distended, no guarding or
rebound,
back: non-tender, no CVA tenderness
ext: no c/c/e 2+pulses
skin: multiple areas of scaring, hypo and hyperpigementation.
L.shin with sutures from recent resection-c/d/i
neuro: AAOx3, CN2-12 intact, motor [**5-27**] x4, sensation intact to
LT, no tremor
psych: calm, cooperative
Pertinent Results:
Labs:
T bili 16 and direct bili 13. AST/ALT: 124/103; AP 303. INR 5.4.
.
Imaging:
CT showed a 7x6x5 cm cystic lesion with calcification at the
head of pancreas.
ERCP-CBD and PD were dilated.
CXR-LLL infiltrate
.
ERCP [**9-20**]-cystic neoplasia of pancreas. Unable to access bile
duct.
.
EKG NSR Q III, TWI III, AVF
.
CT abd/pelvis-[**9-19**]-severe ventilation of the intereim bilary
ducts as well as the main pancreatitic duct. multiloculated
cystic lesion in the head of the pancreas associated with small
punctate calcifications that can be related to a pancreatic
neoplasia like serous cystadenoma of the pancreas. Suboptimal
evaluation due to the lack of IV contrast. ERCP or MRCP is
recommended for further eval. MIld free fluid in pelvis.
Diverticulosis without diverticulitis. b/l cortical renal cysts.
.
RUQ u/s [**9-19**]-marked intrahepatic and extrahepatic biliary ductal
dilatation of ? etiology.
.
CXR [**9-19**]-streaky LLL infiltrate otherwise no significant acute
finding.
.
WBC 13, HCT 29, plt 167. INR 1.3, ap 343, tbili 23.3, direct
13.1, bun 26, ca 9 creat 0.81, gluc 95, lip 33, ast 166, alt
110, TSH 0.654
Brief Hospital Course:
85 yo F with HTN, skin melanoma in [**2153**] and skin squamous cell
cancer in [**2155**] who developed new onset jaundice, nausea with
vomiting and was found to have a cystic pancreatic mass at OSH.
.
# CMO: Patient was made comfort measure after discussion with
family. Palliative care saw patient and it was decided that she
would go home with hospice care. She was comfortable at the time
of discharge. She was sent home on oxycodone, zofran,
promethazine, compazine, & ativan for symptom management.
Patient medications were reviewed and non-palliative medications
were removed from regimen. We called the PCP [**Name Initial (PRE) **] couple of times
during this stay and were only able to reach his answering
machine. We left messages with the new changes in care goals and
with numbers for him to contact us. Family (very involved) has
also said that they will be in touch with her PCP as well. She
will continue to have her foley and oxygen with N as needed at
home, which hospice can provide.
.
#bile duct obstruction with obstructive jaundice/cystic
pancreatic head lesion-Etiology of patients symptoms, abdominal
distention, nausea, jaundice is likely related to obstruction
from pancreatic head mass. DDX includes malignancy vs. cyst. Pt
does have h.o skin cancer, but unlikely to metastasize to
pancreas. Pt may also have stricture or stones. She had an ERCP
with 8cm by 10mm Wallflex fully covered biliary stent which was
successfully placed with large amounts of mucin which drained.
Patient presented with nausea and continued to have nausea
intermittently throughout stay. Have increased regimen as above
to control nausea, able to tolerate PO meds, gingerale, and some
soft foods.
.
#Hypoxia-?LLL infiltrate--Pt thought to have PNA at OSH. CXR
found streaky LLL infiltrate. Pt does have a leukocytosis, but
denies cough. On exam, pt with elevated JVP/crackles more c/w
volume overload. Pt does have suspicion of malignancy, and will
consider if continued hypoxia. Will continue to cover for
suspected pna including atypicals with levofloxacin to end on
[**2156-10-5**]. Able to tolerate PO so will go home with PO regimen.
.
#Transient bacteremia s/p ERCP: will treat with flagyl in
addition to levoflox as above for total of 2 wk course, to end
on [**2156-10-5**]. have been tolerating PO as well.
.
#h.o skin cancer/squamous cell/melanoma--stable, will f/u outpt
if necessary but CMO at this point
.
#Afib: patient found to have atrial fibrillation [**2-25**] to
procedure, which has resolved and has not recurred. No need for
any anticoagulation especially given goals of care.
.
#Hypothyroidism: will continue home levothyroxine as it might
help patient feel better, more energetic.
.
#code-DNR/DNI, CMO, d/w patient in presence of HCP.
Medications on Admission:
levothyroxine 75mcg daily, HCTZ-not on prior to admit, MVI,
prochlorperazine Cipro 250mg [**Hospital1 **]
Inpatient:
She is on Ampicillin 1.5gm Q6hours and prn albuterol.
Allergy: morphine
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ativan 1 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as
needed for nausea.
Disp:*180 Tablet(s)* Refills:*2*
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for sob/wheezing.
4. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 11 days: End Date [**10-5**].
Disp:*32 Tablet(s)* Refills:*0*
5. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 11 days: last day = [**2156-10-5**].
Disp:*11 Tablet(s)* Refills:*0*
6. prochlorperazine 25 mg Suppository Sig: One (1) Suppository
Rectal Q12H (every 12 hours) as needed for nausea.
Disp:*60 Suppository(s)* Refills:*2*
7. promethazine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours) as needed for nausea.
Disp:*240 Tablet(s)* Refills:*0*
8. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q 8H (Every 8 Hours) as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
9. oxycodone 20 mg/mL Concentrate Sig: 5-10 mg PO q2h:PRN as
needed for pain and shortness of breath.
Disp:*100 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Central & [**Hospital3 29991**] [**Hospital3 **]
Discharge Diagnosis:
pancreatic head mass
bile duct obstruction/hyperbilirubinemia
hypoxia
pneumonia
.
HTN, benign
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for further work up of a blockage noted in
your bile ducts and a mass that was seen in your pancreas. You
underwent a procedure called an ERCP that showed significant
blockage of your biliary system. There was a stent placed which
relieved the blockage. You were also continued on antibiotics
for a pneumonia and prophylaxis after ERCP which you will
continue until [**10-6**].
.
You had significant nausea during your hospitalization. You will
be sent on on many different medications for your nausea.
.
Medication changes:
Start Oxycodone liquid 20mg/ml 5-10mg PO q4-6h for pain and
shortness of breath SL
Start Ativan 1mg q4-6h as needed for anxiety and shortness of
breath
Continue Flagyl q8h until [**10-5**]
Continue Levofloxacin 250mg every day until [**10-5**]
Continue Prochlorperazine 25mg twice a day as needed for nausea
Continue Promethazine 50mg Tablet every 6 hours as needed for
nausea
Continue Zofran 8mg every day as needed for nausea
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 30878**] at
[**Telephone/Fax (1) 30879**] after discharge.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2156-9-26**]
|
[
"486",
"42731",
"2449",
"2859"
] |
Admission Date: [**2112-8-18**] Discharge Date: [**2112-8-20**]
Date of Birth: [**2112-8-18**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**First Name5 (NamePattern1) 3825**] [**Known lastname 57289**] is the 3.105
kilogram product of a term gestation pregnancy born to a 35-
year-old G1, P0 now 1 woman. Prenatal screens revealed a
blood type of O positive, antibody negative, rubella immune,
RPR nonreactive, hepatitis B surface antigen negative, group
beta Streptococcus status positive. The pregnancy was
uncomplicated. The mother presented in spontaneous labor.
The temperature maximum in labor was 100 degrees Fahrenheit.
There was artificial rupture of membranes. The mother
received greater than four hours of intrapartum antibiotics
for the known group B Streptococcus colonization. Meconium
stained amniotic fluid was noted. There was maternal
anesthesia with epidural placement. Delivery was by cesarean
section for failure to progress after a failed vacuum
extraction. The infant emerged with decreased tone, gasping
respirations, but continued respirations. The infant was
intubated for pneumonia. No meconium was noted below the
cords. The infant then received positive pressure
ventilation for several minutes. The heart rate was always
greater than 90 and by five minutes the infant had
spontaneous respirations, although remained with decreased
tone. Apgar scores were two at one minute and five at five
minutes and seven at ten minutes. The infant was transferred
to the Neonatal Intensive Care Unit for further evaluation
and treatment.
PHYSICAL EXAMINATION: On physical examination upon admission
to the Neonatal Intensive Care Unit, the weight was 3.015
kilograms, length 49 cm, head circumference 35 cm. The
infant was placed on a radiant warmer and grunting was noted
and was well saturated in room air. A CBC and blood culture
were drawn and the infant was started on antibiotics. He
received one normal saline bolus for pale color and poor
perfusion.
The physical examination on radiant warmer revealed that the
infant was pale pink with grunting. The head, ears, eyes,
nose, and throat revealed positive occipital molding.
Anterior fontanelle open and flat. Mobile sutures. The eyes
were open. Red reflex was deferred. Intact palate. No
elicitable suck. Lungs were clear to auscultation.
Cardiovascular examination revealed a regular rate and rhythm
without murmur. There were 2+ femoral pulses. The abdomen
was soft, positive bowel sounds, no hepatosplenomegaly. GU
examination revealed a normal male. Testes descended
bilaterally. The extremities were pale pink, improved
perfusion after the saline bolus. Neurologically, the
patient was alert, awake, tone improving, normal grasp,
palmar and plantar.
HOSPITAL COURSE: RESPIRATORY: [**Location (un) 3825**] remained in room air.
His grunting, flaring, and retracting resolved within the
next few hours after birth. His respirations at the time of
transfer are 50-60 per minute. Oxygen saturations were
always greater than 95 percent.
CARDIOVASCULAR: As previously noted, [**Location (un) 3825**] received a
normal saline bolus for poor perfusion. He maintained normal
heart rates and blood pressures. No murmurs have been noted.
FLUIDS, ELECTROLYTES, AND NUTRITION: [**Location (un) 3825**] was initially
n.p.o. and maintained on intravenous dextrose fluids.
Enteral feeds were started on day of life number one and well
tolerated. At the time of transfer, he is ad lib breast
feeding or p.o. feeding formula. The weight at the time of
transfer is 3.005 kilograms.
INFECTIOUS DISEASE: Due to the distress at birth and the
known group B Streptococcus colonization of the mother,
[**Name (NI) 3825**] was evaluated for sepsis. A white blood cell count
was 36,900 with a differential of 37 percent of
polymorphonuclear cells and 1 percent band neutrophils. A
blood culture was obtained prior to starting intravenous
ampicillin and gentamicin. The blood culture was no growth
at 48 hours and the antibiotics were discontinued.
HEMATOLOGICAL: The hematocrit at birth was 46 percent.
Platelets were 289,000. [**Location (un) 3825**] did not receive any
transfusions of blood products.
NEUROLOGY: Due to the depression noted at birth, a head
ultrasound was obtained on [**2112-8-19**]. The results were within
normal limits. [**Location (un) 3825**] is maintaining a normal neurological
examination at the time of transfer.
CONDITION ON TRANSFER: Good.
DISCHARGE DISPOSITION: Transfer to the newborn nursery for
further care.
PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) **].
CARE AND RECOMMENDATIONS AT THE TIME OF TRANSFER: Ad lib
feeding, breast feeding as tolerated.
No medications.
Car seat position screening is not recommended.
State newborn screen due on day of life three.
No immunizations administered to date.
DISCHARGE DIAGNOSES: Perinatal depression.
Suspicion for sepsis, ruled out.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 56160**]
MEDQUIST36
D: [**2112-8-20**] 22:03:18
T: [**2112-8-21**] 07:56:02
Job#: [**Job Number 57290**]
|
[
"V290",
"V053"
] |
Admission Date: [**2196-9-23**] Discharge Date: [**2196-10-1**]
Date of Birth: [**2133-11-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Myocardial Infarction
Major Surgical or Invasive Procedure:
[**9-26**] CABG x 5 (LIMA->LAD, SVG->OM, PDA, D1, D2)
History of Present Illness:
Mr. [**Known lastname **] is a 62-year-old male with a recent history of
myocardial infarction and chest pain who underwent cardiac
catheterization that showed severe 3-vessel disease. He has a
tortuous aorta and a history of bad asthma requiring
intermittent steroid treatments. His ejection fraction is
preserved. He is presenting for coronary artery bypass surgery.
Past Medical History:
HTN
Hypercholesterolemia
GERD
Bronchitis
Diabetes Mellitus Type II
Asthma
Social History:
Teacher. Lives with wife. Rare alcohol use. Quit smoking 6 years
ago.
Family History:
Mother with HTN
Sister CABG/DM
Father died of aortic aneurysm
Physical Exam:
NEURO: A+Ox3, nonfocal
LUNGS: Clear
HEART: RRR, Normal S1-s2, no murmur
ABD: Benign
EXT: Warm, no edema, 2+ pulses. Mild varicosities.
Pertinent Results:
[**2196-9-23**] 05:38PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2196-9-23**] 05:38PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2196-9-23**] 10:30PM PT-12.5 PTT-24.8 INR(PT)-1.0
[**2196-9-23**] 10:30PM PLT COUNT-219
[**2196-9-23**] 10:30PM WBC-10.3 RBC-4.46* HGB-14.2 HCT-40.7 MCV-91
MCH-31.8 MCHC-34.8 RDW-13.8
[**2196-9-23**] 10:30PM %HbA1c-6.1* [Hgb]-DONE [A1c]-DONE
[**2196-9-23**] 10:30PM ALT(SGPT)-24 AST(SGOT)-25 ALK PHOS-98
AMYLASE-64 TOT BILI-0.4
[**2196-9-23**] 10:30PM GLUCOSE-146* UREA N-25* CREAT-1.5* SODIUM-142
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-25 ANION GAP-16
[**2196-9-29**] 06:20AM BLOOD WBC-13.8* RBC-3.25* Hgb-10.5* Hct-30.1*
MCV-93 MCH-32.4* MCHC-35.0 RDW-14.0 Plt Ct-151
[**2196-9-29**] 06:20AM BLOOD Plt Ct-151
[**2196-9-30**] 05:40AM BLOOD UreaN-49* Creat-1.6* K-4.9
[**2196-9-23**] 10:30PM BLOOD ALT-24 AST-25 AlkPhos-98 Amylase-64
TotBili-0.4
[**2196-9-28**] CXR
In the interim, the patient has been extubated and Swan-Ganz
catheter has been removed. There is no pneumothorax. Mediastinal
drain and left-sided chest tube are in stable position. NG tube
has been removed. There is bibasilar atelectasis and small
pleural effusions, with an enlarged heart but no evidence of
cardiac failure.
[**2196-9-27**] EKG
Sinus rhythm
ST segment elevation in leads V2-V4 - probably repolarization
but consider
pericarditis
[**2196-9-23**] ECHO
1. The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%).
2. The aortic root is moderately dilated.
3. The aortic valve leaflets are mildly thickened.
4. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
[**2196-9-24**] CTA Chest
1. No pulmonary embolism.
2. Mild dilatation of the aortic root.
3. Dense coronary artery calcifications as above.
4. Cholelithiasis and suggestion of a porcelain gallbladder.
Further followup is recommended given the increased incidence of
gallbladder carcinoma in these patients.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2196-10-23**] via transfer from
the [**Hospital6 3872**] for further management of his
coronary artery disease. He was worked-up in the usual
preoperative manner by the cardiac surgical service. A CT scan
was performed to evaluate his aorta. This showed a mild dilation
of the aortic root, cholelithiasis and a porcelain gallbladder.
An echo was obtained which revealed a mildly dilated aortic root
of 4.4cm and a normal ejection fraction. Heparin and
nitroglycerin were used intravenously and he remained chest pain
free. On [**2196-9-26**], Mr. [**Known lastname **] was taken to the operating room where
he underwent coronary artery bypass grafting to five vessels.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On Postoperative day one, Mr. [**Known lastname **] [**Last Name (Titles) 26228**] neurologically intact and was extubated. His chest tubes
were removed. He was then transferred to the step down unit for
further recovery. He was gently diuresed towards his
preoperative weight while his supplemental oxygen was weaned
off. The physical therapy service was consulted to assist with
his postoperative strength and mobility. Beta blockade and
aspirin were resumed. Mr. [**Known lastname **] continued to make steady progress
and was discharged to his home on postoperative day five. He
will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his
primary care physician as an outpatient.
Medications on Admission:
[**Doctor First Name **] 180 daily
Oscal 500 three time daily
Lisinopril 10mg daily
Lipitor 80 mg daily
Protonix 40mg twice daily
Medrol 40mg PRN
Fosamax 70mg weekly
Aspirin 325mg daily
Niacin 500mg twice daily
Lopressor 25mg twice daily
Singulair
FLonase
Pulmicort
Albuterol
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. 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*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*30 day supply* Refills:*0*
9. Cromolyn Sodium 800 mcg/Actuation Aerosol Sig: Three (3) Puff
Inhalation TID (3 times a day).
Disp:*30 day supply* Refills:*0*
10. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Disp:*30 Disk with Device(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD
Asthma
HTNGERD
Bronchitis
NIDDM
Discharge Condition:
Good.
Discharge Instructions:
Shower, wash incision with soap and water and pat dry. No baths,
lotions, creams or powders. No lifting more than 10 pounds or
driving until follow up with surgeon.
Call for fever, redness or drainage from incision or weight gain
more than 2 pounds in one day or five in one week.
Followup Instructions:
Dr. [**Last Name (STitle) **] 4 weeks - Appointment made for [**2196-10-25**] 1:15 pm
Dr. [**Last Name (STitle) **] (Pulmonology) 2 weeks
PCP 2 weeks
Dr. [**First Name (STitle) **] (Cardiology) 2 weeks
Completed by:[**2196-11-22**]
|
[
"41071",
"41401",
"25000",
"4019",
"53081",
"V1582"
] |
Admission Date: [**2115-9-20**] Discharge Date: [**2115-10-9**]
Date of Birth: [**2053-12-12**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / Biaxin / Azithromycin / Heparin Agents
Attending:[**First Name3 (LF) 1493**]
Chief Complaint:
increased abdominal girth
Major Surgical or Invasive Procedure:
placement of tunnelled dialysis cathether
History of Present Illness:
This is a 61 y/o woman with PMH notable for WPW s/p triple
valve replacement (MV, AV, TV) on chronic coumadin, cirrhosis
[**12-22**] heart failure, and chronic renal insufficiency (renal Cr ~
3) who presents with increased abdominal girth and dyspnea.
Patient has been at home for several weeks following a stay at
[**Hospital3 **]. She states that there she had C diff colitis but
is no longer on antibiotics.
.
In the ED, initial vs were: P 65 BP 137/66 R 16 O2 sat 98%.
Patient was given no medications in the ED. Her BP did
transiently decrease to 88/48 but came back up to 101/53 without
intervention. Temperature was noted to be 94.7.
.
Call in note states patient has had INR 7 for past few days so
coumadin has been held.
.
On the floor, the patient states that she has no dyspnea when
not walking. She [**Hospital3 **] any chest pain. She endorses increased
abdominal girth but [**Hospital3 **] abd pain or fevers. She notes
recently decreased urine output but no dysuria. [**Hospital3 4273**] recent
changes in her meds or antibiotic use. No nausea or vomiting;
normal PO intake for her. She reports she took 2.5 mg coumadin
yesterday after taking 5 mg X 1 week with resultant INR 7.3.
.
ROS: As above. No headaches, slurred speech, confusion. No sore
throat, congestion, difficulty swallowing. No cough or sputum
production. No hematemesis or blood in stool. Chronically has
diarrhea ("IBS" per her report). Has chronic edema from knees to
midchest. No joint pains, rash, or myalgias.
Past Medical History:
Notes for dates: [**Date range (3) 106558**]
[**Doctor Last Name 3271**]-[**Doctor Last Name 679**] A - Last Updated by [**Last Name (LF) **],[**First Name3 (LF) 1037**] on [**2115-9-21**] @ 1328
Patient Location: FA10-1001-01
Intern Accept Note
.
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
Hepatologist: Dr. [**Last Name (STitle) 696**]
.
Intern Accept Note:
.
CC: increased abdominal pain
.
Please see admission H&P for full details of history.
HPI: Ms. [**Known lastname 38403**] is a 61 yo woman with a hx of CRI and WPW
s/p valve replacement on coumadin who presents with anasarca and
acute on chronic renal failure. She has noted increasing girth
for 3 weeks. For the past week she also noticed decreased urine
output.
.
Of note, coumadin had been held for 2 days for increased INR to
7.
.
In the ED, initial vs were: T 94.7 P 65 BP 137/66 R 16 O2 sat
98%. Patient was given no medications in the ED. Her BP did
transiently decrease to 88/48 but came back up to 101/53 without
intervention. US notable for large ascites, labs notable for
creatinine 5.9 and LFTs WNL.
.
On acceptance to the medicine service, Ms. [**Known lastname 38403**] [**Last Name (Titles) **]
dyspnea at rest but does have it with exertion. Further [**Last Name (Titles) **]
chest pain, abdomonial pain, fevers or chills. No dysuria, no
nausea or vomitting. No blood in stools
.
.
Pmhx:
* H/o HIT
* Chronic renal insufficiency (baseline Cr ~ 3)
* h/o diastolic congestive heart failure
* Cirrhosis (thought [**12-22**] heart failure)
* S/p MVR, AVR, TVR (on chronic coumadin), last valve
replacement in [**2085**]
* h/o WPW syndrome status post multiple surgeries with resultant
valve replacements as above, s/p AICD placement
* h/o parathyroid tumor s/p resection
* h/o C diff colitis (several weeks ago at [**Hospital3 **])
* h/o gout
* h/o PVD with chronic leg ulcers
* h/o PUD with GI bleeding
* chronic anemia
* h/o subdural hematoma ([**3-28**]) in setting of supratherapeutic
INR
Social History:
Divorced. Son died 4 years ago from cardiomyopathy. Has one
daughter. Previously lived alone and was independent in ADLS;
recently in rehab but back at home. Previously smoked, one
alcoholic drink per week and [**Month/Year (2) **] illicit drug use. Previously
worked as an aide in nursing homes and hospitals.
Family History:
N/C
Physical Exam:
VS: T 97.8 HR 62 BP 104/69 RR 22 Sat 100% on RA
Gen: NAD
HEENT: mucous membranes moist
Neck: supple, no lad
CV: RRR, loud S1, S2, 2/6 systolic murmur
Resp: L>R crackles in the bases
Abd: distended, nontender, bowel sounds present.
Extrem: 2+ pitting edema, thighs>calves/feet. B/l venous stasis
changes on anterior shins
Breasts: asymmetrical, with L breast edema
Skin: no rash
Neuro: A&O x3, coherent
Pertinent Results:
[**9-20**] US
IMPRESSION: Large amount of ascites, largest pocket in the left
lower and mid
quadrants of the abdomen.
[**2115-9-20**] 07:40PM GLUCOSE-105 UREA N-100* CREAT-6.2* SODIUM-141
POTASSIUM-4.5 CHLORIDE-116* TOTAL CO2-10* ANION GAP-20
[**2115-9-20**] 07:40PM WBC-5.4 RBC-3.55* HGB-10.7* HCT-34.2* MCV-96
MCH-30.0 MCHC-31.2 RDW-19.1*
[**2115-9-20**] 07:40PM NEUTS-77.1* BANDS-0 LYMPHS-12.8* MONOS-7.1
EOS-2.7 BASOS-0.3
[**2115-9-20**] 07:40PM PLT COUNT-82*
[**2115-9-20**] 07:40PM PT-48.3* PTT-47.2* INR(PT)-5.5*
[**2115-9-20**] 05:50AM GLUCOSE-79 UREA N-98* CREAT-5.8* SODIUM-143
POTASSIUM-4.2 CHLORIDE-116* TOTAL CO2-12* ANION GAP-19
[**2115-9-20**] 05:50AM ALT(SGPT)-4 AST(SGOT)-13 LD(LDH)-295* ALK
PHOS-140* TOT BILI-0.7
[**2115-9-20**] 05:50AM CALCIUM-7.8* PHOSPHATE-5.5* MAGNESIUM-2.5
[**2115-9-20**] 05:50AM WBC-4.7 RBC-3.46* HGB-10.6* HCT-33.7* MCV-97
MCH-30.7 MCHC-31.6 RDW-19.4*
[**2115-9-20**] 05:50AM NEUTS-75.7* LYMPHS-13.6* MONOS-6.8 EOS-3.6
BASOS-0.3
[**2115-9-20**] 05:50AM PLT COUNT-87*
[**2115-9-20**] 05:50AM PT-47.2* PTT-50.2* INR(PT)-5.3*
[**2115-9-20**] 05:34AM URINE HOURS-RANDOM UREA N-563 CREAT-114
SODIUM-15 TOT PROT-38 PROT/CREA-0.3*
[**2115-9-20**] 05:34AM URINE OSMOLAL-341
[**2115-9-20**] 02:45AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2115-9-20**] 02:45AM URINE RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2115-9-20**] 02:45AM URINE AMORPH-MOD
[**2115-9-20**] 02:45AM URINE EOS-NEGATIVE
[**2115-9-20**] 12:40AM GLUCOSE-112* UREA N-100* CREAT-5.9*
SODIUM-142 POTASSIUM-4.0 CHLORIDE-115* TOTAL CO2-14* ANION
GAP-17
[**2115-9-20**] 12:40AM ALT(SGPT)-5 AST(SGOT)-13 ALK PHOS-162* TOT
BILI-0.7
[**2115-9-20**] 12:40AM LIPASE-74*
[**2115-9-20**] 12:40AM CALCIUM-8.1*
[**2115-9-20**] 12:40AM AMMONIA-43
[**2115-9-20**] 12:40AM WBC-5.9 RBC-3.93* HGB-11.9* HCT-37.5 MCV-96
MCH-30.2 MCHC-31.7 RDW-19.6*
[**2115-9-20**] 12:40AM NEUTS-76.4* LYMPHS-13.1* MONOS-5.9 EOS-4.1*
BASOS-0.5
[**2115-9-20**] 12:40AM AMMONIA-43
[**2115-9-20**] 12:40AM WBC-5.9 RBC-3.93* HGB-11.9* HCT-37.5 MCV-96
MCH-30.2 MCHC-31.7 RDW-19.6*
[**2115-9-20**] 12:40AM NEUTS-76.4* LYMPHS-13.1* MONOS-5.9 EOS-4.1*
BASOS-0.5
[**2115-9-20**] 12:40AM PLT SMR-LOW PLT COUNT-86*
[**2115-9-20**] 12:40AM PT-52.6* PTT-46.8* INR(PT)-6.1*
[**2115-9-19**] 10:40PM GLUCOSE-113* UREA N-97* CREAT-5.9*#
SODIUM-142 POTASSIUM-4.3 CHLORIDE-116* TOTAL CO2-11* ANION
GAP-19
[**2115-9-19**] 10:40PM estGFR-Using this
[**2115-9-19**] 10:40PM ALT(SGPT)-8 AST(SGOT)-15 ALK PHOS-151* TOT
BILI-0.7
[**2115-9-19**] 10:40PM LIPASE-66*
[**2115-9-19**] 10:40PM ALBUMIN-3.8
Brief Hospital Course:
A 61 yo woman with CRI, WPW s/p 3 mechanical valves, cirrhosis
thought to be cardiac in etiology, presents with acute on
chronic renal failure and ascites.
.
# Renal failure: Creatinine rose from 2.8 to 5.9 in the month
prior to admission. Exam was consistent with anasarca and volume
overload of 20-30 liters. The likely contributing factors were
felt to be poor forward flow (from cardiac failure and from
overdiuresis) with possibly a lesser component of hepatorenal
syndrome. Urinalysis and smear for eosinophils was negative, the
sediment was bland, and there was trivial protein in the urine.
Albumin was given initially, but renal failure persisted and
continued to worsen. Diuretics were held. Plans were made for
dialysis. Given that she was so volume overloaded and had
systolic BP 90-100, CVVH was the preferred initial dialysis
route. After placement of a R tunneled HD catheter, she was
transferred to the ICU for CVVH on [**2115-9-24**].
.
On presenation to the ICU pt was severely fluid overloaded, with
an estimated 30kg weight gain. She was diuresed agressively at a
rate of 300-500ml/hr net, with a total diuresis of approximately
16L. Pt tolerated the fluid removal very well and remained
hemodynamically stable throughout, with SBPs >80s. She was
transferred back to the hepato-renal service.
.
The patient was mildly hypotensive after starting dialysis, and
midodrine treatment was initiated, which improved SBP to 100-110
consistently and helped with orthostatic symptoms. This
medication was continued on discharge.
.
Planning for outpatient dialysis was undertaken, including a
negative PPD and hepatitis panel. The physical therapy team saw
the patient, and her functional status improved considerably.
# cirrhosis/ascites: On admission, the patient appeared to have
worsening diuretic-resistent ascites. SBP was unlikely given
absence of fever or tenderness. Diagnostic paracentesis was not
done secondary to elevated INR and whole-body anasarca. Nadolol
was held given her borderline blood pressures.
.
# Mechanical MV/TV/AV: INR was supratherapeutic on admission.
Given her very high risk for thromboembolism and the absence of
evidence of bleeding, her INR was allowed to drift down slowly.
When the need for a tunneled HD line became apparent, argatroban
was begun so that warfarin effects could be reversed with
Vitamin K. The argatroban was stopped briefly prior to the
procedure and restarted soon after. Warfarin was subsequently
restarted and uptitrated with an ongoing argatroban bridge until
INR was therapeutic at 4-5 (as argatroban falsely elevates INR
by 2.) At that point argatroban was stopped, and the INR drifted
down into the therapeutic range. She was discharged on 5 mg
daily with plans to continue checking her INR at home and have
dose adjustments over the phone as she had been doing prior to
admission.
.
# Atrial fibrillation: During this admission, the patient
developed new atrial fibrillation. She was already undergoing
therapeutic anticoagulation (as above).
.
# History of HIT: All heparin products were avoided, and
argatroban bridge was used instead as above. A non-heparin
dependent tunneled line was placed, and sodium citrate flushes
were used.
# Thrombocytopenia: Platelets were near recent baseline and
likely related to liver dysfunction.
.
# h/o GI bleeding: [**Hospital1 **] PPI was continued
.
# gout: In the CCU, pt developed gout of her right fifth digit.
She was initially treated with Colchicine without response, and
later started on a short course of steroids with rapid
improvement.
Medications on Admission:
coumadin 5 mg daily (X 1 week --> INR to 7), took 2.5 on [**9-19**]
epogen 40,000 U weekly
lasix 120 mg daily
nadolol 20 mg [**Hospital1 **]
potassium 20 mEq daily
protonix 40 mg [**Hospital1 **]
renagel 1600 mg TID
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
primary: end-stage renal disease, atrial fibrillation, gout
secondary: cirrhosis, [**Doctor Last Name 79**]-Parkinson-White syndrome
Discharge Condition:
stable, dialysis-dependent
Discharge Instructions:
You were admitted to the hospital because you had increased
fluid on your body. This was because your kidneys were not
functioning well. In the hospital, a catheter was placed and
dialysis was started to remove the fluid. You were also found
to have an irregular heart rhythm called atrial fibrillation.
The following medications were changed:
lasix was stopped
nadolol was stopped
potassium was stopped
renagel (sevelamer) was stopped
nephrocaps (B-vitamin-B12-folate) were started
midodrine was started.
Please call your physician or return to the ED if you have
worsening swelling, shortness of breath, chest pain, or other
symptoms that are concerning to you. Please adhere to a low
sodium (<2 gm/day) diet.
Followup Instructions:
For your Coumadin, please take 5 mg today ([**10-9**]) and test your
INR on Thursday, [**10-10**]. Call the coumadin clinic as usual. They
will change your dosing as needed.
.
Please follow up for dialysis on [**10-11**] as you discussed
with the renal team.
.
Please follow up with Dr. [**Last Name (STitle) **] on Thursday, [**10-10**],
at 2:15. If you need to reschedule call [**Telephone/Fax (1) 106559**].
.
We also scheduled an appointment with Dr. [**Last Name (STitle) 696**]:
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2115-10-31**]
4:40
Completed by:[**2115-10-9**]
|
[
"5849",
"2762",
"4280",
"V5861",
"42731",
"2875",
"2767"
] |
Admission Date: [**2159-11-12**] Discharge Date: [**2159-11-21**]
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: Patient is an 88-year-old who is
a retired former GM worker who has cardiac history that dates
back to [**2140**] when he was admitted to an outside hospital with
chest pain, shortness of breath and diaphoresis after
shoveling snow at which time ECG was consistent with an acute
inferior MI with a CK peaking at 1273 with 20% MB. He was
originally seen by Dr. [**Last Name (STitle) 5874**] in consultation in 10/98
complaining of dyspnea on exertion.
There is a chest x-ray from [**2154-5-19**] showing cardiomegaly
without congestive heart failure. Chest x-ray in [**2155-8-11**] was consistent with mild congestive heart failure.
The patient was seen at an outside hospital on [**10-1**]
and admitted with diagnosis of congestive heart failure. The
patient on [**10-15**] saw Dr. [**Last Name (STitle) 5874**] in the office and
reported feeling significantly improved since he started
Lasix after his hospitalization.
He denies any orthopnea, PND, palpitations or actual syncope,
although according to his daughter, he has fallen a couple of
times getting out of the bathtub. He has noticed some ankle
swelling. According to his daughter, the patient is
currently back to his usual baseline. There is no history of
alcohol use.
An echo in [**2159-9-18**] demonstrated normal LV chamber size
and systolic function with mild concentric left ventricular
hypertrophy with dilated right atrium and left atrium with
moderate mitral regurgitation and tricuspid regurgitation and
mild aortic insufficiency with at least moderate pulmonary
hypertension.
PAST MEDICAL HISTORY:
1. Significant for atrial fibrillation.
2. Coronary artery disease.
3. Congestive heart failure.
The patient's work up revealed severe three vessel disease,
three vessel coronary artery disease with preserved ejection
fraction.
HOSPITAL COURSE: The patient was admitted on [**2159-11-12**], the
same day as his surgery. He was taken to the Operating Room
and a coronary artery bypass times three vessels was
performed. The LMA was brought to the LAD, SVG was brought
to the OM, SVG was brought to the distal RCA. Cardiac bypass
time was 79 minutes. Cross clamp time was 41 minutes.
The patient was brought to the Cardiothoracic Surgery
Intensive Care Unit postoperatively. Patient on
postoperative day #1 remained intubated with a normal
arterial blood gas. PH was 7.32, pCO2 of 40, pO2 of 152,
bicarbonate 22.
On postoperative day #2, the patient was extubated without
complication and maintained his oxygen saturation. Patient's
urine output was maintained and he was diuresed with IV
Lasix. Chest tubes were discontinued and the patient was
subsequently discharged to the Surgery floor.
Patient's postoperative course was complicated by occasional
rapid atrial fibrillation for which the patient was on
Inderal previously and was subsequently switched to Toprol 25
mg p.o. b.i.d. He maintained his ventricular rate well from
the 70s to the 90s.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To rehab.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: Follow up with Dr. [**Last Name (Prefixes) **] in
four weeks. Follow up with Dr. [**Last Name (STitle) 5874**] in one to two
weeks.
DISCHARGE DIAGNOSES: Coronary artery disease, status post
coronary artery bypass times three vessels.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2159-11-20**] 11:56
T: [**2159-11-21**] 10:23
JOB#: [**Job Number 47329**]
|
[
"41401",
"4280",
"42731",
"412"
] |
Admission Date: [**2163-3-25**] Discharge Date: [**2163-4-3**]
Date of Birth: [**2083-11-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2163-3-25**] - 1. Aortic valve replacement with a size 23-mm
[**Last Name (un) 3843**]-[**Doctor Last Name **] Magna-Ease tissue valve. 2. Coronary artery
bypass graft times 1; saphenous vein graft to right coronary
artery.
History of Present Illness:
79 year old male with severe aortic stenosis demonstrated by
echocardiogram performed [**2163-1-26**] with [**Location (un) 109**] 0.6-0.8 cm2 and
peak/mean gradients of 141/76 mmHg. He was also noted to have
mild mitral stenosis with calcified mitral apparatus and severe
mitral annular calcification. He reports shortness of breath
with any activity, especially when climbing one flight of stairs
and is relieved after 3-4 minutes of rest. He also describes
bilateral lower extremity edema half way up to knees with left
greater than right. He reports difficulty
breathing when first rising in the morning which is resolved
with use of his inhaler. He was referred for cardiac
catheterization. He was found to have coronary disease upon
cardiac catheterization. He is now being referred to cardiac
surgery for revascularization and an aortic valve replacement.
Past Medical History:
Aortic stenosis
Heart Murmur
Hypertension
COPD
Obesity
Renal insufficiency (baseline crt 1.1)
Gout
History of anemia
Mild History ofcolitis
Polymyalgia rheumatica
Low back pain
Elevated PSA
History of basal cell cancer lesion removal [**2135**], again in [**2160**],
Osteoarthritis
Pilonidal cyst x2
Mitral stenosis
Social History:
Race:Caucasian
Last Dental Exam:[**2156**]
Lives with:Wife
Contact:[**Name (NI) **] [**Name (NI) 3535**] (wife) Phone# [**Telephone/Fax (1) 110795**]
Occupation:Retired Episcopal priest
Cigarettes: Smoked no [] yes [x] quit 15 years ago, smoked for
45
years 1 ppd
Other Tobacco use:denies
ETOH:[**2-7**] scotch drinks daily
Illicit drug use:denies
Family History:
Premature coronary artery disease- Mother with
valve replacement in her 80's from which she "never recovered";
sister with pacemaker
Physical Exam:
Pulse:81 Resp:18 O2 sat:93/RA
B/P Right:130/70 Left:135/67
Height:5'8.5" Weight:240 lbs
General: NAD, overweight
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 [] grade _3/6 SEM_
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x], obese
Extremities: Warm [x], well-perfused [x] Edema [x] 1+
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
radiation of cardiac murmur
Pertinent Results:
[**2163-3-25**] ECHO
PREBYPASS
Preserved LV systolic funciton with LVEF > 55% and not SWMA.
Severe AS with valve area < 1.0 cm2 and severe calcification of
mitral valve - aortic valve interannular fibrosa with
significant MV inflow obstruction. MV area by pressure half time
is around 1.3-1.5 cm2, MVA by PISA is 1.0 cm2. Mean gradient is
7-8 mmHg and peak grad is 14-18 mmHg for Mitral inflow
consistent with severe MS. The left atrium is markedly dilated.
No thrombus is seen in the left atrial appendage. There is
severe symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. 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 are severely thickened/deformed. There is severe
aortic valve stenosis (valve area 0.8-1.0cm2). The mitral valve
leaflets are severely thickened/deformed. There is moderate
valvular mitral stenosis (area 1.0-1.5cm2). There is at least
moderate functional mitral stenosis (mean gradient 7-8 mmHg) due
to mitral annular calcification. There is no pericardial
effusion. Normal TV and PV. Intact IAS. Normal coronary sinus.
POSTBYPASS:
S/P AVR + CABG. Normally functioning AV prosthesis. No sig AS or
AI. Otherwise Unchanged.
[**2163-3-31**] 04:41AM BLOOD WBC-6.6 RBC-3.24* Hgb-10.0* Hct-30.8*
MCV-95 MCH-30.9 MCHC-32.5 RDW-13.9 Plt Ct-197
[**2163-3-30**] 08:55AM BLOOD WBC-7.7 RBC-3.56* Hgb-10.9* Hct-34.1*
MCV-96 MCH-30.5 MCHC-31.9 RDW-13.7 Plt Ct-195
[**2163-3-30**] 04:47AM BLOOD WBC-9.9 RBC-3.62* Hgb-10.9* Hct-34.6*
MCV-96 MCH-30.0 MCHC-31.3 RDW-13.7 Plt Ct-188
[**2163-3-31**] 04:41AM BLOOD Glucose-104* UreaN-58* Creat-1.4* Na-138
K-3.4 Cl-100 HCO3-27 AnGap-14
[**2163-3-30**] 08:55AM BLOOD Glucose-95 UreaN-59* Creat-1.5* Na-141
K-4.8 Cl-105 HCO3-22 AnGap-19
[**2163-3-30**] 04:47AM BLOOD Glucose-100 UreaN-58* Creat-1.5* Na-139
K-4.0 Cl-101 HCO3-24 AnGap-18
[**2163-3-31**] 04:41AM BLOOD PT-24.9* PTT-31.5 INR(PT)-2.4*
[**2163-3-30**] 09:00AM BLOOD PT-15.2* INR(PT)-1.4*
[**2163-3-29**] 02:29AM BLOOD PT-13.5* PTT-30.9 INR(PT)-1.3*
Brief Hospital Course:
The patient was brought to the operating room on [**2163-3-25**] where
the patient underwent an aortic valve replacement and coronary
artery bypass grafting. Please see operative note for details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 2 found the
patient extubated, alert and oriented and breathing comfortably.
He did need aggressive pulmonary toilet and was kept in the unit
for several days post op due to respiratory issues. He did use
BIPAP at night and will need a sleep study as an outpatient to
further assess OSA. 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. He did have post
operative ATN and peak creatinine was 2.4. His baseline was 1.1
and creatinine was 1.5 decreasing towards his baseline at the
time of discharge. The patient was transferred to the telemetry
floor for further recovery. Chest tubes and pacing wires were
discontinued without complication. he developed post-operative
atrial fibrillation and was treated with amiodarone and coumadin
tehrpay. He developed serous drainage from his mid sternal pole
and Kefzol was added. He was afebrile and WBC was normal at the
time discharge with scant old bloody sternal drainage from the
distal pole (mid sternal drainage had resolved). The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 9 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to home in good condition with appropriate follow up
instructions.
Medications on Admission:
ALLOPURINOL 300 mg Daily
ATENOLOL 25 mg Daily
SYMBICORT 80 mcg-4.5 mcg/actuation HFA Aerosol Inhaler - two
puffs inhaled twice a day
FELODIPINE 10 mg Daily
GREEK ISLAND LABS NATURAL JOINT Dosage uncertain
HYDROCHLOROTHIAZIDE 25 mg Daily
IPRATROPIUM-ALBUTEROL 18 mcg-103 mcg (90 mcg)/actuation Aerosol
-
two puffs inhaled four times a day as needed
LISINOPRIL 40 mg Daily
QUININE SULFATE [QUALAQUIN] 324 mg once a day as needed for leg
cramps
ASPIRIN 81 mg Daily
MAGNESIUM 250 mg Daily
MULTIVITAMIN Dosage uncertain
Discharge Medications:
1. Outpatient Lab Work
Labs: PT/INR
Coumadin for post-op AFib
Goal INR 2-2.5
First draw day after discharge
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 6589**] [**Telephone/Fax (1) 6590**]
Results to fax [**Telephone/Fax (1) 110796**]
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. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
for 7 days then 200mg ongoing .
Disp:*60 Tablet(s)* Refills:*2*
4. felodipine 2.5 mg Tablet Extended Release 24 hr Sig: Four (4)
Tablet Extended Release 24 hr PO DAILY (Daily).
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for
sob/wheezing.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 10 days: then resume Hydrochlorothyazide.
Disp:*20 Tablet(s)* Refills:*0*
7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
10. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
11. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. warfarin 2.5 mg Tablet Sig: daily per INR Tablet PO once a
day: Indication Afib
goal INR 2.0-2.5.
Disp:*45 Tablet(s)* Refills:*2*
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
14. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily) for 10 days: while
on lasix.
Disp:*20 Tablet Extended Release(s)* Refills:*0*
15. Ultram 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary Artery Disease, Severe Aortic Stenosis, post-op atrial
fibrillation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
[**12-6**]+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Coumadin for post-op AFib
Goal INR 2-2.5
First draw [**2163-4-4**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 6589**] [**Telephone/Fax (1) 6590**]
Results to fax [**Telephone/Fax (1) 110796**]
Followup Instructions:
You are scheduled for the following appointments:
Wound Check, Thursday, [**2163-4-7**], 10:45am at Dr.[**Name (NI) 11272**] office in
the [**Hospital **] medical office building [**Hospital Unit Name **], [**Doctor First Name **].
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**], [**2163-5-3**] 1:00 in the [**Hospital **]
medical office building [**Hospital Unit Name **], [**Doctor First Name **].
Cardiologist Dr. [**Last Name (STitle) 110797**] (office will call you with appt)
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],LINI S [**Telephone/Fax (1) 6590**] in [**3-10**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR
Coumadin for post-op AFib
Goal INR 2-2.5
First draw [**2163-4-4**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by Dr. [**Last Name (STitle) 6589**] [**Telephone/Fax (1) 6590**]
Results to fax [**Telephone/Fax (1) 110796**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2163-4-3**]
|
[
"5845",
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"42731",
"41401",
"2767",
"2875",
"4019",
"2859",
"496",
"V1582"
] |
Admission Date: [**2116-3-11**] Discharge Date: [**2116-3-17**]
Date of Birth: [**2037-5-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
AVR([**Street Address(2) 76617**] tissue valve) [**3-13**]
History of Present Illness:
78 yo F with history of AS followed by echo. Found to have
increased murmur at last visit, referred for cath which showed
[**Location (un) 109**] 0.44 and clean coronaries. She was referred for surgery.
Past Medical History:
HTN, ^lipids, DM II, Hypothyroidism, s/p radiation, Hemorrhoids,
c-section x 2, appy, bladder suspensionx2, radiation to tonsills
as a child, thyroid surgery x2, skin cancer removal on nose
Social History:
works part time
no tobacco\no etoh
Family History:
denies
Physical Exam:
NAD, flat after cath HR 57 RR 16 BP 135/67
Lungs CTAB ant/lat
Heart RRR, SEM->carotids
Abdomen Soft, NT, ND, well healed [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 924**] warm, no edema, some varicosities Pulses 2+ t/o
Pertinent Results:
[**2116-3-16**] 05:00AM BLOOD WBC-10.6 RBC-3.21* Hgb-10.0* Hct-28.6*
MCV-89 MCH-31.3 MCHC-35.1* RDW-13.8 Plt Ct-139*
[**2116-3-16**] 05:00AM BLOOD Plt Ct-139*
[**2116-3-13**] 10:29PM BLOOD PT-14.4* PTT-31.1 INR(PT)-1.2*
[**2116-3-16**] 05:00AM BLOOD Glucose-133* UreaN-17 Creat-0.8 Na-135
K-4.4 Cl-99 HCO3-28 AnGap-12
CHEST (PORTABLE AP) [**2116-3-15**] 12:46 PM
CHEST (PORTABLE AP)
Reason: PTX
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman s/p chest tube removal
REASON FOR THIS EXAMINATION:
PTX
CHEST, SINGLE VIEW, ON [**3-15**].
HISTORY: Chest tube removal.
REFERENCE EXAM: [**3-14**].
FINDINGS: Compared to the prior day, the mediastinal drains have
been removed. There continue to be moderate bilateral pleural
effusions with lower lobe volume loss. An underlying infiltrate
cannot be excluded in the lower lobes. The patient is status
post sternotomy.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 247**] [**Hospital1 18**] [**Numeric Identifier 76618**] (Complete)
Done [**2116-3-13**] at 3:45:03 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2037-5-4**]
Age (years): 78 F Hgt (in): 63
BP (mm Hg): 142/82 Wgt (lb): 155
HR (bpm): 64 BSA (m2): 1.74 m2
Indication: Intra-op TEE for AVR
ICD-9 Codes: 440.0, 424.1
Test Information
Date/Time: [**2116-3-13**] at 15:45 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.7 cm
Left Ventricle - Fractional Shortening: *0.26 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 3.5 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *4.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *99 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 54 mm Hg
Aortic Valve - LVOT diam: 1.9 cm
Aortic Valve - Valve Area: *0.4 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic root. Focal calcifications in aortic root.
Focal calcifications in ascending aorta. Normal aortic arch
diameter. Simple atheroma in aortic arch. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: ?# aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Mild to moderate ([**2-12**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. No MS. Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
The post-bypass study was performed while the patient was
receiving vasoactive infusions (see Conclusions for listing of
medications).
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic root. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
5. The number of aortic valve leaflets cannot be determined. The
right and left coronary cusps are fused giving the appearance of
a bicuspid valve. There is severe aortic valve stenosis (area
0.4 cm2). Mild to moderate ([**2-12**]+) aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and was
initially being AV paced and then was in sinus rhythm.
1. A bioprosthetic aortic valve is noted, well seated. Leaflets
open well. Mean gradient across the valve is 18 mm of Hg. A
small perivalvular jet is noted arising from the right coronary
portion of the valve. This jet diminished significantly with
protamine administration.
2. Biventricular function is preserved.
3. Aorta is intact post decannulation.
4. Other findings are unchanged
Brief Hospital Course:
She was admitted to CMI post cath. She was seen by cardiac
surgery. She awaited carotid u/s, chest CT and dental clearance
prior to surgery. She was taken to the operating room on [**3-13**]
where she underwent AVR. She was given 48 hours of vancomycin as
she was in the hospital preoperatively. She was transferred to
the ICU in stable condition. She was extubated on POD #1. She
was transferred to the floor on POD #2. She did well
postoperatively and was ready for discharge home on POD #4.
Medications on Admission:
Fosamax 70', norvasc 5', synthroid 88', MVI, quinapril 20',
zocor 40'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(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. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*50 Tablet(s)* 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. Quinapril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
AS s/p AVR
HTN, ^lipids, DM II, Hypothyroidism, s/p radiation, Hemorrhoids,
c-section x 2, appy, bladder suspensionx2, radiation to tonsills
as a child, thyroid surgery x2, skin cancer removal on nose
AS s/p AVR
HTN, ^lipids, DM II, Hypothyroidism, s/p radiation, Hemorrhoids,
c-section x 2, appy, bladder suspensionx2, radiation to tonsills
as a child, thyroid surgery x2, skin cancer removal on nose
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**First Name (STitle) **] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Dr. [**First Name (STitle) **] 2 weeks
Completed by:[**2116-3-17**]
|
[
"4241",
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"4019",
"2449",
"25000"
] |
Admission Date: [**2112-2-10**] Discharge Date: [**2112-2-12**]
Date of Birth: [**2034-6-18**] Sex: F
Service: CICU
CHIEF COMPLAINT: Back pain and chest pain.
HISTORY OF PRESENT ILLNESS: This is a 77-year-old female
with a past medical history significant for coronary artery
disease, hypertension, and temporal arteritis, who had a
sudden onset of back pain radiating to the chest wall wiping
off her car at 10:45 on the morning of admission. The
patient denies any history of chest pain, this type of back
pain, no history of lower back pain. The patient describes
pain as in the interscapular radiating to her chest [**11-11**] and
constant. Pain is associated with diaphoresis, but no
nausea, vomiting, shortness of breath.
The pain is currently [**5-12**] when she arrived in the CCU. The
patient called her daughter, who brought her to [**Name (NI) **]
[**Name (NI) **] triage at 12 pm there, and her blood pressure on
admission was 202/110, pulse of 79. She had 8/10 chest pain.
At that point, her electrocardiogram showed normal sinus
rhythm at a rate of 70, normal axis, and normal intervals. Q
in III, and T-wave inversion in V1, T wave flattening in V2.
No change from an electrocardiogram done on [**2111-1-30**]
at the outside hospital.
The patient at the outside hospital was treated with
sublingual nitroglycerin x3 with resolution of the chest
pain, but her back pain was still present, and the blood
pressure remained elevated at 195/68 in the right and 185/60
to the left. The patient was given a total of 60 mg of
Morphine with a relief of the pain of [**3-14**]. She was also
given intravenous Lopressor 50 mg total. Her blood pressure
at that point was 190/70 and heart rate of 70. She had a CT
scan of the chest with contrast which showed acute versus
chronic descending aortic dissection not extending to the
renal arteries. The patient was then transported to the [**Hospital1 1444**] Emergency Room for further
management.
Here, the patient was started on an Esmolol
drip and she remained chest pain and back pain free.
However, her blood pressure remained elevated at 213/87. She
was started on Nipride drip at 2 mcg/kg/minute, however, the
patient then became hypotensive 90/palp, and Nipride was
turned off, and she was restarted on Nipride at a much lower
dose with the Esmolol, and her blood pressure normalized at
135/65.
Patient was seen by CT Surgery, who saw no need for surgical
intervention because the patient had a descending aortic
aneurysm. They recommended a followup CT scan in six months
and every six months to evaluate the dissection.
PAST MEDICAL HISTORY:
1. Hypertension at least 20 years in duration and normal
blood pressure roughly around 150/80 that she takes at home.
2. Silent myocardial infarction in [**2110**] and history of
coronary artery disease. She had a Thallium stress in
[**2110-2-3**] which revealed a reversible inferolateral
defect and posterior bibasilar scar, but the patient refused
cardiac catheterization at that time.
3. Temporal arteritis x4 years diagnosed after headaches.
4. Status post cataract surgery x2.
5. Status post right partial lobectomy for a collapsed lung
30 years ago of uncertain etiology. Of note, the patient
denies this history, but it is noted from our outpatient
cardiologist, Dr. [**Last Name (STitle) 35643**].
MEDICATIONS:
1. Atenolol 100 mg po q day.
2. Prednisone, Prilosec, and Norvasc 5 mg po q day.
3. Imdur 60 mg po q day.
ALLERGIES: The patient had previously taken Lipitor, but had
a myositis with a response of Lipitor, and therefore she has
an allergy to Lipitor noted on her records.
FAMILY HISTORY: Patient had a sister who died of a
myocardial infarction at 62, and a father died of a
myocardial infarction at 49. There is no known family
history of cancer, diabetes, stroke. She has a daughter with
hypertension.
SOCIAL HISTORY: Patient lives alone in [**Hospital1 **]. She has a
daughter who lives five minutes away. The patient does all
of her own cooking and cleaning. She has no history of
alcohol abuse. She quit smoking 30 years ago. She is a
widow.
REVIEW OF SYSTEMS: No headache, no visual changes, no chest
pain, no palpitations, lightheadedness, or dizziness. No
fevers, chills, nausea, vomiting, no cough, or shortness of
breath. She had two episodes of nausea on arrival, and no
diarrhea or abdominal pain.
PHYSICAL EXAMINATION: On presentation in the Cardiac
Intensive Care Unit, the patient had a temperature of 98.6,
blood pressure of 105/60, and a heart rate of 78. She is
breathing 18. Sating 94% on room air. In general, she is in
no acute distress. She is alert and oriented times three.
She had no cardiac bruits, no jugular venous distention.
Heart was regular, rate, and rhythm, normal S1, S2. Lungs
are clear to auscultation bilaterally without wheezes or
crackles. Abdomen is soft, nontender, nondistended, normal
bowel sounds. Extremities were without clubbing, cyanosis,
or edema. Neurologically she was alert and oriented times
three. Cranial nerves II through XII are intact. Strength
is [**6-6**] upper extremities and lower extremities bilaterally
symmetric. She has no focal findings.
ELECTROCARDIOGRAM: As previously mentioned.
LABORATORY DATA: Patient had a white blood cell count of
15.4, 89% neutrophils, 7% lymphocytes, hematocrit of 36.2,
and platelets of 388. She had an INR of 1.1, PT of 12.8 and
PTT of 25.2, sodium of 140, potassium 4.2, chloride 102,
bicarb 22, BUN 14, creatinine 0.4, glucose of 113. Her CK
was 90 at the outside hospital, 75 here, and then 83. MBs
were not done. MB index is not calculated. Her troponins
were negative. She had a urinalysis at the outside hospital
which showed ketones, trace blood, no protein, no leukocyte
esterase, and no nitrites.
She had a CT scan at the outside hospital read by the [**Hospital1 **] senior attending, who read a descending
aortic dissection DeBakey-type III, type A. She also had a
question of a mass in her extra-thoracic along the patient's
stomach although she has a history of hiatal hernia. She had
a chest x-ray which showed clear, no evidence of congestive
heart failure or mediastinum.
Of note, she has a past cardiac workup including the
following: An echocardiogram in [**2111-4-3**] which showed a
normal left ventricular size with low systolic dysfunction.
She had akinesis of the posterior basilar wall. Normal wall
thickness and left ventricular ejection fraction of 55%. LA
was normal size, mild MR, trace AR. Estimated pulmonary
artery pressure 28. She had a Thallium stress test done in
[**2110-2-3**] which showed moderate areas of decreased
Thallium uptake in the inferolateral region which resolved
with rest and there was a fixed defect in the posterior
basilar region, and the patient refused a cardiac
catheterization.
Of note, the patient's total cholesterol was 206, LDL of 133,
and HDL of 58, triglycerides of 73.
HOSPITAL COURSE:
1. Cardiovascular: As mentioned, this patient came in with
back pain, some mild chest pain at that point, and elevated
blood pressures treated with Esmolol and nitroglycerin drip
which were titrated to give her a blood pressure of roughly
130-140 systolic. Her back pain completely resolved by the
second day of hospitalization, and her blood pressures
remained stable as did her heart rate in the generally the
70s or 80s normal sinus rhythm. The CT scan was read as a
possible acute and chronic dissection of the thoracic aorta.
It is hypothesized that the patient was wiping off her car,
had some discomfort, which raised her blood pressure. It
subsequently led to the dissection either initiation of
dissection or worsening of chronic dissection.
There is otherwise no clear etiology of the sudden increase
in her chronic hypertension, so it is hypothesized that it
could be an extension of the dissection to the renal artery,
however, there is no evidence of this on CT scan. Her
creatinine did not bump during her hospital admission. She
was subsequently transitioned from IV nitroglycerin and
Esmolol to metoprolol, and restarted on her Isodur, and her
Norvasc at 5 mg po q day. Her blood pressure was 118 the
afternoon of discharge. She was sent home on metoprolol
instead of atenolol. The other blood pressure medications
remained unchanged.
From a coronary artery disease standpoint, there were no
symptoms or electrocardiogram changes, and she has no
ischemic disease at this point, and there is no indication
for cardiac catheterization or further stress test. As
mentioned previously, the patient would qualify for statin
therapy, however, given her previous myositis from starting
Lipitor, that she was refrained from starting it again.
2. Rheumatologic: The patient has a history of temporal
arteritis, so she was continuing on her prednisone 5 mg po q
day alternating with 2.5 mg po q day.
3. Hematologic: The patient had a drop in her hematocrit
from admission from 36.3 to 28.7, however, it was
subsequently at 33.3 without any transfusions and remained
stable. There was no evidence of acute bleed. She is guaiac
negative.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSES:
1. Chronic and possibly acute descending aortic dissection.
2. Hypertension.
3. Temporal arteritis.
4. Coronary artery disease.
DISCHARGE MEDICATIONS:
1. Isosorbide mononitrate 60 mg po q day.
2. Metoprolol 50 mg po bid.
3. Amlodipine 5 mg po q day.
4. Prednisone 5 mg po qod and 2.5 mg po qod.
5. Aspirin 325 mg po q day.
FOLLOW-UP PLAN: The patient has an appointment with Dr.
[**Last Name (STitle) 35643**], her cardiologist on Wednesday, [**2-17**] at 10
o'clock in the morning. She is also to call her internist,
Dr. [**Last Name (STitle) **] for an appointment in one week after discharge.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2112-2-12**] 15:45
T: [**2112-2-15**] 07:52
JOB#: [**Job Number 45853**]
|
[
"41401"
] |
Admission Date: [**2176-7-2**] Discharge Date: [**2176-7-4**]
Date of Birth: [**2138-11-15**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
PICC line [**2176-7-3**]
History of Present Illness:
Ms. [**Known firstname 26442**] [**Known lastname 11952**] is a 37 year old woman with a history of
[**Known lastname 14165**] cell disease and ulcerative colitis who presents to the
Emergency Department for the third time since [**2176-6-15**] with
complaints of pain. She reports feeling increased pain
overnight. She started taking her dilaudid po and took up 6 mg
with only minimal relief.
.
In ED, initial vital signs were T 98.4 HR 100 BP 107/79 RR 22
SpO2 98%. She became increasingly tachycardic to 130s. She
received 3 L NS IVF, zofran 4 mg IV once, dilaudid po 2mg once,
dilaudid IV 1 mg x 6 with persistent tachycardia and poorly
controlled pain. She developed a fever of 102.9 and was given
acetaminophen 1 gram, ceftriaxone 1 g IV, and vancomycin 1 g IV.
Patient reportedly became diffusely pruritic with vancomycin
infusion. CXR and UA were unremarkable. Vitals on transfer to
the ICU were T 102.9, BP 128/76, HR 123, SpO2 99% RA.
.
On arrival to the floor she admits to diffuse discomfort in her
lower back and bilateral legs. She denies any nausea or vomiting
but admits to decreased po intake. She reports her most recent
UC flare was a month ago and did not require any antibiotics.
She had a colonoscopy performed [**5-/2176**] showing diffuse mild
colitis. She was instructed to start asacol but did not initiate
this medication yet. She denies abdominal pain, chest pain,
shortness of breath, diarrhea, dysuria, constipation. She
admits to some blood with bowel movements multiple times each
week which has increased in recent weeks. She denies melena. She
uses Mirena IUD for contraception. She only occasionally has
vaginal spotting.
.
Review of systems: Per HPI.
Past Medical History:
[**Year (4 digits) **] Cell Disease followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Iron deficiency anemia dx [**2175**] and treated with infusions of
ferumoxytol as well as oral ferrous sulfate supplementation.
Ulcerative Colitis dx [**2172**] most recent colonoscopy [**2176-5-29**] with
evidence of diffuse mild colitis.
Proliferative retinopathy s/p laser surgery [**2164**]
s/p Cholecystectomy for salmonella infection
Social History:
She works full time in the pharmacy at [**Hospital6 **]. She
lives with two children who are currently visiting their father
in [**Name (NI) 4708**]. She reports being under significant stress
recently as her father was diagnosed with "brain cancers" and
was just discharged from [**Hospital1 18**] to [**Hospital3 **].
Family History:
Denies known family history of inflammatory bowel disease. Her
children and brothers and sisters have [**Name2 (NI) 14165**] cell trait.
Physical Exam:
ADMISSION EXAM
VS: HR 111, BP 103/48, RR 19 SpO2 99% RA
GA: AOx3, uncomfortable, tired, not in distress
HEENT: PERRLA. MMM. no JVD. neck supple.
Cards: Tachycardic, RR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, +BS. no g/rt. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: No rashes, no ecchymosis
Neuro/Psych: CNs II-XII intact. 5/5 strength and sensation in
U/L extremities.
Pertinent Results:
ADMISSION LABS:
.
[**2176-7-2**] 03:28PM GLUCOSE-93 UREA N-6 CREAT-0.5 SODIUM-135
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-22 ANION GAP-11
[**2176-7-2**] 03:28PM ALT(SGPT)-16 AST(SGOT)-49* CK(CPK)-36 ALK
PHOS-85 TOT BILI-1.4
[**2176-7-2**] 03:28PM CK-MB-1 cTropnT-<0.01
[**2176-7-2**] 03:28PM CALCIUM-7.2* PHOSPHATE-2.8 MAGNESIUM-1.4*
[**2176-7-2**] 03:28PM FERRITIN-222*
[**2176-7-2**] 03:28PM WBC-10.9 RBC-2.13* HGB-5.8* HCT-17.0* MCV-80*
MCH-27.0 MCHC-33.7 RDW-25.1*
[**2176-7-2**] 03:28PM PLT COUNT-639*
[**2176-7-2**] 01:55PM LACTATE-2.3*
[**2176-7-2**] 09:49AM URINE UCG-NEGATIVE
[**2176-7-2**] 09:10AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2176-7-2**] 09:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2176-7-2**] 08:12AM GLUCOSE-82 K+-4.5
[**2176-7-2**] 08:00AM GLUCOSE-81 UREA N-9 CREAT-0.5 SODIUM-135
POTASSIUM-5.2* CHLORIDE-104 TOTAL CO2-24 ANION GAP-12
[**2176-7-2**] 08:00AM WBC-15.8* RBC-2.66* HGB-7.3* HCT-21.5*
MCV-81* MCH-27.5 MCHC-34.0 RDW-25.1*
[**2176-7-2**] 08:00AM NEUTS-54 BANDS-2 LYMPHS-36 MONOS-4 EOS-4
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-8*
[**2176-7-2**] 08:00AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-OCCASIONAL ELLIPTOCY-OCCASIONAL
[**2176-7-2**] 08:00AM RET AUT-11.8*
HCT Trend:
[**2176-7-4**] 12:50 25.9*
[**2176-7-4**] 06:55 24.5*
[**2176-7-4**] 02:05 23.7*
[**2176-7-3**] 15:22 24.9*
[**2176-7-3**] 05:28 24.8*1
[**2176-7-2**] 15:28 17.0*
[**2176-7-2**] 08:00 21.5*
.
[**2176-7-2**] Blood cx: negative as of day of discharge, final
results still pending
.
Imaging:
.
[**2176-7-2**] CXR: (prelim) no acute process; unchanged from CXR on
[**2176-6-19**]
.
[**2176-7-2**] EKG: sinus tachycardia, rate 127, na/ni, no ST-T wave
changes
.
Brief Hospital Course:
37 year old F with history of Hc SC Disease and UC admitted for
[**Month/Day/Year 14165**] cell pain cirsis in setting of UC flair.
#[**Month/Day/Year **] cell disease - Likely triggered by dehydration and GI
blood loss anemia from UC flair. Treated with 2U pRBC, O2, IVF,
folic acid, and narcotic analgesics. Pts HCT initially was 17 on
admission and stabilized at 25 after transfusions. [**Month (only) 116**] be a
candidate for hydroxyurea as outpatient, pt will follow with Dr.
[**Last Name (STitle) **]. Pt has had increased UC flairs within the last few months
that keep triggering [**Last Name (STitle) 14165**] cell pain crises. Patient aware of
the importance of controling UC to prevent recurrent [**Last Name (STitle) **] pain
crises.
#Ulcerative Colitis Flair: Patient with diffuse mild colitis on
most recent colonoscopy [**5-25**]. She was instructed to start asacol
but had not started this medication yet. Pt had several episodes
of bloody diahrea while inaptient. Pt was started on asacol
1200mg TID and Fe supplements while inpatient. She had
improvement of symptoms and decreased bloody stool. Pt will
follow with GI outpatient.
#Tachycardia - EKG shows sinus tachycardia, likely explained by
pain, dehydration, fever, anemia. Resolved with IVF, blood, and
pain control. Pt's HR was in the 80's on day of discharge.
#Fever/leukocytosis - Attributed to [**Month/Year (2) 14165**] crisis. Infectious
workup negative to date. Elevated WBC count and fever on
admission initially concerning for infection. However patient
was without localizing symptoms and UA and CXR were
unremarkable. Fever and leukocytosis likely a response to her
[**Month/Year (2) 14165**] cell crisis. WBC trended down 11->10 on day of discharge.
# Anemia: Multifactorial. Likely due to iron deficiency from GI
blood loss, chronic disease of colitis, and [**Month/Year (2) 14165**] cell
destruction. Hct at presentation was 17 with fluid
resuscitation. She was given folic acid, ferrous sulfate, 2
UPRBC, and HCT stabalized at 25.
#Vtach: Patient was on Tele throughout hospitalization. Tele
reported 7 beats of Vtach and patient felt palpitations that
quickly resolved. EKG unremarkable. Her electrolytes were within
normal limits from earlier that morning, however, she was given
extra potassium and magnesium to ensure adequate levels. She had
no further episodes. She was scheduled for outpatient
echocardiogram.
Medications on Admission:
Folate 1 mg daily
Ferrous Sulfate 325 mg po daily
Dilaudid 2 mg po prn
Motrin prn
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
once daily PRN as needed for constipation.
4. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
Disp:*270 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO q4hrs PRN as
needed for pain.
Disp:*16 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
1)[**Month/Year (2) **] Cell Pain Crisis
2)Ulcerative COlitis Flair
3)Anemia
4)Ventricular tachycardia- non-sustained
5)Sinus Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to provide care for you during your
hospitalization.
You were admitted for [**Month/Year (2) 14165**] cell pain crisis as well as an
ulcertaive colitis flair. It was thought that the ulcerative
colitis flair caused blood loss and anemia which then triggered
the [**Month/Year (2) 14165**] cell pain crisis. For this reason, it is important
that our next goal is to focus on management of your ulcerative
colitis.
For your [**Month/Year (2) 14165**] cell pain crisis, you were given oxygen, fluids,
pain medications, and blood transfusion. Your symptoms improved
and you were sent home on your home dialudid regimen.
For your ulcerative colitis, you were started on Asacol. It is
very important that you take this medication to prevent
worsening of your colitis and another pain crisis. You will meet
with Dr. [**Last Name (STitle) 2161**] very soon to discuss how best to manage the
ulcerative colitis. Continue to take this medication every day
until you see Dr. [**Last Name (STitle) 2161**].
Importantly, you had a brief episode of palpitations while you
were in the hospital. You had an arythmia called Ventricular
Tachycardia that was brief (lasted 7 beats) and gave you
palpitations. It is important that we follow up with this. You
might need an echocardiogram of your heart. If you have any
other palpitations, please tell your primary care doctor.
Following changes were made to your medications.
Please START taking the Asacol every day until your appointment
with Dr. [**Last Name (STitle) 2161**]. You can take 1200mg 3 times a day (breakfast,
lunch, dinner).
Please resume all of your home medications, including your iron
and folate supplements
Make sure you follow up with your Colon, [**Last Name (STitle) 14165**] cell, and
primary care doctors.
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: MONDAY [**2176-7-8**] at 4:15 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2163**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Department: [**Hospital3 249**]
When: THURSDAY [**2176-7-11**] at 9:20 AM
With: [**First Name8 (NamePattern2) 1409**] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Echocardiogram: [**2176-7-12**], [**Hospital Ward Name 23**], [**Location (un) 436**].
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2176-7-30**] at 10:00 AM
With: [**Name6 (MD) 5145**] [**Name8 (MD) 5146**], MD, PHD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"42789",
"2851"
] |
Admission Date: [**2179-4-28**] Discharge Date: [**2179-5-3**]
Date of Birth: [**2119-3-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
post infarction angina
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x
4(LIMA-LAD,SVG-Diag,SVG-OM,SVG-PDA)
History of Present Illness:
This 60 year old white male developed chest pain on [**4-17**]
while driving. He was found to be bradycardic in the 40s and
was admitted to [**Hospital3 417**] Hospital and ruled in for
infarction with a Troponin of 11. Angioplasty and DES were
performed to the mid right coronary. A stress test was
performed prior to discharge and was positive with ECG changes
and pain. He was transferred here after recatheterization
revealed triple vessel disease.
Past Medical History:
Coronary artery disease
s/p stents x 2 to left anterior descending
hypertension
HIV positive
s/p right carotid endarterectomy
peripheral vascular disease
h/o deep vein thrombophlebitis
Social History:
He denies any use of alcohol or IV drugs. He has smoked [**1-30**]
packs of cigarettes per day for the last 30 years.
Family History:
non contributary
Physical Exam:
Admsiision:
Pulse: 72 Resp:17 O2 sat: 98% on RA
B/P Right: Left:
Height:5'[**80**]" Weight:152 LBS
General:
Skin: Dry [xx] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] R CEA incision
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 0 Varicosities
+1
Neuro: Grossly intact
Pulses:
Femoral Right: Dressing in place Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2179-4-30**] 05:00AM BLOOD WBC-10.1 RBC-2.87* Hgb-10.3* Hct-29.5*
MCV-103* MCH-35.8* MCHC-34.7 RDW-12.3 Plt Ct-124*
[**2179-4-30**] 05:00AM BLOOD Glucose-122* UreaN-27* Creat-1.2 Na-136
K-4.3 Cl-103 HCO3-28 AnGap-9
Brief Hospital Course:
Cardiac catheterization after stenting demonstrated triple
vessel disease with an EF by echocardiogram of 45%. He was
prepared for surgery.
On [**4-28**] he was taken to the Operating Room where
revascularization was performed. See operative note for
details. He weaned from bypass on Propofol infusions. He
awoke, was weaned from the ventilator and extubated. He
remained stable. CTs were removed according to protocol. He was
transferred to the floor being atrially paced with a slow sinus
underlying. He developed rapid atrial fibrillation which was
treated with Amiodaone and lopressor with conversion to sinus
bradycardia in the 50s. Amiodarone was stopped and the
Lopressor dose dropped.
He remained in sinus for 48 hours and felt well. He was
preparing to go home on POD 4 when he developed atrial
fibrillation again with a ventricular rate of 120s. He
tolerated this well and Amiodarone was begun. He quickly
converted to sinus rhythm and Coumadin was begun. Arrangements
were made for his primary carer physician to regulate this with
as target INR of [**3-2**].5. Amiodarone was prescribed for 4 weeks
and it will be discontinued, along with the Coumadin, at that
time if sinus rhythm persists.
Physical Therapy worked with him for strength and mobility
prior to discharge. The lasix was stopped when his BUN elevated
to 38 but fell to 28 the next day. Even though his weight was
slightly above preop he had minimal edema and was doing well.
Follow up, medications and precautions were discussed with the
patient before discharge.
Medications on Admission:
Medications at home:
ASA 325mg po daily
Pravastatin 80mg po daily
Lisinopril
Truvada
Nevirapine
Metoprolol (dose unknown)
Meds on Transfer:
Prasugrel 10mg po daily
Percocet PRN
Nitrostat PRN
Lipitor 80mg po daily
ASA 325mg po daily
Zestril 2.5mg po daily
Discharge Medications:
1. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily). Tablet(s)
2. Nevirapine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 weeks.
Disp:*56 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
10. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
11. Amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day) for 4 weeks: two tablets twice daily for 2 weeks,
then one tablet twice daily for two weeks, then discontinue.
Disp:*92 Tablet(s)* Refills:*0*
12. Outpatient [**Date Range **] Work
Please draw a PT/INR on [**5-5**] and then prn. Report results to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 798**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
s/p coronary artery stents
peripheral vascular disease
HIV positive
s/p right carotid endarterectomy
h/o deep vein thrombophlebitis left
s/p femoral embolectomy
h/o pulmonary tuberculosis
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet 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:
Dr. [**Last Name (STitle) 914**] on Tuesday, [**6-8**] at 1PM ([**Telephone/Fax (1) 170**])
Please [**Telephone/Fax (1) **] appointments with:
Primary Care: Dr.[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in [**1-30**] weeks ([**Telephone/Fax (1) 798**])
Cardiology: Dr. [**First Name4 (NamePattern1) 5699**] [**Last Name (NamePattern1) **] in 2 weeks
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks. Your nurse [**First Name (Titles) **] [**Last Name (Titles) **] an
appointment.
Completed by:[**2179-5-3**]
|
[
"41401",
"9971",
"2762",
"42731",
"2724",
"4019",
"2859",
"3051"
] |
Admission Date: [**2176-4-26**] Discharge Date: [**2176-4-29**]
Date of Birth: [**2103-11-23**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Macrolide Antibiotics / Quinolones / Ursodiol /
Tape / Neomycin/Polymyxin/Dexameth
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Bloody bowel movements s/p needle biopsy of prostate on [**2176-4-25**]
Major Surgical or Invasive Procedure:
[**2176-4-25**]: transrectal prostate biopsy (prior to admission)
[**2176-4-26**]: Flex sigmoidoscopy
History of Present Illness:
Pt is 72 yo M with a history of cirrhosis s/p liver
transplnat in [**2174-10-29**] (Dr.[**First Name (STitle) **]) who presents with BRBPR on
[**4-26**], one day after the Pt had a transrectal prostate ultrasound
with bx x 12 by Urology. Pt had an elevated PSA this past
[**Month (only) 404**]. The procedure was painful due to internal hemorrhoids.
Two hours after the procedure, pt had a bowel movement mixed
with
blood. Yesterday morning (PPD #1) pt had 4 more bowel movements
progressively converting to frank blood and clot. During the
last
few of episodes, pt was near-syncopal as he reports being
lightheaded having to sit on the bathroom floor though he [**Month (only) **]
any loss of consciousness. Pt denied any fever, chills, abominal
pain, diarrhea prior to the procedure. He had one episode of n/v
after breakfast yeaterday which was nonbloody and non bilious.
He
denied any CP, SOB, headaches.
.
He presented to [**Hospital3 10310**] Hospital. On arrival to OSH, BS
were BP 79/49, HR 90, RR 18, 100% O2 sat. Pt received 1L NS and
VS improved to BP range of 95/52 to 120/59, HR range of 70s-80s.
HCT was 27, and patient received 1 unit of PRBCs.
.
In [**Hospital1 18**] ED, initial VS were: 98.3 78 114/92 18 100. HCT upon
arrival was 31.8. INR of 1.2 at 2:30pm. Pt continued to pass
clot
and red blood per rectum, repeat HCT at 8pm was 30.5. Pt
admitted
to MICU service, reveived 3 units of PRBC since 8pm. A felxible
sigmoidoscopy was done at the bedside which showed blood in the
rectum, sigmoid, descending and distal transverse colon. There
was profuse bleeding at the beginning of the procedure but no
active bleeding noted at the end of the 1.5 hour scope.
GI/Hepatology recommending RBC Scan if bleeding returns. His
SBPs
have ranged from the 70s to 120s with HR 70s to 103 while in the
MICU. Evaluated by Urology in ED who feels that bleeding source
is likely the internal hemorrhoids and not the biopsy site and
recommends rectal packing if bleeding returns.
Past Medical History:
1. ETOH induced ESLD with portal hypertension, refractory
ascites, now s/p orthotopic liver transplant in [**2174-10-10**]
2. Upper GI bleed ([**2174**]) s/p variceal banding at [**Hospital1 2025**], second
UGIB s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and TIPS on [**2174-1-14**] - EGD with varices in
lower 3rd of esophagus, portal gastropathy
3. Candidemia [**8-16**], no evidence of ocular involvement on exam,
TTE clean, s/p IV fluconazole
4. h/o alcohol abuse, quit with dx of liver disease
5. Biliary Colic s/p biliary stenting -- now removed
6. Cholangitis complicated elective ERCP
7. h/o hyponatremia as low as 119
8. Herniated discs between L3/L4
9. Psoriasis
10. L eye retinal repair ~[**2174-11-28**], s/p retinal lasering
recently, s/p L cataract repair
Social History:
Significant history of alcohol use, drinking from the age of 25
until recently, stopping approximately one year ago. He has no
history of illicit drug use. He smoked half a pack of cigarettes
per day for 20 years, but has been off them for 20 years. He
never received a blood transfusion prior to [**2157**].
Family History:
His father was an alcoholic. There is no known family history of
liver disease.
Physical Exam:
Temp 97.1, HR 79, BP 110/75, RR 16, O2 100% on 2lit NC
Gen: Well, NAD, A&O, Conversive
CV: RRR, No R/G/M
RESP: Lungs CTAB
ABD: Well healed chevron insicion, non-tender, non-distended
EXT: No edema
Pertinent Results:
On Admission: [**2176-4-26**]
WBC-5.8 RBC-3.84* Hgb-10.5* Hct-31.8* MCV-83 MCH-27.3 MCHC-33.0
RDW-14.4 Plt Ct-246
PT-13.6* PTT-27.2 INR(PT)-1.2*
Glucose-97 UreaN-20 Creat-2.1* Na-137 K-4.7 Cl-108 HCO3-21*
AnGap-13
ALT-19 AST-33 LD(LDH)-189 AlkPhos-101 TotBili-0.3
Albumin-3.9 Calcium-8.5 Phos-3.9 Mg-2.2
On Discharge [**2176-4-29**]
WBC-3.1* RBC-3.45* Hgb-10.1* Hct-28.6* MCV-83 MCH-29.2
MCHC-35.1* RDW-15.2 Plt Ct-140*
Glucose-102 UreaN-19 Creat-1.7* Na-139 K-4.0 Cl-111* HCO3-21*
AnGap-11
ALT-14 AST-26 AlkPhos-58 TotBili-0.3
Brief Hospital Course:
72 y/o male s/p liver transplant about 18 months ago who
underwent transrectal biopsy of the prostate the day prior to
admission and was having rectal bleeding and weakness.
His hematocrit dipped as low as 24% and he received 7 units of
packed RBCs over the 4 day course of his hospitalization.
The patient underwent a flex sigmoidoscopy with the GI service
on the day of admission which showed "Clotted and fresh blood
was seen in the rectum, distal sigmoid colon, distal descending
colon, splenic flexure and distal transverse colon. Protruding
Lesions, Medium non-bleeding grade [**1-12**] internal & external
hemorrhoids with skin tags were noted."
He was also seen by the urology service in followup to the
prostate biopsy and as it was felt the bleeding was due to the
hemorrhoids seen on scope and not bleeding from the biopsy, they
had no further intervention at this time.
His hematocrit was stable [**4-28**] and [**4-29**] and he was discharged to
home, tolerating diet, ambulating and having no evidence of
current/active bleeding.
Medications on Admission:
Cellcept [**Pager number **] mg [**Hospital1 **], Sirolimus 3 mg daily, Bactrim 400mg-80mg
daily, Lysine 500 mg [**Hospital1 **]
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
5. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic TID (3 times a day).
6. Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl
Ophthalmic DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
s/p prostate biopsy with post procedure bleeding, determined to
be hemorrhoidal bleeding
Discharge Condition:
Stable/Good
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever >
101, chills, nausea, vomiting, blood in stool or urine, dizzy or
light-headed or any other concerning symptoms
Continue labwork per transplant clinic guidelines
Followup Instructions:
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2176-5-8**]
9:00
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1669**] Date/Time:[**2176-5-8**]
10:15
EYE IMAGING Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2176-5-29**] 8:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2176-4-30**]
|
[
"5859"
] |
Admission Date: [**2190-5-27**] Discharge Date: [**2190-5-31**]
Date of Birth: [**2129-11-28**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin / metronidazole
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
fever and jaundice
Major Surgical or Invasive Procedure:
ERCP (Endoscopic retrograde cholangiopancreatography) with
sphincterotomy and stent placement [**2190-5-28**].
History of Present Illness:
Mr. [**Known lastname 110070**] is a 60M with history of advanced ALS, chronic
trach/mechanical ventilation/PEG, DVT/PE on warfarin who is
transferred to [**Hospital1 18**] now with concern for acute cholecystitis
and need for ERCP. Patient initially admitted to [**Hospital1 392**] after
presenting with fevers and jaundice. The pt is nonverbal so hx
is per wife. Over past 10 days has noticed him to becoming
increasingly more jaundice associated with darker colored urine
and [**Male First Name (un) 1658**] colored stools. Went to PCP who referred him to the
hospital. On arrival to [**Hospital3 5365**] pt was febrile to 101.5
w/ tachycardia. His initial labs were notable for WBC 20,000 w/
16% bands, bili of 8.3, alk phos of 559 and INR supratherapeutic
at 6.1. CT scan and RUQ at OSH revealed dilated intrahepatic
biliary ducts. Patient was started on empiric antibiotics with
vanc/zosyn. He remained hemodynamically stable with good UOP.
He received FFP and vitamin K prior to transfer.
.
With regard to his ALS, he has been bed-ridden for 2 years.
Currently communicates by raising his eye brows, up indicating
"yes," and no movement indicating "no." He has a chronic trach
and is on mechanical ventilation, and also has a PEG through
which he receives nutrition and meds. His care is provided by
his wife at home.
.
On arrival to the ICU,he was not in appearant distress although
difficult to assess in this pt. He was notably jaundice on exam
and was complaining of some abominal pain with palpation but
difficult to assess exactly where in his abdomen.
.
Review of systems:
per HPI
Past Medical History:
ALS, chronic trach/mechanical ventilation/PEG
DVT/PE
Hypothryoidism
Social History:
lives w/ his wife
- [**Name (NI) 1139**]: denies
- Alcohol: denies
- Illicits: denies
Family History:
Father had unknown type of cancer
Physical Exam:
On admission
Vitals: T:98 BP:162/70 P:110 R:12 O2: 100%
General: Jaundice, Alert, no acute distress, non verbal,
communicates with eye brow raising, rising eye brows indicates
yes, no response is no movement of eyes.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not able to assess, trach in place
Lungs: Clear to auscultation bilaterally on ant exam, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, hypoactive BS, no
rebound tenderness or guarding, no organomegaly
GU:foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
On admission:
[**2190-5-27**] 09:42PM BLOOD WBC-14.7* RBC-3.65* Hgb-9.5* Hct-30.5*
MCV-84 MCH-26.2* MCHC-31.3 RDW-17.8* Plt Ct-397
[**2190-5-27**] 09:42PM BLOOD PT-25.6* PTT-42.8* INR(PT)-2.5*
[**2190-5-27**] 09:42PM BLOOD Glucose-59* UreaN-6 Creat-0.1* Na-136
K-3.5 Cl-104 HCO3-19* AnGap-17
[**2190-5-27**] 09:42PM BLOOD ALT-85* AST-48* LD(LDH)-135 AlkPhos-368*
TotBili-8.6*
[**2190-5-27**] 09:42PM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.3*
Mg-2.0
[**2190-5-27**] 09:42PM BLOOD TSH-5.1*
.
Prior to discharge:
[**2190-5-31**] 04:31AM BLOOD WBC-6.5 RBC-3.63* Hgb-9.2* Hct-30.6*
MCV-84 MCH-25.3* MCHC-30.0* RDW-17.9* Plt Ct-416
[**2190-5-30**] 03:56AM BLOOD PT-12.7* PTT-29.6 INR(PT)-1.2*
[**2190-5-31**] 04:31AM BLOOD Glucose-170* UreaN-7 Creat-0.1* Na-135
K-3.9 Cl-101 HCO3-26 AnGap-12
[**2190-5-31**] 04:31AM BLOOD ALT-45* AST-33 AlkPhos-316* TotBili-3.0*
[**2190-5-31**] 04:31AM BLOOD Calcium-7.8* Phos-2.1* Mg-2.1
.
Imaging
RUQ U/S [**2190-5-27**] (prelim read)
Cholelithiasis and mild gallbladder wall edema in a minimally
distended
gallbladder. Additionally, there is mild prominence of the
intrahepatic ducts with a top-normal CBD. These findings are
more suggestive of a chronic cholecystitis as opposed to an
acute cholecystitis. Furthermore, the liver demonstrates areas
of increased echogenicity and hepatitis must be excluded
clinically. Multiple hepatic cysts and granulomas incidentally
noted. Correlation with outside imaging recommended.
.
ERCP [**2190-5-28**]:
Procedures: Multiple balloon sweeps were performed and no sludge
or stone were extracted.A sphincterotomy was performed in the 12
o'clock position using a sphincterotome over an existing
guidewire. Cytology samples were obtained for histology using a
brush in the narrowing at the bifurcation of the bile duct. A
10cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed successfully.
Impression: The tip of a G tube was noted to be in place in the
stomach
Major papilla had a lacerated appearance suggestive of recent
passage of stone.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
The bile duct had a thin calibur. A small area of narrowing was
noted at the level of the bifurcation of the CBD. Rest of the
biliary tree appeared unremarkable with no filling defects.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Cytology samples were obtained for histology using a brush in
the narrowing at the bifurcation of the bile duct.
A 10cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed
successfully.
Otherwise normal ercp to third part of the duodenum.
Recommendations:
Return to ICU
NPO overnight. If patient's condition appears clinically stable,
would advance diet as tolerated tomorrow to clears
IV hydration with LR as tolerated hemodynamically
Continue antibiotics
Await brush cytology results.
If the cytology is positive for malignancy, patient will need
surgical consult. Otherwise will need repeat ERCP in 3 months
for stent pull and evaluation of stricture
LABS PENDING AT TIME OF DISCHARGE:
- Cytology from ERCP
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
60yM with PMH significant for ALS who is vent and PEG tube
dependent who initially presented to OSH w/ fever, jaundice,
abdominal discomfort consistent with ascending cholangitis.
.
# Ascending Cholangitis - On admission patient w/ WBC 20,000,
fever, tachycardia with elevated cholestatic LFT concerning for
cholangitis. He was started on antibiotics and underwent ERCP
and was found to have evidence of recent CBD stone passage as
well as a stricture at bifurcation. A Sphincterotomy was
performed and stent placed. Cytology samples were obtained for
histology using a brush in the narrowing at the bifurcation of
the bile duct. After ERCP the patient improved rapidly with WBC
and LFTs downtrending. All Blood cultures were negative.
- Patient was discharged on zosyn to complete a 7 day course
(last dose on 4.18)
- [**Name (NI) **] wife will schedule follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
(GI) in [**3-19**] weeks.
- Cytology from ERCP to be followed up by GI (Dr. [**Last Name (STitle) **] as
outpatient
- If the cytology is positive for malignancy, patient will need
surgical consult. Otherwise will need repeat ERCP in 3 months
for stent pull and evaluation of stricture
.
# History of DVT/PE - pt on warfarin chronically for history of
DVT/PE. ? IVC filter present. Presented with INR of 6 from OSH.
[**Month (only) 116**] have been related to acute illness or acute liver injury
causing decreased synthetic function. Patient given Vit K / FFP
for procedure to reverse. Now subtherapeutic.
- restarted warfarin with lovenox bridge until therapeutic
- VNA will check INR on [**6-1**] with result faxed to PCP.
[**Name Initial (NameIs) **] [**Name11 (NameIs) **] [**Name Initial (NameIs) **]/c lovenox when INR > 2.0
.
CHRONIC ISSUES:
# Elevated TSH ?????? the patient has a history of hypothyroidism
although he is not on levothyroxine (confirmed w/ PCP) also with
history of elevated TSH (up to 20) in critical illness. He was
found to have a TSH of 5.1 on admission.
- PCP should recheck thyroid studies in 4 weeks following acute
illness
.
# [**Name (NI) **] Pt has tracheotomy tube and is ventilator dependent. He
also has PEG tube in place for nutrition. He has been bed bound
for 2yrs now. Received prior care from [**Hospital1 2025**].
- held Rilutek in setting of acute liver injury, will restart
after discharge.
- cont Scopolamine Patch for secretion management
.
# Chronic Respiratory Failure- a complication of ALS. Pt is
trached and is now vent dependent. Currently comfortable in no
acute respiratory distress on home vent settings.
- continue home vent settings of FiO2 of 25%, Vt 700, RR 12,
Peep of 5
.
TRANSITIONAL ISSUES:
- PCP should recheck thyroid studies in 4 weeks following acute
illness
- INR subtherapeutic at discharge therefore discharged on
lovenox bridge. INR check on [**6-1**] to be faxed to PCP. [**Name10 (NameIs) 116**] need
further INR checks until subtherapeutic.
.
LABS PENDING AT TIME OF DISCHARGE:
- Cytology from ERCP
Medications on Admission:
1. Combivent 18-103 mcg/actuation Aerosol Sig: Four (4) puffs
Inhalation q3h as needed for shortness of breath or wheezing.
2. omeprazole 2 mg/mL Suspension for Reconstitution Sig: Twenty
(20) mg PO once a day.
3. Rilutek 50 mg Tablet Sig: One (1) Tablet PO twice a day.
4. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal EVERY 3 DAYS ().
5. glycopyrrolate 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
6. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO EVERY OTHER DAY (Every Other Day) as
needed for constipation.
7. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS (MO,FR).
8. warfarin 3 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,WE,TH,SA).
Discharge Medications:
1. piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig:
4.5 grams Intravenous Q8H (every 8 hours) for 2 days: Last dose
in evening on [**6-2**].
Disp:*15 doses* Refills:*0*
2. Combivent 18-103 mcg/actuation Aerosol Sig: Four (4) puffs
Inhalation q3h as needed for shortness of breath or wheezing.
3. omeprazole 2 mg/mL Suspension for Reconstitution Sig: Twenty
(20) mg PO once a day.
4. Rilutek 50 mg Tablet Sig: One (1) Tablet PO twice a day.
5. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours) for as directed days: until
INR > 2.0 .
Disp:*qs ml* Refills:*0*
6. scopolamine base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal EVERY 3 DAYS ().
7. glycopyrrolate 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO EVERY OTHER DAY (Every Other Day) as
needed for constipation.
9. warfarin 2 mg Tablet Sig: One (1) Tablet PO DAYS (MO,FR).
10. warfarin 3 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],TU,WE,TH,SA).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapies
Discharge Diagnosis:
Primary:
- Ascending Cholangitis
Secondary:
- Sepsis
- Amyotrophic Lateral Sclerosis
- Chronic Respiratory Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 110070**], it was a pleasure taking care of you here at [**Hospital1 18**].
You were transferred here because you had an infection in your
bile ducts, which is called "Ascending Cholangitis". You were
given antibiotics and also had a procedure called ERCP where a
stent was placed to open up your bile duct. After this you
improved. You will need to have another ERCP in about 3 months
to remove the stent. You will need to see Dr. [**Last Name (STitle) **] in clinic
to set this up. You will need 2 more days of antibiotics as
detailed below. You also will need a blood thinner called
lovenox until your INR goes back up.
The following additions were made to your medications:
- Zosyn (Antibiotic) 4.5 g IV every 8 hours last dose to be
given in evening on [**2190-6-2**]
- Lovenox (Blood Thinner) 80mg subcutaneous injection twice
daily: Until your INR is above 2.0
No other changes were made to your medications. You should
continue taking all other medications as you were previously.
Followup Instructions:
You will need to make a follow-up appointment with your
Gastroenterologist (Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]) in the next [**3-19**]
weeks. You should call [**Telephone/Fax (1) 1983**] to make the appointment.
You should also make an appointment in the next 2-4 weeks with
your primary care provider.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"0389",
"5119",
"2449"
] |
Admission Date: [**2117-9-24**] Discharge Date: [**2117-10-10**]
Date of Birth: [**2057-8-17**] Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
Cough and Fever
Major Surgical or Invasive Procedure:
Flexible Bronchoscopy.
Rigid Bronchoscopy with cryotherapy.
History of Present Illness:
This is a 60 M w/ pmh of stage IV non-small cell lung cancer and
is status post thoracic radiation and 2 cycles of chemotherapy
with cisplatin/pemetrexed. He presented with fevers earlier in
the week and he was started on azythromycin. he remained febrile
on this regimen and a CT Scan of chest showed a new
consolidation in the LLL as well as extensive ground-glass
pattern in the left lung. Notable also was [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] patern
suggestive of necrosis. These finding were attributed to an
acute infectious pneumonia.
In the ED, the patient was febrile 100.8 and his BP decreased to
80's, and he received IVF. His CBC showed a WBC of 8.5, HTC of
28.7 and PLt of 587. The patient was admited to the [**Hospital Unit Name 153**], where
he received broad coverage with vancomycin (HAP), cefepime (CAP
and per ONC fellow), and clindamycin (post-obstructive
pneumonia). The patient remained stable in the [**Hospital Unit Name 153**] and is now
transfered to the OMED floor.
ROS:
(+)
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Stage IV NSCLC
Anemia
Social History:
The patient is originally from [**Location (un) 6847**] and is Cantonese
speaking. He currently lives in [**Location 8391**] with his wife and
daughter. [**Name (NI) **] has been working as a driver for a funeral home.
Tobacco: One pack per day for 10 years, quit 20 years ago.
Alcohol: Rare wine. Illicits: None.
Family History:
His mother was diagnosed with lung cancer in her 60s and died of
this disease. His father had COPD and throat cancer.
Physical Exam:
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Pertinent Results:
[**2117-10-10**] 06:00AM BLOOD WBC-9.5 RBC-3.53* Hgb-10.3* Hct-30.6*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.2 Plt Ct-492*
[**2117-10-9**] 01:12PM BLOOD WBC-10.9 RBC-3.47*# Hgb-10.2*# Hct-30.1*#
MCV-87 MCH-29.3 MCHC-33.8 RDW-15.2 Plt Ct-477*
[**2117-10-9**] 05:53AM BLOOD WBC-11.7* RBC-2.61* Hgb-7.9* Hct-22.3*
MCV-86 MCH-30.3 MCHC-35.3* RDW-15.2 Plt Ct-567*
[**2117-10-8**] 03:52PM BLOOD WBC-13.3* RBC-2.75* Hgb-8.3* Hct-24.2*
MCV-88 MCH-30.4 MCHC-34.5 RDW-14.8 Plt Ct-476*
[**2117-9-25**] 06:08AM BLOOD WBC-6.8 RBC-3.15* Hgb-9.6* Hct-26.7*
MCV-85 MCH-30.4 MCHC-35.8* RDW-14.6 Plt Ct-514*
[**2117-9-24**] 09:20PM BLOOD WBC-8.5 RBC-3.43* Hgb-10.0* Hct-28.7*
MCV-84 MCH-29.0 MCHC-34.6 RDW-14.8 Plt Ct-587*
[**2117-10-10**] 06:00AM BLOOD Glucose-100 UreaN-7 Creat-0.7 Na-133
K-4.1 Cl-97 HCO3-25 AnGap-15
[**2117-10-9**] 05:53AM BLOOD Glucose-108* UreaN-6 Creat-0.7 Na-135
K-4.1 Cl-101 HCO3-27 AnGap-11
[**2117-10-9**] 01:12PM BLOOD LD(LDH)-164 TotBili-0.4 DirBili-0.1
IndBili-0.3
[**2117-10-8**] 03:52PM BLOOD CK(CPK)-22*
[**2117-10-10**] 06:00AM BLOOD Calcium-8.1* Phos-3.6 Mg-1.9
[**2117-10-9**] 01:12PM BLOOD Hapto-519*
[**2117-10-4**] 06:00AM BLOOD calTIBC-139* VitB12-554 Folate-11.5
Ferritn-1528* TRF-107*
[**2117-9-25**] 12:24AM BLOOD Lactate-0.7
Brief Hospital Course:
60 y.o. Male with NSLC with post-obstructive PNA with
radiographic evidence of LUL mass with gas pockets.
##. Left Upper Lobe obstruction: Pt was admitted for fevers and
cough, chest x-ray on admission showed post-obstructive
pneumonia that failed to improve on a course of Ceftriaxone,
Vancomycin and Clindamycin. Pt was then seen by interventional
pulmonary for possible stent placement to improve drainage for
his pneumonia. Upon flexible bronchoscopy pt was noted to have
tumour with the left main bronchus. Pt was then rescoped with
rigid bronchoscopy and cryotherapy which unfortunately showed
complete obliteration of the left upper lobe bronchus secondary
to his thoracic mass. Pt's thoracic mass most likely tumour
versus abscess formation, case was discussed with pt's
outpatient Oncologist; he will follow up as an outpatient and
will likely be referred to Thoracic surgery for possible mass
removal. Per ID recommendation pt was discharged on Levofloxacin
and Clindamycin to prevent bacterial spread of possible abscess
to the vascular system.
##. Left lung atelectasis: Following Mr. [**Known lastname **] rigid bronch his
Chest X-ray was notable for complete atelectasis. Pt's clinical
pulmonary exam however showed adequate aeration and saturation.
Pt was discharged following a course of incentive spirometry,
PEP therapy and respiratory therapy.
##. Anemia: Pt was noted to be anemic during hospitalization
requiring a 1unit of PRBC transfusion. Hemolysis labs for anemia
work up was negative, pt's anemia most likely due to his
chemotherapy.
##. Latent TB: Pt reported a history of a positive TB test with
only a month of treatment. As pt will also be undergoing
chemotherapy treatment for latent TB was started, pt currently
on a 9 month course of Isoniazid and Pyridoxine. Pt will also be
followed up in [**Hospital **] clinic.
Medications on Admission:
Azithromycin D3
Lorazepam 0.5 mg p.r.n., nausea/anxiety
Zofran 8 mg p.r.n. nausea.
Compazine 10 mg p.r.n. nausea.
Folic acid 0.4 mg daily.
Discharge Medications:
1. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 9 months: Day 1=[**2117-10-6**], to be given while receiving
Isoniazid therapy for 9 months duration. .
Disp:*30 Tablet(s)* Refills:*8*
2. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 9 months: Day 1 = [**2117-10-6**], to receive 9 months of therapy.
Disp:*30 Tablet(s)* Refills:*8*
3. Outpatient Lab Work
Please draw AST, ALT, Alkaline Phosphatase, LDH, Total
bilirubin, once per month.
4. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
5. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours).
Disp:*180 Capsule(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*3*
7. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Left Upper Lobe obstruction
Latent TB
Non-small cell lung carcinoma
Discharge Condition:
Stable, febrile.
Discharge Instructions:
You were admitted to the hospital for fevers and a mass in the
left upper part of your lung. Whilst in the hospital you were
given antibiotics but you still continued to have fevers. You
had two bronchoscopies which showed that there was a mass that
was blocking the left upper lobe of your lung. The blockage may
be from an abscess or your tumour. You will be seen by Dr. [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) 1852**] on [**2117-10-12**] to see if a surgeon can remove the
mass which is likely the cause of your fevers. We checked your
blood multiple times which showed no bacteria in your blood
system. Your fevers are most likely from the mass, you have been
clinically stable with the fevers and we feel it is safe for you
to be discharged.
We started you on two antibiotics in case the mass is an
abscess. The antibiotics will help stop any bacteria spreading
to your blood system.
Whilst in the hospital we also found that you had a history of a
positive TB skin test, when we tested you we found that your TB
infection is latent (not active but asleep). We started you on a
medication called Isoniazid which you will need to take over the
next 9 months. Please nake sure you take the Pyridoxine for the
next 9 months whilst you take the Isoniazid. You will have to
see the Infectious Disease doctor in a month, we will call you
to tell you when the appointment is.
You have been started on 4 new medications:
1) You have been givewn two antibiotics to stop any abscess you
might have spread into your blood. These medications are called
Levofloxacin 750mg once a day and Clindamycin 300mg three times
a day. You will be taking both of these medications until Dr.
[**Last Name (STitle) **] or Dr. [**Last Name (STitle) 1852**] says you can stop.
2) You have also been started on an antibiotic called Isoniazid
for your history of a positive TB test. You will need to take
this medication for 9 months last dose of this medication will
be [**2118-7-6**]. Please take Pyridoxine 100mg once a day for the
next month when you are taking the Isoniazid. You will also get
your blood checked once a month to check your liver function
once a month when you are on this medication.
3) You have also been started on a stomach pill called
Pantoprazole, please take 40mg once a day.
Please make sure you go to all of your appointments, we will
call you to tell you when to see the Infectious Disease doctor.
If you start having fevers greater than 102 degrees, have
difficulty breathing, coughing up blood, chest pain please
return to the Emergency or call your doctor.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2117-10-12**] 11:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 831**], MD Phone:[**0-0-**] Date/Time:[**2117-10-12**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 14688**], RN Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2117-10-12**] 12:00
|
[
"0389",
"5119",
"2761"
] |
Admission Date: [**2131-12-28**] Discharge Date: [**2132-1-3**]
Date of Birth: [**2065-12-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Latex / Pollen Extracts / Adhesive Bandages
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p MVR (mechanical)
History of Present Illness:
66 year old woman with a history of hypertrophic cardiomyopathy
and dyspnea on exertion who was first seen by our service in
[**2131-3-24**]. She wanted to evaluate her options and in the
mean time her medications were advanced. She continued to have
dyspnea on exertion despite maximal medical therapy.
Past Medical History:
IHSS/HOCM
Hypertension
Dyslipidemia
Colonic polyps
History of scarlet fever
Ventral hernia
s/p Tonsillectomy
Social History:
Works as a director of housing. Lives with her husband. Denies
smoking and drinks rare alcohol.
Family History:
Father died at 61 from "severe" CAD
Physical Exam:
Discharge:
Vitals: 98.2 132/68 86 20 98% RA
General: pleasant, answers questions appropriately
Lungs: clear to auscultation bilaterally
Sternum: stable. Incision clean and dry
COR: RRR
Abdomen: normoactive bowel sounds. Soft and nontender without
rebound and guarding
Extremities: warm
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 101201**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 101202**] (Complete)
Done [**2131-12-28**] at 11:16:38 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**]
[**Last Name (LF) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2065-12-21**]
Age (years): 66 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Abnormal ECG. Aortic valve disease. Hypertension.
Hypertrophic cardiomyopathy. Mitral valve disease. Shortness of
breath.
ICD-9 Codes: 402.90, 786.05, 440.0, 424.0
Test Information
Date/Time: [**2131-12-28**] at 11:16 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% to 65% >= 55%
Aortic Valve - Peak Gradient: *140 mm Hg < 20 mm Hg
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous
echo contrast in the body of the RA. A catheter or pacing wire
is seen in the RA and extending into the RV. No spontaneous echo
contrast in the RAA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size.
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic root. Normal ascending aorta diameter. Simple
atheroma in ascending aorta. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild (1+) AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe
mitral annular calcification. [**Male First Name (un) **] of mitral valve leaflets. No
MS. Mild to moderate ([**1-24**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
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 patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the left atrial appendage.
2. No spontaneous echo contrast is seen in the body of the right
atrium.
3. No atrial septal defect is seen by 2D or color Doppler.
4. There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal.
5. Right ventricular chamber size is normal. with normal free
wall contractility.
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. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. Mild (1+) aortic
regurgitation is seen. Severe LVOT gradient is seen with dagger
like velocity profile of outflow tract obstruction.
8. The mitral valve leaflets are moderately thickened. There is
severe mitral annular calcification. There is systolic anterior
motion of the mitral valve leaflets. Mild to moderate ([**1-24**]+)
mitral regurgitation is seen and is exaggerated by provocative
maneuvers.
Dr. [**Last Name (STitle) **] and [**Doctor Last Name **] were notified in person of the
results
POST-CPB: On infusion of phenylephrine. AV pacing. Well-seated
mechanical valve in the mitral position with 5 mmHg mean
gradient and trivial washing jets seen. LVOT gradient is now
mild with a peak of 14-16 mmHg. LVEF is preserved at 60 %.
Aortic contour is normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2131-12-28**] 13:27
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 101203**],[**Known firstname **] S [**2065-12-21**] 66 Female [**-8/4756**]
[**Numeric Identifier **]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 80901**]/dif
SPECIMEN SUBMITTED: mitral valve leaflets.
Procedure date Tissue received Report Date Diagnosed
by
[**2131-12-28**] [**2131-12-28**] [**2132-1-1**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl
Previous biopsies: [**-7/3434**] COLON BIOPSIES 2.
DIAGNOSIS:
Mitral valve leaflets:
Valvular tissue with myxomatous change.
Clinical: Mitral insufficiency, septal myoma.
Gross:
The specimen is received fresh labeled with the patient's name,
"[**Known firstname 2048**] [**Known lastname **]," the medical record number, and "mitral valve
leaflets." It consists of multiple fragments of tan white
valvular tissue measuring in aggregate 4.5 x 3.5 x 0.9 cm.
Attached to the valve is a piece of tan brown spongy tissue
measuring 1.1 x 0.9 x 0.4 cm. The specimen is represented as
follows: A = valve with attached mass, B = additional
representative sections of mitral valve.
Brief Hospital Course:
The patient was admitted as a same day and was brought to the
operating room following standard protocol. She received IV
cefazolin for peri-operative antibiotics as she was not in the
hospital for more than 24 hours. She underwent a mitral valve
replacement with a mechanical valve. Please see operative note
for full details. Post-operatively she was admitted to the
CVICU for invasive hemodynamic monitoring. She was weaned from
her drips and extubated on POD 1. She was transferred to the
step down floor on POD 1.
She was started on coumadin on POD 1 for a mechanical mitral
valve. Her coumadin was titrated and she was started on IV
heparin on POD 4 for a subtherapeutic INR. On POD 6 her INR was
therapeutic at 2.9.
Physical therpay was consulted and to work on strength and
balance. She was gently diuresed towards her pre-operative
weight. On POD 6 she was stable for discharge to home.
Medications on Admission:
Toprol XL 150 mg po BID
MVI
Colace 100 mg po bid
Omega 3 fatty acids
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 30 days.
Disp:*60 Capsule(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
6. 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*
7. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day: Please
take 1.5 pills daily until Dr [**Last Name (STitle) 2912**] instructs you to take a
different dose.
Disp:*50 Tablet(s)* Refills:*0*
8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day:
Please take daily dose as prescribed by Dr [**Last Name (STitle) 2912**]. Take 7.5 mg
(using the 5 mg pills) until he instructs otherwise.
Disp:*50 Tablet(s)* Refills:*0*
9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
s/p MVR
HOCM
hypertension
dyslipidemia
s/p scarlet fever
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 ([**Telephone/Fax (1) 170**]) please call for
appointment
Dr. [**First Name (STitle) 807**] in 1 week ([**Telephone/Fax (1) 823**]) please call for appointment
Dr. [**Last Name (STitle) 2912**] in [**2-25**] weeks please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Need INR checks monday/wednesday/friday for mechanical mitral
valve, goal INR 3-3.5. Level checked friday [**2132-1-4**] with
results to Dr[**Name (NI) 43030**] office (fax - [**Telephone/Fax (1) 13359**])
Completed by:[**2132-1-3**]
|
[
"4019",
"2724"
] |
Admission Date: [**2154-12-29**] Discharge Date: [**2155-1-2**]
Date of Birth: [**2101-4-11**] Sex: F
Service: MICU
CHIEF COMPLAINT: Bright red blood per rectum.
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
woman, with past medical history most notable for advanced
unresectable pancreatic cancer, who underwent cystic duct
stenting in [**2154-11-25**], and received Xeloda chemotherapy
and radiotherapy. She states that after completing the
course of chemotherapy and radiation, she has appreciated
several episodes of hematochezia, the last being 3 days prior
to presentation, and approximately 3 tbsp in volume/episode,
and there are 3-5 episodes/day.
On review, the patient also states that she has no appetite,
limited PO intake, decreased energy, lightheadedness and
dizziness, without chest pain. She also states she has
occasional abdominal pain.
She also reports significant weight gain attributed entirely
to edema in her legs and ascites collection in her abdomen.
She also states she has limited ambulation owing to
discomfort in her legs. She also reports nausea and bilious
vomiting that was not bloody.
In the Emergency Department, the patient declined nasogastric
lavage. She received 3 liters of normal saline volume
resuscitation, as well as 1 unit of packed red blood cells.
PAST MEDICAL HISTORY:
1. Pancreatic cancer, as described above. Please see Dr.[**Name (NI) 95388**] notes in the OMR for details of the diagnosis and
treatment course.
2. Portal venous thrombosis.
3. Cholecystitis.
MEDICATIONS ON ADMISSION:
1. Morphine SR 50 mg q 12 h.
2. Morphine sulfate SA 10 mg q 4-6 h prn.
3. Pantoprazole 40 mg qd.
4. Metronidazole--recently completed a course of 500 mg po
tid for 7 days and Levofloxacin 500 mg for 7 days.
5. Furosemide 20 mg qod.
6. Ondansetron 2-4 mg prn.
ALLERGIES:
1. Prozac causes hives.
2. Azithromycin causes abdominal pain.
3. Gemcitabine causes bleeding and hives.
FAMILY HISTORY: Significant for [**Name (NI) 499**] cancer.
SOCIAL HISTORY: There is no history of alcohol, or tobacco
exposure, or injection drug use. She is married and has 2
children.
PHYSICAL EXAMINATION: Temperature 99.4, heart rate initially
120, blood pressure 123/70, respiratory rate 18, oxygen
saturation 97% on room air.
HEENT: She had a clear oropharynx with dry mucous membranes.
She had anicteric sclerae with normal conjunctivae. The
pupils equal, round and reactive to light and accommodation.
NECK: Supple. She had prominent carotid pulsations at the
base of the neck.
HEART: Sinus rhythm. Normal S1 and S2. There were no S3 or
S4 murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Distended with a fluid wave and percussion splash
present. It was not tender. No organs palpable.
EXTREMITIES: Warm, no rash, no clubbing, no cyanosis. There
was +2 edema from the toes to the midcalves.
VASCULAR: The radial, carotid and dorsalis pedis pulses were
brisk and equal.
INITIAL LABORATORY EVALUATION: Hemoglobin 6.5, hematocrit
24.4, platelets 277. Chemistry panel - sodium 135, potassium
3.4, chloride 95, bicarbonate 32, blood urea nitrogen 10,
creatinine 0.7, glucose 137, AST 58, ALT 27, alkaline
phosphatase 734, amylase 27, total bilirubin 1.3, magnesium
1.8, albumin 2.7, calcium 8.8, phosphate 2.7, INR 1.1.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit and received transfusion with
packed red blood cells, a total of 3 in the first 24 hours.
She then underwent esophagogastroduodenoscopy which revealed
an actively bleeding gastric ulcer that underwent epinephrine
injection on [**2154-12-31**] with good hemostasis.
Hematocrit following the procedure remained stable for 2
days. However, repeat endoscopic evaluation on [**2155-1-2**] showed persistent bleeding from said site. Attempts at
electrocautery and epinephrine injection did not limit the
bleeding significantly, and at the time of this dictation
serial hematocrit checks were continuing.
Owing to the patient's poor nutrition, a percutaneously
inserted central catheter was placed, and total parenteral
nutrition was administered without complications. Once the
patient's hemodynamic status was stabilized, furosemide and
spironolactone were added to her medications to relieve the
peripheral edema, specifically to decrease the swelling in
her legs and the ascites.
MEDICATIONS AT TIME OF DICTATION:
1. Furosemide 40 mg po q am.
2. Spironolactone 25 mg po q hs.
3. Beclomethasone diproprionate nasal spray 2 sprays in both
nares [**Hospital1 **].
4. Morphine sulfate SA 15 mg q 12 h.
5. Pantoprazole 40 mg intravenously q 12 h.
6. Ondansetron 2 mg q 6 h prn nausea.
7. Morphine sulfate intravenously q 2 h prn pain.
8. Senna 1 tablet [**Hospital1 **].
9. Docusate 100 mg [**Hospital1 **].
DISPOSITION: Pending serial evaluation of hematocrit.
Should her hematocrit fail to stabilize, angiography shall be
ordered.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Name8 (MD) 7102**]
MEDQUIST36
D: [**2155-1-2**] 10:56
T: [**2155-1-2**] 12:34
JOB#: [**Job Number 95389**]
|
[
"5990"
] |
Admission Date: [**2139-9-17**] Discharge Date: [**2139-10-7**]
Date of Birth: [**2064-1-10**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Weakness, diarrhea, atrial fibrillation with RVR
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms [**Known lastname **] is a 75 yo woman with CLL diagnosed in [**2131**], atrial
tachycardia, CAD s/p stent the RCA on '[**28**] who initially
presented to the oncology clinic today with one week of profuse
watery diarrhea, fevers/chills, and an elevated WBC count. She
was recently admitted to the OMWS servuice from [**Date range (1) 19377**] with
pneumonia, initially treated with vanc/cefepime, then switched
to a course of cefpodoxime. She received first dose of campath
on [**2139-9-1**], began to have fevers and a painful rash at the site
of injetcion. Thus, the campath was stopped, last dose being
[**9-7**].
.
She was seen in clinic by Dr. [**Last Name (STitle) **] on [**9-15**], where she noted
several episodes of loose, watery bowel movements. Plan was to
send her home for that night, collect stool samples, and begin
Rituxan and bendamustine treatment for CLL given her rising
white count on [**9-16**]. She presented to clinic today stating that
she was extremely weak and that she had 20 episodes of profuse,
foul smelling watery diarrhea overnight. Her initial vitals in
clinic were 103.1.BP 130/66, P 96 RR 20. For concern for c.
diff, she was given flagyl and tylenol. While sleeping, her
heart rate had increased to 140s and an ECG showed atrial
fibrillation. She remained febrile and was given IV cefepime.
She continued to have RVR into 190s with stable BPs in 120s-130s
with chills and rigors. Of note, she had not taken any of her
blood pressure or rate control medications today. She was sent
to the ED for further evaluation, vitals on transfer were HR 136
132/66 24 98% 2L.
.
In the ED, inital vitals were 101 100 146/58 20. She apparently
triggered immediately for heart rate in 150s and ECG showed
atrial fibrillation. Lactate was .9. She was given 2L NS and
her HR decreased to the low 100s with stable blood pressures.
She was given 1 g of IV vancomycin as well. CT abdomen, which
showed was done which showed pancolitis, no perforation, and
concern for c diff. When resturning from her CT scan, patient
went up to go to the commode, and HR increased to 170s. At this
point, patient was given her dose of PO metoprolol 125 mg and
her heart rate decreased to 113. Vitals on transfer were 101.5,
113, 147/77, 26 100% on 2L.
.
On the floor,
.
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:
CLL dx [**12/2131**]:
- [**5-24**] weekly Rituxan x 8 weeks
- [**10-24**] FCR x 6 months to [**3-25**]
- relapsed [**1-26**] then 2 cycles of FCR [**2-26**] again
- Bendamustine for 2 cycles in [**7-26**]
- progression in [**1-27**]
- [**Date range (1) 39954**] RCVP x 2 cycles
- [**2139-6-12**] C1 R-[**Hospital1 **]
Severe arm cellulitis, ?necrotizing fasciitis, admitted at [**Hospital1 112**]
[**4-27**]
Detached retina treated at [**Hospital **]
SVT/Atrial Tachycardia
Hyperlipidemia
Osteoporosis
CAD, RCA stent in [**2128**], EF 60% in [**5-27**]
Hysterectomy in [**2130**]
Hx of breast biopsy, benign
History of bladder prolapse [**2130**]
Toes turn blue in cold weather - seen by vascular surgery
several times and told that this is not a vascular problem
Social History:
Divorced in the [**2108**]. Retired nurse.
-Smoking Hx: Short interval at age 18-21, never since.
-Alcohol Use: rare use.
-Recreational Drug Use: none.
Family History:
One son had [**Name (NI) 4278**] lymphoma at age 25. Daughter has lupus.
No other known cancer history.
Physical Exam:
On admission:
Clinic 103.1.BP 130/66, P 96 RR 20
ED triage: HR 136 132/66 24 98% 2L.
ICU transfer: 101.5, 113, 147/77, 26 100% on 2L. .
Accept Note: 110/71, 101, 14, 96%RA
General: Alert, oriented, no acute distress
HEENT: Cachectic, patchy hairloss, Sclera anicteric, MMM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, sporadic
right sided rales, ronchi
CV: Tachy, irregular rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, umbillical hernia, bowel
sounds present, no rebound tenderness or guarding, no
hepatomegaly and ++splenomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, mild cyanosis,
no edema. Black blister/eschar over left forth toe.
On Discharge:
vitals: hr:81 BP:128/60 RR:20 T:96.8 o2sat:96%/RA
HEENT: Cachectic, patchy hairloss, Sclera anicteric, anisocoria
R>L, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB
CV: irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, distended, umbillical hernia, bowel
sounds present
no rebound tenderness or guarding, splenomegaly, no hepatomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, +2 edema.
Pertinent Results:
[**2139-9-17**] 10:55AM WBC-309.8* RBC-2.56* HGB-8.2* HCT-25.2*
MCV-99* MCH-32.1* MCHC-32.6 RDW-22.3*
[**2139-9-17**] 10:55AM NEUTS-2* BANDS-0 LYMPHS-91* MONOS-4 EOS-0
BASOS-0 ATYPS-3* METAS-0 MYELOS-0
[**2139-9-17**] 10:55AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
ELLIPTOCY-1+
[**2139-9-17**] 10:55AM PLT SMR-VERY LOW PLT COUNT-38*
[**2139-9-17**] 10:55AM LD(LDH)-361*
[**2139-9-17**] 10:55AM UREA N-22* CREAT-1.0 SODIUM-130*
POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-20* ANION GAP-17
[**2139-9-17**] 04:09PM LACTATE-0.9
[**2139-9-17**] 10:55AM BLOOD WBC-309.8* RBC-2.56* Hgb-8.2* Hct-25.2*
MCV-99* MCH-32.1* MCHC-32.6 RDW-22.3* Plt Ct-38*
[**2139-9-20**] 06:50AM BLOOD WBC-157.2* RBC-2.36* Hgb-8.1* Hct-23.9*
MCV-101* MCH-34.4* MCHC-34.0 RDW-22.8* Plt Ct-21*
[**2139-9-21**] 09:29AM BLOOD WBC-221.9* RBC-2.67* Hgb-9.0* Hct-26.5*
MCV-99* MCH-33.9* MCHC-34.1 RDW-22.2* Plt Ct-48*#
[**2139-9-22**] 01:00AM BLOOD WBC-190.4* RBC-2.67* Hgb-8.7* Hct-26.1*
MCV-98 MCH-32.5* MCHC-33.3 RDW-22.5* Plt Ct-38*
[**2139-9-26**] 12:00AM BLOOD WBC-392.7* RBC-2.67* Hgb-8.8* Hct-26.2*
MCV-98 MCH-32.5* MCHC-33.5 RDW-21.5* Plt Ct-23*
[**2139-9-27**] 12:10AM BLOOD WBC-413.0* RBC-2.58* Hgb-8.8* Hct-25.9*
MCV-100* MCH-34.2* MCHC-34.1 RDW-21.3* Plt Ct-20*
[**2139-9-28**] 12:00AM BLOOD WBC-415.0* RBC-2.49* Hgb-7.8* Hct-24.7*
MCV-99*
[**2139-10-1**] 12:00AM BLOOD WBC-322.2* RBC-2.63* Hgb-8.7* Hct-26.1*
MCV-100* MCH-33.1* MCHC-33.2 RDW-20.4* Plt Ct-36*
[**2139-10-5**] 12:05AM BLOOD WBC-187.4* RBC-2.77* Hgb-9.6* Hct-26.8*
MCV-97 MCH-34.7* MCHC-35.9* RDW-21.4* Plt Ct-31*
[**2139-9-18**] 03:57AM BLOOD Glucose-124* UreaN-20 Creat-0.8 Na-135
K-3.9 Cl-110* HCO3-15* AnGap-14
[**2139-9-21**] 09:29AM BLOOD Glucose-124* UreaN-15 Creat-0.6 Na-133
K-3.8 Cl-108 HCO3-12* AnGap-17
[**2139-9-22**] 12:00AM BLOOD Glucose-87 UreaN-13 Creat-0.5 Na-135
K-4.1 Cl-110* HCO3-16* AnGap-13
[**2139-9-25**] 12:00AM BLOOD Glucose-114* UreaN-24* Creat-0.7 Na-135
K-3.3 Cl-103 HCO3-22 AnGap-13
[**2139-9-28**] 12:00AM BLOOD Glucose-81 UreaN-23* Creat-0.5 Na-135
K-4.6 Cl-106 HCO3-25 AnGap-9
[**2139-10-2**] 12:01AM BLOOD Glucose-147* UreaN-39* Creat-0.6 Na-131*
K-4.9 Cl-105 HCO3-20* AnGap-11
[**2139-10-4**] 12:00AM BLOOD Glucose-89 UreaN-15 Creat-0.4 Na-138
K-3.9 Cl-102 HCO3-29 AnGap-11
[**2139-10-5**] 12:05AM BLOOD Glucose-176* UreaN-15 Creat-0.5 Na-137
K-4.0 Cl-102 HCO3-28 AnGap-11
[**2139-9-17**] CT ABDOMEN WITH CONTRAST: The imaged lung bases
demonstrate unchanged bibasilar opacities likely atelectasis or
scarring. There is no pleural or pericardial effusion. Coronary
calcifications are noted. The liver is normal in attenuation
without focal lesion. Mild periportal edema is noted. The portal
and hepatic veins appear patent. The gallbladder is nondistended
with surrounding wall edema which could be related to the
adjacent colonic edema. The pancreas is unremarkable. The spleen
is not fully assessed, but is enlarged to at least 18.7 cm. The
bilateral adrenal glands are unremarkable. The kidneys enhance
and excrete contrast symmetrically. Exophytic upper pole right
renal cyst is seen along with multiple hypodensities in the left
kidney which are too small to be fully characterized. The small
bowel is grossly unremarkable. There is pancolonic mural edema
and thickening. There is surrounding stranding as well. There is
no free intraperitoneal air. Extensive lymphadenopathy is seen
within the periportal, mesenteric and paraaortic nodal chains
without notable interval change from the prior study. Dense
aortic calcifications are noted. CT OF THE PELVIS WITH CONTRAST:
The bladder is distended. The uterus appears surgically absent.
A circumferential rectal mural thickening is noted. There may be
trace perirectal stranding without free pelvic fluid. Pelvic
side wall, external iliac and inguinal lymphadenopathy is also
noted to a similar degree as on the prior. OSSEOUS STRUCTURES:
There is no lytic or sclerotic bony lesion concerning for
osseous malignant process. Scoliosis is again seen with
degenerative change centered in the upper lumbar spine.
IMPRESSION:
1. Mural edema involving the entire colon extending to the
rectum compatible with pancolitis and proctitis.
Pseudomembranous colitis, such as C. difficile, is most likely.
Other infectious colitides are secondary diagnostic
considerations.
2. Unchanged extensive adenopathy compatible with provided
history of CLL along with splenomegaly.
[**2139-9-24**] MRI/A Head:
FINDINGS: There is no acute intracranial hemorrhage, infarction,
edema, mass effect or masses seen. Ventricles and sulci are of
normal size and configuration. There is diffuse pachymeningeal
enhancement. There appears to be diffusely abnormal [**Month/Day/Year 15482**]
signal involving the calvarium and the visualized upper cervical
spine. Multiple T2/FLAIR hyperintensities are seen in bilateral
periventricular white matter, most likely represents small
vessel ischemic disease. Chronic lacunar infarcts are seen in
the right frontal white matter. The visualized orbits, paranasal
sinuses, and mastoid air cells are unremarkable. Major
intracranial flow voids appear normal. MRA BRAIN: Bilateral
internal carotid arteries, vertebral arteries and basilar artery
and their major branches show normal flow signal without
evidence of stenosis, occlusion, dissection, or aneurysm
formation.
IMPRESSION:
1. Diffusely abnormal [**Month/Day/Year 15482**] signal in the calvarium and upper
cervical spine, likely secondary to CLL involvement.
2. Diffuse pachymeningeal thickening and enhancement. This may
be secondary to tumor involvement. However, it can also be seen
secondary to intracranial hypotension from prior lumbar
puncture, inflammatory or infectious etiologies.
3. Small vessel ischemic disease.
[**2139-10-2**] MRI L-Spine
FINDINGS: Study is limited due to patient motion-related
artifacts, despite multiple attempts. There is also
levoscoliosis, which limits assessment of the structures. Within
these limitations, the following are the findings. The numbering
used for the present study is shown on series 4, image
10. The lumbar vertebral bodies are grossly normal in height.
There is heterogeneous signal intensity of the [**Month/Day/Year 15482**], two focal
T2 hyperintense areas in the L1 and L3 vertebral bodies with
minimal enhancement. These also demonstrate mildly increased
signal intensity on the pre-contrast T1-weighted sequence and
hence may represent atypical hemangiomas. There is diffuse
hypointense signal of the [**Month/Day/Year 15482**] likely related to the
underlying condition of CLL/other amrrow abn. On STIR sequence,
there is no focal area of altered signal intensity to suggest a
mass-like lesion in the lumbar vertebrae. Minimal areas of
[**Month/Day/Year 15482**] edema are noted in the endplates and in the facets. There
is disc desiccation at multiple levels. Mild bulge, with
bilateral facet degenerative changes are noted at multiple
levels, with mild indentation on the ventral thecal sac and mild
foraminal narrowing. There is no significant canal or foraminal
stenosis, on the axial images. The spinal cord ends at L1 level.
The roots of the cauda equina are otherwise unremarkable. There
is a small T2 hyperintense focus, at the posterior aspect of the
S2 vertebral body measuring approximately 1.3 x 1.2 cm without
enhancement and likely represents a Tarlov's cyst or perineural
cyst. No pre- or para-vertebral soft tissue swelling or masses
are noted within the limitations. No obvious abnormal
enhancement is noted in the epidural space. There is atrophy of
the paraspinal muscles, with fatty infiltration. A few T2
hyperintense foci, in the kidneys, please see the details on the
CT torso from [**2139-9-23**]. IMPRESSION:
1. Study limited due to levoscoliosis and motion-related
artifacts despite attempts. Within this limitation, multilevel
multifactorial degenerative changes are noted in the form of
facet degenerative changes and disc bulges without significant
canal stenosis. Possible mild foraminal narrowing at multiple
levels. No compression on the lower cord or roots of the cauda
equina or abnormal enhancement.
2. Two small foci of increased STIR signal, in the L1 and L3
vertebral bodies, may relate atypical hemangiomas. Attention on
followup can be considered. Hypointense signal intensity of the
[**Last Name (LF) 15482**], [**First Name3 (LF) **] be related to the underlying condition of CLL.
3. A few T2 hyperintense foci, in the kidneys, please see the
details on the CT torso from [**2139-9-23**].
Brief Hospital Course:
75 yo woman with CLL diagnosed in [**2131**], atrial tachycardia, CAD
s/p stent the RCA on '[**28**] who initially presented to the oncology
clinic today with one week of profuse watery diarrhea,
fevers/chills, and an elevated WBC count, with atrial
fibrillation with RVR.
.
#. C. diff colitis- The patient presented with fevers and severe
hypovolemia secondary to severe C. diff colitis. A C. diff
toxin was positive. A CT scan revealed mural edema involving
the entire colon extending to the rectum compatible with
pancolitis and proctitis. The patient was started on IV flagyl
and PO vancomycin 500. Pt was also given IVIG. IV flagyl was
switched to IV tigecycline after 7 days of minimal improvement.
After resolution of diarrhea on hospital day 12, IV tigecycline
was discontinued. The patient should continue PO vancomycin 500
QID after discharge and f/u with infectious disease to determine
when to discontinue PO vanco.
.
#. CLL- The patient presented with a WBC greater than 300, which
peaked at greater than 400. After resolution of diarrhea,
bendamustine 170 mg (100 mg/m2) IV was given on [**2139-9-27**] and
[**2139-9-28**] without incident. Rituxan 625 mg (375 mg/m2) IV was
given on [**2139-9-30**] after pre-medicating with tylenol,
methylprednisolone, Diphenhydramine, and famotidine. The
patient should schedule a follow up with Dr. [**Last Name (STitle) **] for further
monitoring and treatment. After discharge, twice weekly CBC
should be faxed to Dr.[**Name (NI) 3930**] office at [**Telephone/Fax (1) 21962**].
.
#. CLL in CSF- An LP was performed without complication. CSF was
sent for cytology and flow cytometry, which revealed atypical
lymphocytes with immunophenotypic findings highly suspicious for
involvement by patient's known chronic lymphocytic leukemia
(CLL). The patient was given Liposomal Cytarabine (Depocyt) 50
mg IT on [**2139-10-4**] and started on Dexamethasone [**Doctor Last Name 2949**].
Dexamethasone should be slowly tappered-4mg daily x 3 days, then
2mg daily x 3 days, then 1mg daily x 3 days, then stopped. The
patient should follow up with neuro-oncology for further
management and repeat IT-Liposomal Cytarabine the week of
[**2139-10-19**].
.
#. Afib with RVR- presented with sinus tachycardia to 140 [**2-18**] to
hypovolemia. After aggressive fluid resuscitation, the patient
developed paroxysmal a fib w/ venticular rates in the 60-70's.
The patient was rated controlled with Metoprolol 125mg TID and
Diltiazem 60 QID, which should be held for HR<60 or SBP<95.
These medication should be continued after discharge.
.
#. prolapsed bladder- long standing. OB-Gyn recommended f/u
after discharge in their clinic. Continue premarin gel twice
weekly.
.
#. ? pna- The patient presented fevers and a possibile pneumonia
by chest X-ray and was started on levoquin, cefepime, and
vancomycin. A CT chest was not consistent with a pneumonia and
these antibiotics were discontinued per ID recommendations.
.
#. Vision changes- The patient was seeing red spots during her
hospitalization. Ophthalmology was consulted given the patient
h/o retinal detachment. Her symptoms and exam were consistent
with a intravitreous hemorrhage without evidence of retinal
detachment. The patient should f/u with ophthalmology after
discharge.
Medications on Admission:
ALLOPURINOL - 300 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
DILTIAZEM HCL - (Prescribed by Other Provider) - 120 mg
Capsule,
Extended Release - 1 Capsule(s) by mouth twice a day
FLUCONAZOLE - 200 mg Tablet - 1 (One) Tablet(s) by mouth once a
day.
LORAZEPAM - 0.5 mg Tablet - [**1-18**] Tablet(s) by mouth at bedtime
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 5 Tablet(s) by mouth three times a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth once a day
PREDNISONE - 2.5 mg Tablet - 3 (Three) Tablet(s) by mouth once a
day until next follow-up visit.
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 (One)
Tablet(s) by mouth once a day.
VALACYCLOVIR - (Prescribed by Other Provider) - 500 mg Tablet -
1 (One) Tablet(s) by mouth twice a day
ZOLPIDEM - 5 mg Tablet - 1 (One) Tablet(s) by mouth at bedtime
as
needed for insomnia
Medications - OTC
B COMPLEX VITAMINS - (Prescribed by Other Provider) - Capsule
- 1 (One) Capsule(s) by mouth once a day
DOCUSATE SODIUM - (OTC) - 100 mg Capsule - 1 (One) Capsule(s)
by
mouth once a day as needed for constipation
MULTIVITAMIN - (OTC) - Tablet - 1 (One) Tablet(s) by mouth
once a day
SENNOSIDES - (OTC) - 8.6 mg Tablet - 1 (One) Tablet(s) by mouth
once a day as needed for constipation
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
4. metoprolol tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day): hold if HR<60 or SBP<100.
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: then take Dexamethasone 2mg PO daily for 3 days,
then take Dexamethasone 1mg PO daily for 3 days, then stop.
7. conjugated estrogens 0.625 mg/gram Cream Sig: One (1)
Vaginal QMON/FRI ().
8. vancomycin 125 mg Capsule Sig: Four (4) Capsule PO four times
a day.
9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
12. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for Constipation.
13. B complex vitamins Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
14. DILT-XR 120 mg Capsule,Ext Release Degradable Sig: One (1)
Capsule,Ext Release Degradable PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Chronic Lymphocytic Leukemia
Clostridium difficile Colitis
Atrial Fibrillations
Bladder Prolapse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to [**Hospital1 69**] for
severe dehydration from Clostridium difficile Colitis. We gave
you intravenous fluids and antibotics and you are are now doing
better. We also treated your chronic lymphocytic leukemia with
chemotherapy and you will need to return to the
[**Hospital 39955**] clinic for further evaluation and treatment
of the chronic lymphocytic leukemia.
Medication Changes:
START taking Vancomycin 500mg by mouth every 6 hours
Followup Instructions:
Hematology/Oncology
Dr. [**Last Name (STitle) **] at [**Location (un) 39956**].
[**Hospital Ward Name 23**] Center [**Location (un) 436**]
[**2139-10-12**] 9:30am
.
Urology/Gynecology
Phone: [**Telephone/Fax (1) 39957**]
Dr. [**Last Name (STitle) 18522**], [**Name8 (MD) **] MD
[**Location (un) **]; [**Hospital Ward Name **]
[**Hospital Ward Name 23**] Center [**Location (un) **]
Tuesday [**2139-10-13**] 8:00am
.
Opthalmology [**Telephone/Fax (1) 39958**]
Dr. [**Last Name (STitle) **]
[**Location (un) **]; [**Hospital Ward Name **]
[**Hospital Ward Name 23**] Center [**Location (un) 442**]
Thursday [**2139-10-15**] (9:45am)
.
Nuero-Oncology/Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 724**]
[**Hospital Ward Name 23**] Center [**Location (un) **]; [**Hospital Ward Name **]
Tuesday [**2139-10-20**] at 9:30am
Phone: [**Telephone/Fax (1) 1844**]
.
Department: HEMATOLOGY/BMT
When: WEDNESDAY [**2139-10-21**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Cardiology/Dr. [**Last Name (STitle) **]
[**Last Name (STitle) **]: Friday [**2139-11-13**] 9:40am
Phone: [**Location (un) 39959**]; [**Hospital Ward Name 39960**] Center; [**Location (un) 436**]
|
[
"2762",
"2761",
"42731",
"42789",
"2724",
"V4582"
] |
Admission Date: [**2114-4-11**] Discharge Date: [**2114-4-30**]
Date of Birth: [**2046-12-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
Lower Extremity Edema
Major Surgical or Invasive Procedure:
IVC Filter Placement
Upper Endoscopy
History of Present Illness:
67 year old man with PMH of DM, HTN, and recently diagnosed
adenocarcinoma who presents with leg swelling to the ED. He
reports that he was in his usual state of health until [**3-23**],
when he fell and hit his head in a [**Company 39532**] in [**State 26110**]. He got
a CTA for syncope and a mass was found in his pancrease with
similar liver masses. Biopsy showed moderate to poorly
differentiated adenocarcinoma, consistent with upper GI origin.
His children all live in [**Last Name (LF) 86**], [**First Name3 (LF) **] he decided to come here for
treatment. He reports that they went to [**Hospital1 2025**] straight from the
airport, but for unclear reasons then decided to come to the
[**Hospital1 18**] instead.
In the ED, he was complaining of LE edema over the last few
weeks. He was evaluated and found to have a HCT of 30 from 41.5
on [**2114-4-5**] and tachycardia, but otherwise his vitals were normal.
He had guaiac positive stool and repeat hct went to 26, so he
was admitted to the ICU and GI was contact[**Name (NI) **] who agreed to scope
in the morning.
ROS: He complains of [**5-10**] abdominal pain in the RLQ worse with
cough that is occasionally productive. He has also been somewhat
more fatigued over the last few weeks. He denies any shortness
of breath, chest pain, fever, chills, nausea, vomiting,
lightheadedness, diarrhea.
Past Medical History:
DM type 2 since [**2098**]
HTN
LE edema
recent diagnosis of adenocarcinoma, with liver mets
hyperlipidemia
possible h/o hypothyroidism
colon polyps removed in [**2110**]
pancreatitis with elevated triglyceridemia in [**2108**]
depression
erectile dysfunction
Social History:
Lived in [**State 26110**] until yesterday, alone. Divorced with many
chilren in [**Location (un) 86**]. 20 pack year smoking history, quit 25 years
ago. Denies alcohol or other drug use.
Family History:
Father and mother died of CAD in their 80's. 1 brother with
alcoholic cirrhosis, other two brothers healthy.
Physical Exam:
PE: T99.1 BP 123/60 P122 R32 96% 2LNC
HEENT: PERRLA, OP clear, MMM
RESP: clear bilaterally, with cough with inspiration
CV: tachycardic, nl s1s2 no M
Abd: soft, slight nonspecific TTP diffusely
Ext: 3+ pedal edema bilaterally - 2+ in legs
Neuro: CN 2-12 intact, str [**5-5**] UE and LE. Oriented x 2 - to self
and [**Hospital1 **], but not date. Slightly slowed speech
Pertinent Results:
Laboratory studies on admission:
[**2114-4-11**]
CK-MB-NotDone cTropnT-0.01
ALT-42* AST-62* CK(CPK)-16* AlkPhos-425* Amylase-15 TotBili-1.8*
ALT-33 AST-73* AlkPhos-263* TotBili-4.1*
Glucose-474* UreaN-46* Creat-1.1 Na-131* K-5.6* Cl-92* HCO3-26
PT-13.0 PTT-24.3 INR(PT)-1.1
WBC-11.5* RBC-3.31* Hgb-9.3* Hct-30.2* MCV-91 MCH-28.2
MCHC-30.9* RDW-17.3* Plt Ct-170
Other laboratory studies:
[**2114-4-14**]
CEA-279* PSA-0.8 CA [**25**]-9 [**Numeric Identifier 71783**]
Radiology outside hospital ([**2114-3-23**])
CT head - no enhancing masses
CT pancreas: 2/8x2/3 rounded solid lesion in the tail of the
pancreas, highly suspicious for malignancy. Liver hypodensities.
No adenopathy
Bone scan- no osseous metastatic disease
Radiology [**Hospital1 18**]
[**4-12**] Chest CT: Evaluation for pulmonary embolism is slightly
limited due to non-optimal timing of contrast bolus, however,
the main and subsegmental branches of the pulmonary vessels
appear patent without filling defects bilaterally. A 3.5 mm
pulmonary nodule was noted within the right upper lobe with an
additional 1-2 mm pulmonary nodule was noted within the right
middle lobe (2:27, 30). A slightly likely calcified nodule is
identified more medially within the right middle lobe (2:27)
likely representing calcified granuloma. A 3-mm nodule was noted
along the major fissure in the left lobe (2:33) with an
additional 2-3 mm nodules noted more posteriorly within the left
lower lobe (2:33,37). There are areas of bilateral dependent and
subsegmental atelectasis within the lower lobes with no enlarged
pericardial or pleural effusion identified. No pathologically
enlarged axillary, hilar, or mediastinal lymph nodes are
identified. There are calcifications noted within the LAD and
circumflex vessels.
[**4-12**] CT abdomen/pelvis: There is diffusely infiltrating
hypoattenuating liver lesions consistent with extensive
metastatic disease. No intrahepatic biliary dilatation is
identified in the portal and hepatic veins appear patent. A 2.6
x 2.8 cm hypoattenuating pancreatic tail mass is identified with
a probable necrotic center just adjacent to the splenic hilum.
Remaining pancreatic parenchyma appears unremarkable. There is
no pancreatic ductal dilatation. A small splenule is noted
adjacent to a normal appearing spleen. Multiple collateral
vessels and gastric varices are noted throughout the abdomen
related to thrombosis noted within the distal splenic vein with
patent splenic hilum vessels and recanalization more proximally.
The stomach, intraabdominal bowel, adrenal glands, and kidneys
appear otherwise unremarkable. There is a slightly prominent
retroperitoneal lymphadenopathy, however, none meet CT criteria
for pathologically enlarge. No pathologically enlarged
mesenteric lymphadenopathy is identified. There is a moderate
amount of ascites noted throughout the abdominal cavity with no
free air noted. Small amount of free fluid is noted within the
pelvic cavity with the intrapelvic bowel, prostate, and urinary
bladder appearing otherwise unremarkable. No pathologically
enlarged pelvic or inguinal lymph nodes are identified. There is
evidence of colonic diverticulosis without acute diverticulitis.
[**2114-4-13**] MRI/A Head: No evidence of acute infarct. Chronic
right-sided basal ganglia lacune. No enhancing brain lesions,
mass effect or hydrocephalus.
[**4-15**] CTA Chest Filling defect is seen in a left lower lobe
pulmonary artery segment consistent with pulmonary embolism.
More subtle filling defect in right lower lobe suggests possible
pulmonary emboli on the right side. Multiple sub- centimeter
pulmonary nodules are again seen bilaterally, little change from
study three days prior. Wedge shaped linear opacities at the
bases suggest infarct vs. atelectasis. Limited views of the
upper abdomen again demonstrate multiple low-attenuation lesions
scattered throughout the liver consistent with metastatic
disease. Free fluid again seen within the abdomen. No new
suspicious lytic or blastic lesions are identified within the
osseous structures.
Pathology:
Cell block, peritoneal fluid:
Rare atypical degenerated epithelioid cells present singly and
in clusters, in a background of mesothelial cells and
inflammatory cells, suspicious for adenocarcinoma.
Brief Hospital Course:
67 year old male with newly diagnosed metastatic adenocarcinoma
(likely pancreatic in origin) admitted with gastrointestinal
bleed. Hospital course notable for pulmonary embolism and
rapidly declining performance status.
1) Gastrointestinal bleeding: The patient was admitted to the
medical ICU and transfused with PRBC. He underwent an EGD, which
revealed portal gastropathy, likely due to large metastatic
burden in liver along with splenic vein thrombosis. He was
started on a [**Hospital1 **] PPI and his hematocrit stabilized after 5 units
of blood.
2) Pulmonary embolism: Following transfer to the general medical
floor, given persistent sinus tachycardia and mild oxygen
requirement, a chest CTA was obtained, which revealed a LLL
pulmonary embolism. He was initially anticoagulated with a
heparin drip. However, given recent significant upper GI bleed
requiring ICU admission and high risk for recurrent bleeding due
to known portal gastropathy, an IVC filter was placed on
[**2114-4-18**].
3) Metastatic pancreatic CA (liver/lung): CA [**25**]-9 [**Numeric Identifier 71783**]. The
oncology service was consulted, who felt that the patient would
need an improved functional status before palliative chemo could
be considered. However, during the patients hospital course,
the patient's performance status declined significantly, and he
essentially became bed bound. Because of this and his poor
prognosis (rising liver function tests, new renal failure), the
decision was made with the family and patient to pursue hospice
care as home as he was unlikely to become strong enough to be
eligible for palliative chemotherapy.
4) Ascites: The patient underwent a paracentesis [**4-17**]; analysis
was consistent with portal hypertension without spontaneous
bacterial peritonitis. Cytology was suggestive of
adenocarcinoma.
5) Type II DM poorly controlled with complications: The
patient's glargine dose was titrated to 34 units qhs.
The patient was discharged home with hospice care. He is
DNR/DNI.
Medications on Admission:
KCL 8 meq po qd
lasix 20 mg po qd
avandia 8 mg po qd
zetia 10 mg po qd
metoprolol 50 mg po qd
HCTZ 12.5 mg po qd
lantus ?20 units daily
glucophage 1000 mg po bid
amlodipine 10 mg po qd ; benazapril 20 mg po qd - not takign
since [**3-23**]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO QID (4 times a
day) as needed for pain.
Disp:*240 Tablet(s)* Refills:*0*
4. Methylphenidate 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Please give at 8 am, 2 pm.
Disp:*120 Tablet(s)* Refills:*0*
5. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Lantus 100 unit/mL Solution Sig: Thirty Four (34) Units
Subcutaneous at bedtime.
Disp:*qs 1 month supply* Refills:*0*
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for low back pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
8. Insulin Syringe 1 mL 27 x [**5-8**] Syringe Sig: One (1)
Miscellaneous as directed.
Disp:*100 * Refills:*2*
9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Metastatic Pancreatic Cancer with Liver/Lung metastases
Upper GI bleed
Pulmonary Embolism s/p IVC filter placement
Hypertension
Ascites
Type 2 DM poorly controlled with complications
Anasarca
Discharge Condition:
being discharged home with hospice services
Discharge Instructions:
Please take all your medications as prescribed. Please return
to the hospital if you are experincing pain or shortness of
breath that cannot be controlled with medications at home.
Followup Instructions:
1) Primary Care: Your new primary care physician is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6739**]
[**Last Name (NamePattern1) 71784**] ([**Telephone/Fax (1) 71785**]) who works in the [**Company **]
system. Please contact her office with any questions or concerns
2) Oncology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2114-5-23**] 2:00 p.m.
Provider: [**First Name11 (Name Pattern1) 14497**] [**Last Name (NamePattern1) 25880**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2114-5-23**] 2:00
p.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2114-4-30**]
|
[
"2761",
"4019"
] |
Admission Date: [**2194-5-3**] Discharge Date: [**2194-5-26**]
Date of Birth: [**2138-6-4**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
BACK PAIN
Major Surgical or Invasive Procedure:
1) debridement and removal of hardware/ placement of VACS
2) wound debridement/removal VACS
3) Thoracic fusion
4) Wound washout/debridement
History of Present Illness:
HPI: 55 y/o male with metastatic renal Ca to spine, transferred
from rehab due to worsening drainage from surgical incision
site at midincision point (about 3cm opening), recent admit
[**Date range (3) 75880**] during which on [**2194-1-28**] he
underwent thoracic instrumented fusion T1-12 by Dr. [**Last Name (STitle) 548**] for
stabilization and due to increased difficulty walking and
numbness/weakness/pain in his legs. Prior to this the patient
was found to have a renal tumor in [**2190**] s/p resection. In [**6-21**]
the patient was found to have an extradural mass at T5 that was
felt to be metastatic. The patient is also known to have a
kyphotic collapse at T10. On [**1-28**] he underwent excisional
biopsy
T5, T19, T10 vertebrectomy; instrumented fusion
T1-T12 with pedicle screws; iliac crest bone graft.
Past Medical History:
rheumatoid arthritis x 20 years
renal ca s/p nephrectomy
metastatic spine disease s/p thoracic instrumented fusion T1-12
on [**2194-1-28**] for extradural mass at T5 and kyphotic collapse at
T10
h/o IVDA
Social History:
Lives with a friend and his wife; tobacco 2 ppd x 30-40 years
but notes has not smoked for the last 2 weeks; recovering
alcoholic but no ETOH recently; history of drug abuse, but none
for last two years, on Methadone.
Family History:
Family History: father deceased at 63 yo of heart disease.
Physical Exam:
PHYSICAL EXAM
General: lying in bed, NAD
HEENT: NCAT, dry and erythematous mucous membranes
Neck: supple, no carotid bruits
Pulmonary: CTA b/l
Cardiac: tachycardia, regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, mildly distended with some echymoses,
normal bowel sounds
Extremities: radial deviation of MCP joints of both hands due to
RA. Left elbow open wound with exposed bone.
Back: covered in extensive tattoos, 2 JP drain sutures removed,
R
paraspinal hematoma unchanged, mild serosanguinous drainage from
wound, no wound dehiscence.
NEURO
MSE: alert, oriented times 3, follows commands all 4 extremities
CN: PERRL 4-->2mm bilat, EOMI without nystagmus, facial
sensation
intact, smile symmetric but weak orbicularis oculi bilat,
hearing
intact b/l to finger rubbing, palatal elevation symmetrical, SCM
[**5-19**], tongue midline without fasciculations.
MOTOR: Normal bulk. Normal tone. No pronator drift. Mild
asterixis.
Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham DF PF [**Last Name (un) 938**] EDB
C5 C7 C6 C8 L2 L3 L4-S1 L4 L5 L5
RT: 5 5 5 5 5 5 5 5- 5 5- 5- 5 5- 5-
LEFT: 5 5 5 5 5 5 5 5- 5 5- 5 5 4+ 5
SENSATION: normal to light touch in bilateral upper extremites,
mild decreased sensation over bilateral lowers
REFLEXES: DTRs 1 + and symmetric, plantars upgoing bilat
COORDINATION: FNF intact with RUE, some tremor with LUE.
Pertinent Results:
[**2194-5-3**] 05:30PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2194-5-3**] 05:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-SM
[**2194-5-3**] 05:30PM URINE RBC-[**3-19**]* WBC-[**3-19**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2194-5-3**] 04:00PM GLUCOSE-115* UREA N-13 CREAT-0.7 SODIUM-133
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-31 ANION GAP-12
[**2194-5-3**] 04:00PM WBC-15.0*# RBC-3.95* HGB-11.0* HCT-33.7*
MCV-85 MCH-27.9 MCHC-32.7 RDW-15.4
[**2194-5-3**] 04:00PM NEUTS-90.5* BANDS-0 LYMPHS-4.1* MONOS-4.1
EOS-1.2 BASOS-0.1
[**2194-5-3**] 04:00PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+
[**2194-5-3**] 04:00PM PLT SMR-HIGH PLT COUNT-501*
[**2194-5-21**] 04:46AM BLOOD Hct-25.5*
[**2194-5-20**] 06:35AM BLOOD WBC-6.1 RBC-3.11* Hgb-8.5* Hct-25.6*
MCV-82 MCH-27.4 MCHC-33.3 RDW-15.2 Plt Ct-407
[**2194-5-20**] 06:35AM BLOOD Neuts-68.7 Bands-0 Lymphs-18.8 Monos-9.8
Eos-2.4 Baso-0.2
[**2194-5-20**] 06:35AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Tear Dr[**Last Name (STitle) 833**]
[**2194-5-20**] 06:35AM BLOOD Plt Smr-NORMAL Plt Ct-407
[**2194-5-21**] 04:46AM BLOOD K-3.3
[**2194-5-4**] 05:45AM BLOOD CRP-282.0*
[**2194-5-4**] 05:45AM BLOOD ESR-67*
[**2194-5-15**] 10:11 am PLEURAL FLUID
GRAM STAIN (Final [**2194-5-16**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2194-5-18**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2194-5-21**]): NO GROWTH.
ACID FAST SMEAR (Final [**2194-5-16**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
[**2194-5-14**] 12:25 pm BLOOD CULTURE Source: Venipuncture 2 OF
2.
**FINAL REPORT [**2194-5-20**]**
Blood Culture, Routine (Final [**2194-5-20**]): NO GROWTH.
[**2194-5-13**] 8:30 pm SWAB T9.
**FINAL REPORT [**2194-5-16**]**
GRAM STAIN (Final [**2194-5-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2194-5-16**]):
STAPH AUREUS COAG +. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 75881**]
([**2194-5-7**]).
[**2194-5-4**] 1:20 pm BLOOD CULTURE
**FINAL REPORT [**2194-5-10**]**
Blood Culture, Routine (Final [**2194-5-10**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # 249-7676P [**2194-5-3**].
Anaerobic Bottle Gram Stain (Final [**2194-5-5**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
Brief Hospital Course:
Pt was admitted to the hospital and monitored closely in ICU.
He was seen in consultation by ID and plastic surgery. He was
begun on antibiotics. He was brought to the OR [**2194-5-6**] for wound
debridement, removal of hardware and placement of VAC
dressing.He was also seen by pain service.He was kept at strict
bedrest while hardware was out. He returned to OR [**2194-5-9**] for
debridement and application of VAC device. He then returned to
OR [**2194-5-13**] for removal of instrumentation,
debridement,reinsertion of spinal instrumentation, revision
arthrodesis/pseudoarthrosis repair. He was extubated [**2194-5-15**]. He
was evalutaed by thoracic surgery for increasing plueral
effusions with recommendation to tap which was performed without
difficulty [**2194-5-16**]. He was transferred out of ICU to floor. His
drainage was monitored from JP. Incision is healing
well/clean/dry. He was followed closely by ID throughout his
hospital course. He had post op xrays that showed good hardware
positioning. He worked with PT/OT and was recommended for acute
rehab. His albumin and protein were low and he has been given
supplements at each meal.
Medications on Admission:
Active Medication list as of [**2194-5-3**]:
Medications - Prescription
Atenolol - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth daily
Citalopram - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth daily
Enoxaparin - (Prescribed by Other Provider) - 40 mg/0.4 mL
Syringe - 40mg subq daily
Folic Acid - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth daily
Gabapentin - (Prescribed by Other Provider) - 400 mg Tablet - 1
Tablet(s) by mouth every eight (8) hours
Methadone - (Prescribed by Other Provider) - 10 mg Tablet - 3
Tablet(s) by mouth three times a day
Methotrexate Sodium - (Prescribed by Other Provider) - 15 mg
Tablet - 1 Tablet(s) by mouth q7days
Modafinil - (Prescribed by Other Provider) - 200 mg Tablet - 1
Tablet(s) by mouth daily
Omeprazole - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
Oxycodone - (Prescribed by Other Provider) - 60 mg Tablet
Sustained Release 12 hr - 1 Tablet(s) by mouth three times a day
Tizanidine - (Prescribed by Other Provider) - 4 mg Tablet - 1
Tablet(s) by mouth every eight (8) hours
Medications - OTC
Ascorbic Acid - (Prescribed by Other Provider) - 500 mg Tablet
-
1 Tablet(s) by mouth twice a day
Docusate Sodium [Colace] - (Prescribed by Other Provider) - 100
mg Capsule - 1 Capsule(s) by mouth twice a day
Ferrous Sulfate [FerrouSul] - (Prescribed by Other Provider) -
325 mg (65 mg Elemental Iron) Tablet - 1 Tablet(s) by mouth
three
times a day
Miconazole Nitrate - (Prescribed by Other Provider) - Dosage
uncertain
Senna - (Prescribed by Other Provider) - Dosage uncertain
Zinc Sulfate - (Prescribed by Other Provider) - 220 mg Tablet -
1 Tablet(s) by mouth MWF
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): You should continue this antibiotic until you complete
your course of other antibiotics. .
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
9. Hydromorphone 4 mg Tablet Sig: 2.5 Tablets PO Q3H (every 3
hours) as needed for breakthru.
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): sliding scale coverage.
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
12. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
17. Methadone 10 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
18. Nafcillin 2 gram Recon Soln Sig: One (1) Injection every
four (4) hours: this medication should continue until at minimum
[**2194-7-15**] per ID team .
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. Rifampin 300 mg IV Q 8H
21. Outpatient Lab Work
to be fax'd to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital **] clinic at [**Telephone/Fax (1) **]
CBC, Chem Panel, LFT's, CRP, ESR, LFT's please
thank you
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
wound infection
hardware failure
septecemia
poor nutrition
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean and dry / No tub baths or pools until cleared
by Dr. [**First Name (STitle) **] - plastic surgeon.
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for 2 weeks.
?????? Check incision daily for signs of infection
?????? You are required to wear your back brace while out of bed,
even if only for short distances or being out of bed to chair.
?????? You may shower without the back brace.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. - it decreases opportunity for
fusion.
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits
Followup Instructions:
[**Last Name (un) **] CALL DR. [**Last Name (STitle) **]' OFFICE/ PLASTIC SURGERY UPON PTS ARRIVAL
TO YOUR INSTITUTION TO SCHEDULE FOLLOW UP APPOINMENT WITHIN NEXT
2 WEEKS AT [**Telephone/Fax (1) 1416**].
PLEASE SCHEDULE AN APPOINTMENT TO SEE DR. [**Last Name (STitle) **] / NEUROSURGERY
AT [**Telephone/Fax (1) **] TO BE SEEN IN 6 weeks WITH XRAYS OF YOUR
THORACO-LUMBAR SPINE
YOU HAVE A SCHEDULED APPOINTMENT TO SEE DR [**Last Name (STitle) **]- INFECTIOUS
DISEASE
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2194-6-30**] 10:00
Completed by:[**2194-5-22**]
|
[
"0389",
"5119",
"2859"
] |
Admission Date: [**2125-9-13**] Discharge Date: [**2125-9-18**]
Date of Birth: [**2083-7-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
asymptomatic
Major Surgical or Invasive Procedure:
[**2125-9-13**]: Bental(29 StJude mech Ao valved graft)[**9-13**]
History of Present Illness:
42 year old gentleman with a known bicuspid aortic valve and a
dilated ascending aorta which has been followed by serial
echocardiograms. His most recent echocardiogram showed mild to
moderate aortic insufficiency however his CT scan showed his
aortic root to measure 6.0cm. Given the size of his aorta, he
has
been referred for surgical evaluation. He denies any chest pain,
dyspnea, palpitations, edema or syncope but does admit to mild
fatigue.
Past Medical History:
Past Medical History:
Bicuspid aortic valve
Aortic insufficiency
Dilated ascending aorta
Hyperlipidemia
Hypertension
Past Surgical History:
[**Last Name (un) 8509**] eye surgery [**2117**]
Social History:
Race: Caucasian
Last Dental Exam: [**1-22**] yrs ago
Lives with: Wife
Contact: Wife Phone #
Occupation: HVAC
Cigarettes: Smoked no [X] yes [] last cigarette Hx:
Other Tobacco use: Denies
ETOH: < 1 drink/week [] [**2-27**] drinks/week [] >8 drinks/week [X] -
2
drinks/day
Illicit drug use: Denies
Family History:
Family History: Father with CAD and stent at age 60. GF
underwent
CABG. Mother and brother without issues.
Physical Exam:
Physical Exam
Pulse: 69 Resp: 16 O2 sat: 100%
B/P Right: 116/69 Left: 136/70
Height: 70" Weight: 196
General: Well-developed male in no acute distress
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade [**2-26**] sys/diastolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema [X]
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: Right: - Left: -
Pertinent Results:
[**2125-9-18**] 02:55AM BLOOD WBC-6.3 RBC-3.36* Hgb-10.5* Hct-29.5*
MCV-88 MCH-31.2 MCHC-35.6* RDW-13.3 Plt Ct-191
[**2125-9-18**] 02:55AM BLOOD PT-26.3* PTT-60.3* INR(PT)-2.5*
[**2125-9-18**] 02:55AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-138
K-5.1 Cl-102 HCO3-28 AnGap-13
[**2125-9-17**] 03:46AM BLOOD WBC-7.3 RBC-3.37* Hgb-10.3* Hct-29.4*
MCV-87 MCH-30.6 MCHC-35.0 RDW-13.1 Plt Ct-148*#
[**2125-9-17**] 03:46AM BLOOD Plt Ct-148*#
[**2125-9-17**] 03:46AM BLOOD PT-18.2* PTT-34.3 INR(PT)-1.7*
[**2125-9-17**] 03:46AM BLOOD Glucose-98 UreaN-16 Creat-1.0 Na-138
K-4.8 Cl-102 HCO3-29 AnGap-12
[**2125-9-17**] 03:46AM BLOOD Mg-2.0
[**2125-9-14**] 05:31AM BLOOD Glucose-108* K-4.4
TEE [**2125-9-13**]
Conclusions
Pre-Bypass:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated at the sinus level. The
ascending aorta and arch are moderately dilated. The aortic
valve is bicuspid. Moderate (2+) aortic regurgitation is seen.
There is no aortic stenosis.
The mitral valve appears structurally normal with trivial mitral
regurgitation.
Post-Bypass:
The patient is in sinus ryhthm on a phenylephrine infusion.
#29 St. [**Male First Name (un) 923**] Mechanical Aortic Valve graft appears well seated.
There are no apparent peri-valvular leaks. Washing jets are
present.
Normal left ventricular function - EF50-55%
Trace MR remains.
Remainder of exam is unchanged.
[**2125-9-18**] 02:55AM BLOOD WBC-6.3 RBC-3.36* Hgb-10.5* Hct-29.5*
MCV-88 MCH-31.2 MCHC-35.6* RDW-13.3 Plt Ct-191
[**2125-9-18**] 02:55AM BLOOD PT-26.3* PTT-60.3* INR(PT)-2.5*
[**2125-9-18**] 02:55AM BLOOD Glucose-98 UreaN-16 Creat-0.9 Na-138
K-5.1 Cl-102 HCO3-28 AnGap-13
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2125-9-13**] where the patient underwent Bental
with #29 mechanical aortic valve. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring.
He was initially hypertensive and required a nicardipine gtt. He
was started on lopressor and lasix. POD 1 found the patient
extubated, alert and oriented and breathing comfortably. The
patient was neurologically intact and hemodynamically stable. On
POD#1 he transferred to the floor. Chest tubes and pacing wires
were discontinued without complication. Post opertatively he was
noted to have a new LBBB which has since resolved. The patient
was evaluated by the physical therapy service for assistance
with strength and mobility. He was started on anticoagulation
therapy his goal INR 2.5-3.5. He was given the following
Coumadin doses -5mg/7.5mg/7.5mg/7.5mg/5 mg with INR 2.5 at the
time of discharge. By the time of discharge on POD# 5, the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to home with visiting nurse services in good condition with
appropriate follow up instructions. His first VNA INR draw is to
be done [**2125-9-19**].
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Lisinopril 5 mg PO DAILY
2. LeVITRA *NF* (vardenafil) unknown Oral unknown
3. Clindamycin 150 mg PO Frequency is Unknown
prn dental
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*100 Tablet Refills:*0
2. Furosemide 20 mg PO Q12H
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*5 Tablet
Refills:*0
3. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone 2 mg [**1-22**] tablet(s) by mouth Q 4 hrs Disp #*30
Tablet Refills:*0
4. Metoprolol Tartrate 50 mg PO BID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate [Lopressor] 50 mg 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
5. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Warfarin MD to order daily dose PO DAILY mechanical AVR
Take as directed for INR goal 2.5-3.5 for mechanical valve
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Milk of Magnesia 30 ml PO HS:PRN constipation
Discharge Disposition:
Home With Service
Facility:
amedisys
Discharge Diagnosis:
Bicuspid aortic valve
Aortic insufficiency
Dilated ascending aorta
Hyperlipidemia
Hypertension
[**Last Name (un) 8509**] eye surgery [**2117**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema minimal
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming, and look at your incisions
NO lotions, cream, powder, 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 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 at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2125-9-27**]
at 10:30a
Surgeon Dr. [**Last Name (STitle) **] on [**2125-10-17**] at 1:00p
Cardiologist: Dr. [**Last Name (STitle) 2912**] on [**2125-10-8**] at 1:45pm
Please call to schedule the following:
Primary Care Dr [**First Name (STitle) **] in [**4-26**] weeks
Coumadin for Prosthetic Aortic Valve
INR Goal: 2.5-3.5
Coumadin follow-up with Dr. [**First Name8 (NamePattern2) 5045**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 63696**]
Confirmed fax [**Telephone/Fax (1) 112397**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Next INR Draw: [**2125-9-19**]
**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:[**2125-9-18**]
|
[
"2859",
"4019",
"2724"
] |
Admission Date: [**2181-3-5**] Discharge Date: [**2181-3-12**]
Date of Birth: [**2119-5-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Breast pain
Major Surgical or Invasive Procedure:
evacuation of right breast hematoma [**2181-3-8**]
History of Present Illness:
The patient is a 61 year old female with history of atrial
fibrillation refractory to lopressor, amiodarone, felxanide and
cardioversion who was recently admitted to the cardiothoracic
surgery service from [**2181-2-13**] to [**2181-2-18**] for MINI MAZE procedure.
On [**2181-2-14**] the patient underwent minimally invasive bilateral
thoracoscopic
epicardial pulmonary vein isolation with resection of left
atrial appendage and autonomic ganglia stimulation and ablation.
The patient's procedure was reported to have been
non-complicated. There was noted to be difficulty surrounding
pain control for which narcotics and toradol were required, the
patient ultimately required a paravertebral block finally with
good effect. The patient was noted to develop rapid afib x 1 and
was treated w/ IV lopressor and
amiodarone with subsequent conversion to sinus rhythm. The
patient was discharged to home on coumadin.
The patient reports she was doing generally well
post-discharge although she did notice some nausea and
intolerance ot pain meds. 2 days ago the patient reports she was
doing some routine cleaning around her home without difficulty
using her right arm, later in the day she reports sneezing and
coughing frequently with sense of sharp pain in her right breast
during this. The patient noted some ongoing pain, took a
percocet and attempted to go to sleep. She woke up at 2:00a.m.
with ongoing pain and noted a palpable lump on her breast over
area of pain. The patient presented to the ED yesterday a.m. Her
care was discussed with CT surgery with impression she may have
some local bruising related to procedure and recommended
outpatient follow up with pain control. Apparently the patient
represented because of onogoing pain.
.
ED Course: Vitals 97.3, 131/73, 70, 20, 100% RA. In the ED the
patient had an ultrasound performed with wet read revealing for
5.5 x 8.5 x 10 cm heterogeneous collection at 10 o'clock, 7 cm
deep, medial to patient's incision concerning for a post-op
seroma although super-infection not excluded. This was noted not
fluid filled, thereby may be difficult to drain. Additionally,
more diffusely, centered at 2 oclock, there is a large
hypoechoic region approximately 12 x 13 cm, concerning for
intra-mammary hematoma. In the ED the patient was seen by CT
surgery team, no note of this encounter is available for review.
Per ED signout CT surgery did not feel admission was warranted
and recommended outpatient follow up, holding coumadin until
therapeutic. ED felt patient's pain was difficult to control and
recommended admission for this as well as concern for
fellulitis. I contact[**Name (NI) **] CT surgery team when request was made
for admission to medicine. I confirmed that CT surgery team was
not concerned about findings on ultrasound, did not recommend
any INR reversal beyond holding coumadin.
Past Medical History:
atrial fibrillation
s/p mini-maze [**2181-2-14**]
obesity
hyperlipidemia
degenerative disc disease
pacer [**11-24**] for tacycardia/bradycardia syndrome
appendectomy
left and right knee arthroscopy
uterine polypectomy
Social History:
The patient currently lives in [**Location 745**], MA with her sisters. She
is employed as a computer programmer, no children
Tobacco: None
ETOH: None
Illicit drugs: None
Family History:
father died MI at 52.
mothr with Afib-died at age 82
Physical Exam:
Vitals: 99.7, 131/80, 72, 20, 99% RA
General: Patient is a middle aged female lying in bed, appears
tired, no acute distress. Affect flat
HEENT: NCAT, EOMI, sclera anicteric
OP: MMM
Neck: JVP not visible, does not appear obviously elevated
Chest: CTA anterior and posterior
Right breast: Patient with bilateral axillary incisions. Right
incision appears clean, dry, without erythema or induration.
Medial to incision is a very faint area of faint erythema
congruent with nipple, appears non-blanching, not warm,
non-tender. Superior and medial to nipple is large area with
normal overlying skin but deeper induration appreciated with
firm deep tissue consistent with ultrasound findings of
hematoma. This area is very tender to palpation, no erythema, no
fluctuance.
Cor: Regular, no murmurs
Abdomen: Obese, soft, non-tender, non-distended
Ext: No edema, DP 2+ bilaterally
Skin/Nails: Rash as above
Neuro:Grossly intact
Pertinent Results:
Labs on admission:
[**2181-3-4**] 10:05AM BLOOD WBC-9.3 RBC-4.00* Hgb-11.8* Hct-34.8*
MCV-87 MCH-29.5 MCHC-33.9 RDW-14.9 Plt Ct-295#
[**2181-3-4**] 10:05AM BLOOD Neuts-82.7* Lymphs-9.2* Monos-4.9 Eos-2.8
Baso-0.5
[**2181-3-4**] 10:05AM BLOOD PT-37.3* PTT-40.3* INR(PT)-4.0*
[**2181-3-4**] 10:05AM BLOOD Glucose-138* UreaN-35* Creat-1.0 Na-139
K-5.1 Cl-104 HCO3-24 AnGap-16
[**2181-3-5**] 07:10AM BLOOD ALT-22 AST-19 AlkPhos-85 TotBili-0.5
.
Hematocrit trend:
34.8 --> 31 --> 28.3 --> 27.1 --> **********
.
Imaging:
[**3-4**] Chest x-ray:
IMPRESSION: No acute cardiopulmonary process.
.
[**3-4**] Chest wall ultrasound:
5.5 x 8.5 x 10 cm heterogeneous collection at 10 o'clock, 7 cm
deep, medial to patient's incision - concerning for a post-op
seroma, super-infection not excluded. Not fluid filled, thereby
may be difficult to drain.
More diffusely, centered at 2 oclock, there is a large
hypoechoic region
approximately 12 x 13 cm, concerning for intra-mammary hematoma
especially
given the supra-therapeutic INR.
[**2181-3-12**] 05:25AM BLOOD WBC-5.3 RBC-3.38* Hgb-9.7* Hct-28.8*
MCV-85 MCH-28.8 MCHC-33.7 RDW-15.0 Plt Ct-276
[**2181-3-12**] 05:25AM BLOOD PT-13.7* PTT-30.3 INR(PT)-1.2*
[**2181-3-12**] 05:25AM BLOOD Glucose-107* UreaN-14 Creat-0.8 Na-142
K-4.4 Cl-108 HCO3-26 AnGap-12
Brief Hospital Course:
The patient is a 61 year old female with history of atrial
fibrillation status post MINI MAZE who now presents with right
breast pain with ultrasound revealing for post-op seroma as well
as large hematoma. She was transferred to the cardiac surery
service on [**2181-3-6**]. INR drifted down and the patient was
brought to the operating room on [**2181-3-8**] for evacuation of right
breast hematoma. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in good
condition. POD 1 found the patient extubated, alert and
oriented and breathing comfortably. She was transferred to the
telemetry floor. The patient remained in rate controlled atrial
fibrillation/atrial flutter throughout the hospital course. She
was maintained on amiodarone and lopressor. Coumadin was
discontinued. The patient did develop some dizziness and was
found to have orthostatic hypotension. This resolved with a
bolus of albumin and decrease in her beta blockade. She made
progress and was discharged home on POD 4. By the time of
discharge, the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics.
Medications on Admission:
Lasix 40mg twice daily until [**2181-2-28**] (completed)
Amiodarone 400mg twice daily until [**2181-2-25**], once daily until
[**2181-3-4**], 200mg daily
Aspirin 81mg daily
Metoprolol 50mg three times daily
Pravastatin 40mg daily
Coumadin 4mg daily
Docusate 100mg twice daily
Oxycodone-Acetaminophen 5-325mg: 1-2tables every 4hours PRN
Colchicine 0.6mg PO daily
Indomethacin 25mg PO three times daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
200mg 2x/day for 1 week, then 200mg daily until further
instructed.
Disp:*45 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 3 months.
Disp:*30 Tablet(s)* Refills:*2*
5. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 3 months.
Disp:*90 Capsule(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Chest wall hematoma
Acute blood loss anemia
Atrial fibrillation
hyperlipidemia
uterine polypectomy
degenerative disc disease
appendectomy
s/p mini-maze [**2181-2-14**]
Discharge Condition:
good
Discharge Instructions:
You were admitted to the hospital with right sided chest wall
pain and found to have a hematoma, with elevated INR (coumadin)
level. You were monitered, and transferred to the CT surgery
service...
Please take medications as directed.
Please follow up with appointments as directed.
Please contact physician if develop worsening pain,
lightheadedness/dizziness, fainting, fevers/chills, any other
questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] 4 weeks
[**Last Name (LF) 80886**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 80887**] 2 weeks
Dr. [**Last Name (STitle) 73**] [**Telephone/Fax (1) 62**] 1 week
Completed by:[**2181-3-12**]
|
[
"2851",
"42731",
"2724"
] |
Admission Date: [**2104-11-18**] Discharge Date: [**2104-11-23**]
Date of Birth: [**2052-5-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
R-Sided Weakness, Lethargy
Major Surgical or Invasive Procedure:
Burr Hole for SDH evacuation/Drain placement
History of Present Illness:
This is a 52 year old male well known to the NSurg service,
as he is status post R cranioplasty on [**2104-11-12**]. In summary,
he suffered a SDH and IPH from a MVC in [**2104-7-5**] and underwent a
craniotomy; however, he developed a post op infection, and the
bone flap was removed in [**Month (only) 205**]. He returned [**11-12**] for an
elective
cranioplasty. He had an uneventful post op course, and was
discharged to home on [**2104-11-14**]. His wife states that he did
well over the weekend, but slowly developed progressive RUE and
RLE weakness, to the point where he could no longer lift his arm
or leg today. This prompted them to report to their local ER,
where a CT Scan demonstrated a large extra axial and well as a
large sub dural collection beneath the cranioplasty site, with
14
mm of midline shift. He was transferred to [**Hospital1 18**] for further
evaluation
Past Medical History:
TBI, left clavicular fracture, right hip repair
Social History:
- lives in [**Location 85717**] NH
- married with a son and daughter
- serves as a [**Doctor Last Name 9808**] operator a naval shipyard
- denies tobacco, etoh, drugs
Family History:
Noncontributory
Physical Exam:
PHYSICAL EXAM:
O: T: 98.8 BP: 139/90 HR: 57 R:14 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Obvious edema to L crani site, mild L eye edema Pupils:
PERRLA EOMs limited upward gaze
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake but lethargic, cooperative with exam
Orientation: Oriented to person and date, thinks he is in [**State 1727**].
Recall: [**3-19**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements with limited upward gaze. no
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-21**] throughout the L side. RIGHT
Hand, Bicep, Tricp and Deltoid all [**3-21**], Right IP, Quad, and
Hamstring [**4-21**].
Sensation: Reports tingling sensation to entire R-side.
CT Read from OSH:Large left subdural fluid collection
compressing
the left cerebral hemisphere subfalxian herniation towards right
side with midline shift measuring 14mm. Bilateral dilated
temporal horns of lateral ventricles compression of and edema in
the left frontal and parietal lobed. Fluid collection measure
up
to 28mm between thickened dural and plate
Pertinent Results:
ADMISSION LABS:
[**2104-11-18**] 07:50PM WBC-7.1 RBC-4.81 HGB-13.8* HCT-40.0 MCV-83
MCH-28.6 MCHC-34.5 RDW-14.1
[**2104-11-18**] 07:50PM GLUCOSE-107* UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-30 ANION GAP-15
[**2104-11-18**] 10:13PM GLUCOSE-113* LACTATE-1.1 NA+-138 K+-4.5
CL--98*
CT Head [**11-19**]
Status post evacuation of left subdural collection with
placement
of a small caliber catheter with interval decreased mass effect
on the brain
as compared to [**2104-11-18**] at 15:08 o'clock. No evidence of
acute
process within the brain parenchyma.
CT head [**11-20**]
1. Post-evacuation with left-sided cranioplasty changes with
decreased amount
of pneumocephalus.
2. Small caliber catheter on the left is unchanged in position.
Interval
decrease of rightward shift of normally midline structures.
3. No acute intracranial process
CT Head [**11-22**]
1. No interval change since the previous examination. Stable
left temporal
lobe encephalomalacia. Stable appearance to cranioplasty.
Brief Hospital Course:
The patient was taken to the operating room from the Emergency
Department for evacuation of the Sub Dural Collection. It was
discovered perioperatively that the collection was sub acute
blood, and about 50cc was drained. A sub dural drain was placed
for continuous drainage. He was admitted overnight to the ICU
for Q1 neuro checks and close monitoring. Post operative head CT
revealed good evacuation.
Mr [**Known lastname 10983**] continued to remain stable. His drain began to have
good output on the evening of [**11-19**]. Overnight he also developed
intermittent Afib with rates to the 110's. He was started on
Labetolol TID. He remained asymptomatic of the arrythmia and
some notes suggest that he has had episodes of this before.
On [**11-20**] he was cleared for transfer to the stepdown unit. A
routine head CT was requested and showed stable appearance with
post op changes. His subdural drain remained in and had good
output. His neurologic exam remained intact and he was seen by
the physical therapy team and cleared for home. On [**11-21**] his
subdural drain was clamped in the evening and remained clamped
through [**11-22**]. A head CT showed no subdural collection and his
drain was removed without complication. He was discharged home
in stable condition on [**11-23**]. He will follow up with Dr. [**Last Name (STitle) **]
for suture removal in 10 days and have a general follow up with
repeat CT scan in 4 weeks.
Medications on Admission:
Keppra 500mg twice daily
MVI 1 tab daily
labetalol 100mg twice daily
Discharge Medications:
1. Outpatient Occupational Therapy
Please evaluate and treat
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*70 Tablet(s)* Refills:*0*
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*1*
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: do not exceed 4 grams in 24 hours.
9. labetalol 100 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for atrial fibrillation.
Disp:*20 Tablet(s)* Refills:*0*
10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: do not drive while taking this
medication , do not take if you are lethargic.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Left chronic SDH / fluid collection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after [**Last Name (STitle) 2729**] at surgical incision
and staples at drain site have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We recommend taking an over the
counter stool softener, such as Docusate (Colace) while taking
narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If need to begin a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin,you will need to discuss when
it is safe to start this medication with Dr [**Last Name (STitle) **].
?????? You have been discharged on Keppra (Levetiracetam)an
antiseizure medication.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-26**] days(from your date of
surgery) for removal of your staples and [**Date Range 2729**] and a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2104-11-23**]
|
[
"42731"
] |
Admission Date: [**2145-5-28**] Discharge Date: [**2145-6-18**]
Date of Birth: [**2084-3-2**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
Dehydration.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 61 year old man with metastatic esophageal
cancer to liver and lung presents from clinic with dehydration
and severe mucositis. He is s/p initiation of cycle 1 of ECX
(epirubicin, cisplatin, and xeloda) on [**5-20**]. Since his
treatment, he has been feeling fatigued and developed a sore
throat and mouth sores. He has been able to eat and drink
although drinking sometimes makes him nauseated. He was
prescribed magic mouthwash and did not noticed much improvement.
Patietn also states that he feels confused sometims and with a
slow mind. He had dairrhea in the morning with normal color, but
watery stool. He denies any sick contacts or exposure to people
in nursing homes, children or other infectious agents.
.
He had planned on coming into the outpatient treatment area for
IVFs, but because he has been feeling so unwell, he presented in
clinic today for evaluation.
.
In clinic, he was found to be orthostatic and appeared
dehydrated on exam. He was noted to have oral thrush. He was
given 2L NS, zofran 8 mg IV and nystatin 5 cc as well as
diflucan 200 mg. he was seen by Dr. [**Last Name (STitle) **]. He is now being
admitted for rehydration and treatment of his mucositis and
thrush.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
He initially presented in [**11/2142**] due to dysphagia and weight
loss. At that time, he had a barium swallow, which showed a
pinpoint narrowing of his distal esophagus. He had endoscopy
and underwent dilatation of this stricture. He did not have
much improvement with the dilatation and in [**Month (only) 116**] of this year
underwent a second dilatation once again with no improvement.
He had motility tests, which were most consistent with
achalasia. In [**Month (only) **], he underwent a Botox injection to the
narrowing in order to help to release it. He had a CT scan
after this which showed a 1.5 cm gastrohepatic lymph node. On
[**2143-8-28**] he underwent an upper endoscopy on which they saw
distal esophageal narrowing. They also performed multiple
biopsies of the area of narrowing. Of note, they saw some
ulceration in the GE junction and a thick abnormal fold
concerning for esophageal or gastric cardia cancer. The biopsy
showed moderate to poorly differentiated adenocarcinoma. After
this he underwent endoscopic ultrasound, however, they were
unable to pass the ultrasound probe beyond the stricture. He
has had a port, g-tube, and esophageal stent
placed. He started treatment with 5-FU and Cisplatin on [**2143-10-10**]
with concurrent radiation therapy. Radiation was completed on
[**2143-11-26**]. He was admitted from [**2143-11-26**] to the [**2143-12-3**]
with febrile neutropenia and dehydration. He underwent an
esophagectomy on [**2144-1-20**]. Pathology from this showed a
metastatic adenocarcinoma with 4/6 perigastric lymph nodes
positive, and a separate foci of tumor in the adjacent adipose
tissue. He completed treatment in [**2144-1-4**]. He had liver
lesions noted on a CT scan [**2145-1-16**]. He had these biopsied on
[**2145-1-27**] and the pathology came back as consistent with
metastasis from esophageal cancer.
.
PAST MEDICAL HISTORY:
====================
- Esophageal cancer- moderate to poorly differentiated
adenocarcinoma; Rec'd 5-FU/cisplatin with concurrent XRT in
[**10-11**], now s/p minimally invasive esophagectomy [**1-10**].
- h/o atrial fibrillation
- h/o S. viridans bacteremia
- Sinusitis, status post surgery
- Hypertension
- Vocal cord paralysis
Social History:
He originally moved from [**Country 6171**] 17 years ago. Married, 2
children. Teaches French and Spanish. He used to smoke a pack a
day, but quit 15 years ago. He used to drink a couple of glasses
of wine with dinner each night, but not since diagnosis.
Family History:
He has a father with pancreatic cancer who died at the age of
70.
Physical Exam:
Vitals - T: 98.1 BP: 104/74 HR: 67 RR: 16 02 sat: 100% on RA
.
GENERAL: NAD, very pelasant gentleman, hoarse, very french
accent
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strenght [**6-8**] in upper and lower
extremities, DTRs [**6-8**], [**Name2 (NI) 73082**] 27
Pertinent Results:
On Admission:
[**2145-5-28**] 10:00AM WBC-2.9*# RBC-4.84 HGB-15.0 HCT-43.9 MCV-91
MCH-30.9 MCHC-34.1 RDW-13.8
[**2145-5-28**] 10:00AM PLT SMR-VERY LOW PLT COUNT-35*#
[**2145-5-28**] 10:00AM GRAN CT-2240
[**2145-5-28**] 10:00AM ALT(SGPT)-100* AST(SGOT)-51* ALK PHOS-75 TOT
BILI-1.4 DIR BILI-0.3 INDIR BIL-1.1
[**2145-5-28**] 10:00AM ALBUMIN-3.5 PHOSPHATE-3.5 MAGNESIUM-2.2
[**2145-5-28**] 10:00AM UREA N-36* CREAT-1.0 SODIUM-138 POTASSIUM-3.6
CHLORIDE-102 TOTAL CO2-27 ANION GAP-13
[**2145-5-28**] 10:00AM GRAN CT-2240
Pertinent Interim/Discharge Labs
[**2145-6-18**] 12:23AM BLOOD WBC-12.3* RBC-3.46* Hgb-10.7* Hct-30.5*
MCV-88 MCH-31.0 MCHC-35.2* RDW-18.6* Plt Ct-228
[**2145-6-14**] 12:00AM BLOOD WBC-19.3* RBC-3.03* Hgb-9.4* Hct-28.2*
MCV-93 MCH-30.9 MCHC-33.2 RDW-17.9* Plt Ct-98*
[**2145-6-13**] 12:00AM BLOOD PT-15.5* INR(PT)-1.4*
[**2145-6-8**] 09:36AM BLOOD PT-28.0* PTT-31.1 INR(PT)-2.8*
[**2145-6-6**] 12:00AM BLOOD Gran Ct-253*
[**2145-6-7**] 12:00AM BLOOD Gran Ct-704*
[**2145-6-9**] 12:00AM BLOOD Gran Ct-7521
[**2145-6-18**] 12:23AM BLOOD Glucose-91 UreaN-19 Creat-0.5 Na-134
K-4.4 Cl-103 HCO3-24 AnGap-11
[**2145-6-15**] 12:00AM BLOOD ALT-27 AST-32 LD(LDH)-292* AlkPhos-160*
TotBili-2.1*
[**2145-6-18**] 12:23AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.9
[**2145-6-15**] 12:00AM BLOOD Albumin-2.0* Calcium-6.9* Phos-3.1 Mg-1.9
CT abdomen/pelvis [**5-30**]:
1. No evidence of diverticulitis, abscess, or any acute
pathology to explain LLQ pain.
2. New wedge-shaped hypodensities within the spleen, likely
infarcts given relatively rapid appearance from the prior study.
3. Although incompletely assessed due to collapsed bowel,
apparent wall thickening of the ascending colon which may
represent bowel wall edema. No secondary signs of inflammation
(ie no fat stranding).
CXR [**6-3**]:
As compared to the previous radiograph, there is increasing
opacity
at the left lung base, combined with a newly appeared blunting
of the left
costophrenic sinus, presumably due to effusion. The size of the
cardiac
silhouette is unchanged. Unchanged normal right lung, unchanged
Port-A-Cath system.
CT chest [**6-4**]:
1. New diffuse transverse colon wall thickening and surrounding
inflammatory change consistent with colitis, only partially
visualized. Further evaluation with dedicated CT enterography of
the abdomen and pelvis may be obtained for further evaluation.
2. New, small left, and trace right, pleural effusions.
3. New tree-in-[**Male First Name (un) 239**] opacities in the right lower lobe with mild
improvement in right upper lobe tree-in-[**Male First Name (un) 239**] opacities. These
findings may be due to
aspiration.
TTE [**6-8**]:
No vegetations seen (suboptimal-quality study). Mild mitral
regurgitation. Normal global and regional biventricular systolic
function.
RUE U/S [**6-8**]:
DVT involving the right distal brachial vein, as well as the
cephalic vein.
CXR [**6-9**]:
Compared to [**6-3**], there is more opacification in the left
lower lobe,
which could be worsening atelectasis or pneumonia particularly
due to recent aspiration. There has also been increase in
diameter of the cardiac
silhouette and the azygos vein which may indicate volume
overload but there is no pulmonary edema.
MICRO
[**6-1**] blood cx: Strep Pneumoniae
Brief Hospital Course:
1. Pneumococcal infection: While the patient was neutropenic, he
was febrile once. Cultures were sent and he was started on
empiric cefepime. Imaging suggested a LLL pneumonia, and blood
cultures grew GPC, for which vancomycin was added. The GPC were
speciated as S. pneumoniae. TTE showed no vegetations. No
further blood cultures were positive, and his antibiotics were
eventually narrowed to ceftriaxone alone for a 14 day course,
starting at the resolution of neutropenia. For easier dosing at
home, he was changed to Cefpodoxine to finish course after
discharge.
2. Mucositis: Unable to tolerate PO and was resuscitated with
IVF. He was started on oral lidocaine and gelclairm as well as
oral fluconazole and nystatin for [**Female First Name (un) 564**]. He was later taken
off the fluconazole as it elevated his transaminases and changed
to micafungin. However, this was also stopped as it elevated his
bilirubin. IV morphine was used for pain control and he briefly
required a PCA pump. Once his neutropenia resolved, his
mucositis began to improve. However, the resultant increase in
secretions caused respiratory distress and hypoxia, requiring
ICU transfer for frequent deep suctioning and nebulizers. This
resolved rapidly and he returned to the floor. Mucositis
subsequently improved.
3. Acute renal failure: Despite normal creatinine at 1.0, this
essentially doubled from low baseline of 0.4-0.7 and
BUN/creatinine 36. Likely in the setting of poor PO. He was
agressively hydrated with IVF and creatinine improved.
4. Neutropenia: Secondary to chemotherapy. His ANC continued to
trend down during admission until he became severely
neutropenic. He was started on filgrastim and eventually his ANC
completely recovered.
5. Thrombocytopenia: Also secondary to chemotherapy. Early in
the admission, he had some hematochezia, so was transfused plts
to keep his count over 30,000.
6. Right UE DVT: Found on U/S in the setting of arm swelling. He
was started on enoxaparin.
7. Colitis: Early on, paient complained of LLQ pain, associated
with hematochezia and then dark stools. He required 2 units RBCs
for this, but endoscopy could not be done due to his neutropenia
and thrombocytopenia. Stool studies were negative. CT abdomen
showed some bowel edema, but no diverticulitis. A CT chest done
a few days later noted some transverse colitis, although he was
asymptomatic. Metronidazole was empirically started and
continued for 5 days. Later on, in the setting of starting
enoxaparin for DVT, he had dark guaiac positive stools. GI was
consulted and felt bleeding was related to mucositis vs
colitis/inflammation in setting of anticoagulation and did not
feel there was indication for scope as an inpatient. His
hematocrit was stable prior to discharge.
8. Esophageal cancer: On admission, he was day 9 status post
chemotherapy. He received no further treatments as an inpatient,
and he will follow up with his oncologist as an outpatient.
9. Nutrition: Due to poor POs, PPN was started as there was not
enough access for TPN in the patient's chest port due to
antibiotics and IV fluids. Once his antibiotics were weaned, TPN
was initiated via his port. He also had an elevated INR that was
likely nutritional, and improved with vitamin K.
Medications on Admission:
Emend 125mg day 1, 80mg days [**3-9**]
Xeloda 2g [**Hospital1 **] (days [**2-17**])
Dexamethasone 4mg (days [**3-10**])
Magic mouthwash tid prn
Lorazepam 0.5-1mg q4-6h prn
Megestrol 100mg/10ml susp daily
Metoclopramide 5mg tid
Metoprolol 100mg [**Hospital1 **]
Ondansetron 8mg q8h prn (? GI upset)
Gelclair tid
Oxycodone 5-10mg q4-6h prn
Prochlorperazine 10mg q6-8h prn
Ranitidine 150mg [**Hospital1 **]
Sucralfate 1g tid
Zolpidem 10mg hs prn
Discharge Medications:
1. Flushes
Saline flush 10cc SASH and prn
heparin flush 10U/ml 5cc SASH and prn
Heparin 100U/ml 5cc deaccess port
2. Lidocaine HCl 2 % Solution Sig: Fifteen (15) ML Mucous
membrane TID (3 times a day) as needed.
Disp:*1 bottle* Refills:*0*
3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for anxiety or nausea.
4. Megestrol 400 mg/10 mL Suspension Sig: 100mg/10ml suspension
PO once a day.
5. Reglan 5 mg Tablet Sig: One (1) Tablet PO three times a day.
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
8. Oral Wound Care Products Gel in Packet Sig: One (1) ML
Mucous membrane TID (3 times a day) as needed.
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
10. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea or vomit.
11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO three times
a day.
12. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
13. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*60 syringe* Refills:*0*
14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
16. Outpatient Lab Work
Please do weekly lab work and fax to [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 18971**] [**Telephone/Fax (1) 55043**] to monito while on TPN. Check CBC, BUN, Cr,
electrolytes, albumin, LFTs.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary:
Chemotherapy induced diarrhea and mucositis
Pneumococcal bacteremia
Pneumonia
Deep venous thrombosis
Secondary:
Esophageal cancer
Hypertension
Discharge Condition:
hemodynamically stable, afebrile, shortnes of breath and cough
improved
Discharge Instructions:
You were admitted to [**Hospital1 18**] with dehydration, diarrhea, and
inflammation of the mucous membranes (mucositis). We gave you IV
fluids and started TPN, a form of nutrition given through the
veins. We also treated you with antibiotics for a bloodstream
infection and a pneumonia. We also started enoxaparin (Lovenox),
a blood thinner, due to a blood clot found in your arm veins.
Once your white blood cells recovered from your chemotherapy,
your mucositis continued to improve. We changed your ranitidine
to pantopraxole.
Please take all medications as prescribed and go to all follow
up appointments.
If you experience fevers, chills, vomiting, diarrhea, abdominal
pain, worsening mouth/throat pain, bloody stools, or any other
concerning symptoms, please seek medical attention or come to
the ER immediately.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 6568**] for an
appointment in [**2-5**] weeks.
|
[
"486",
"5849",
"2859",
"42731",
"4019"
] |
Admission Date: [**2111-7-7**] Discharge Date: [**2111-7-21**]
Date of Birth: [**2050-9-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
hypoxia, tachycardia
Major Surgical or Invasive Procedure:
Right Pleurex Placement
Pericardial Window
History of Present Illness:
This is a 60 year old female with estrogen receptor positive
breast CA metastatic to lung with a recurrent left malignant
pleural effusion s/p PleurX catheter placement on [**2111-5-7**] and
high output with drainage at home 400-500cc daily who presented
to Interventional Pulmonary Clinic [**2111-7-7**] for follow up of left
PleurX catheter and continued shortness of breath with a
persistent right-sided pleural effusion. Thoracentesis was for
palliative purpose. 1600cc was removed on the R and about 500cc
from the Pleurx on the left. Pt was tachycardic during recovery.
Pt has baseline tachycardia to 120's but now was in 140's. Also,
began coughing blood tinged sputum. Pt had no CP, SOB, fever.
Pt was sent to ED.
.
In the ED, initial vs were: 97.8 150 134/96 28 88% 6L nc.
Patient was given Lorezapam 2mg IV x2 and Lasix 40mg IV x1.
Patient and family refusing further venipunctures. Pt confirmed
to be DNR/DNI. IP fellow evaluated her and recommended ED obs.
However, pt continued to be tachycardic. Pt also noted to be
hypoxic to 85% on NC 4L. Then, on NRB, O2 sats recovered. Was
also on BiPap for a while, intermittently. Denies pain. IP
recommended getting CTA chest to r/o PE however pt has only a 22
PIV and refusing any other sticks. Will need additional IV
access tomorrow, then will go for CTA. K was noted to be 6.1,
however, sample appears hemolyzed. EKG showed NSR with PACs,
RBBB w/LAFB, TWI V5-V6, no peaked T waves. CXR showed
persistent bilat pleural effusions. VS on transfer were 108/72,
P 138, 96%NC 4L.
.
Upon arrival to ICU, pt appears comfortable. Endorses chronic
dry cough. Denies hemoptysis, just some pinkish frothy sputum
earlier in day. Endorses poor appetite, but tries to keep up
with her calorie intake. Endorses chronic shortness of breath.
Denies any pain. States she has chronic tachycardia, usually in
110-120s sometimes up to 130-140s. Pt is on 2L NC at home at
baseline.
.
Of note, pt states that the thoracentesis have never helped her
symptoms (breathing, shortness of breath). However, without
them, she states she will be unable to breathe.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, abdominal pain, or changes in bowel habits. Endorses
chronic constipation. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.
Endorses neuropathy in left hand.
Past Medical History:
Past Oncologic History:
- Screening mammogram on [**2105-12-12**] noted a nodular mass with
distortion in the posterior central medial left breast. U/S
showed a left breast mass irregularly marginated hypoechoic area
at 9 o??????clock, measuring just under 2.0 cm. Core biopsy at
[**Hospital1 882**] revealed invasive lobular carcinoma measuring at least
0.7 cm ER/PR
positive and her2neu negative.
- Pt underwent left partial mastectomy with axillary dissection
on [**2106-1-29**]. Pathology revealed invasive lobular carcinoma,
multifocal, largest at 4cm; invasive grade III T2N1
- Multiple chemotherapy regimens with DD AC, abraxane, endocrine
blockade w/ TAM and Arimadex. Cancer progression on xeloda and
faslodex.
- [**2-28**] CT torso showed progressive disease with possible new
lung, definite new liver, progressive pancreatic and new bone
lesions.
- [**12-2**] underwent XRT for new cervical metastasis. Was restarted
on doxil.
- Her last dose of Doxil at 80% was in early [**2111-3-22**].
- [**5-2**] CT scan shows disease progression in her lungs, was
started on Exemestane
.
Other Past Medical History:
deaf in R ear with tinnitis
L hand neuropathy [**12-24**] Doxil
Social History:
Lives with husband. Now retired, used to work as manager in
Accounts Receivable. Denies hx of smoking; denies alcohol or
other drug use.
Family History:
3 cousins: Breast cancer
Aunt: DM
[**Name (NI) **] family history of ovarian or other cancers
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.1 BP: 102/73 P: 142 R: 14 O2: 98% on 6L NC
General: alert, oriented, no acute distress
HEENT: sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decr breath sounds at bases, diffuse crackles
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, neg [**Last Name (un) 5813**] sign
.
Physical Exam on Discharge:
Vitals: 95.7-98.5 81-94/51-62 72-124 18 99-100% on 3L N/C
I/O: 180/775 + 800 drained from L PleurX in afternoon
GEN: AOx3, NAD
HEENT: PERRL. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: Tachycardic, regualr rhythm, no murmurs/rubs/gallops
Pulm: Dullness at bases bilaterally [**11-23**] way up lung fields
(somewhat higher on right), absent breath sounds at bases,
crackles at left mid lung field posteriorly
Abd: hypoactive BS, soft, NT, no rebound/guarding, no HSM, no
[**Doctor Last Name 515**] sign
Extremities: wwp, trace b/l edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs
2+ BL. sensation intact to LT, cerebellar fxn intact (FTN, HTS).
gait WNL.
Pertinent Results:
Labs on Admission:
[**2111-7-7**] 03:38PM GLUCOSE-156* LACTATE-2.5* NA+-129* K+-6.1*
CL--90* TCO2-23
[**2111-7-7**] 01:46PM PLEURAL TOT PROT-2.8 LD(LDH)-95 ALBUMIN-2.1
[**2111-7-7**] 01:46PM PLEURAL WBC-515* RBC-223* POLYS-2* LYMPHS-31*
MONOS-17* MESOTHELI-20* MACROPHAG-17* OTHER-13*
[**2111-7-7**] 03:38PM GLUCOSE-156* LACTATE-2.5* NA+-129* K+-6.1*
CL--90* TCO2-23
[**2111-7-7**] 03:38PM PH-7.46* COMMENTS-GREEN TOP
.
Micro:
[**2111-7-7**] 1:46 pm PLEURAL FLUID
GRAM STAIN (Final [**2111-7-7**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method, please
refer to hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
.
Imaging & Studies:
CXR [**7-7**]:
1. Patchy opacifications in right lower lung concerning for
infection versus aspiration.
2. Improved aeration of previously noted left upper lobe
collapse related to known left paramediastinal mass.
3. Bilateral small pleural effusions, stable.
4. Unchanged left chest tube. No pneumothorax.
.
LENI [**7-7**]: no DVT in lower extremities
.
DISCHARGE LABS:
[**2111-7-21**] 03:45AM BLOOD WBC-11.0 RBC-4.29 Hgb-12.2 Hct-36.2
MCV-84 MCH-28.4 MCHC-33.7 RDW-14.6 Plt Ct-440
[**2111-7-21**] 03:45AM BLOOD Neuts-85.3* Lymphs-7.8* Monos-5.8 Eos-0.8
Baso-0.3
[**2111-7-20**] 07:05AM BLOOD Glucose-119* UreaN-14 Creat-0.6 Na-127*
K-4.6 Cl-85* HCO3-36* AnGap-11
Brief Hospital Course:
This is a 60 year old female with progressive metastatic breast
cancer with bilateral pleural effusions s/p thoracentesis now
here with tachycardia and hypoxia after the procedure
(thorocentesis).
.
Active Diagnoses:
.
#Pericardial Tamponade from Malignant Pericardial Effusion: Pt
was in sinus tachycardia and was hypotensive to the 80's
systolically when transferred out of the intensive care unit.
Her Echo showed frank tamponade physiology, and CT surgery was
immediately consulted and took her for emergent pericardial
window in the OR. The procedure was successful, and she spent
several in the C-[**Doctor First Name **] unit for monitoring. After her drain was
d/c'd she was transferred back to the OMED service. Her cardiac
status was monitored with daily EKG's assessing for voltage
changes as well as daily pulsus measurements using a doppler
probe (she remained in the 5-6 range, >8 was our threshold for
concern for recurrent tamponade). Prior to discharge she had
another echo which showed no definite change. She was set up
with CT surgery follow-up as an outpatient.
.
#Recurrent Bilateral Malignant Pleural Effusions: This patient
had recurrent bilateral pleural effusions related to metastatic
breast cancer. She had a left pleurex placed in the ED as well
as drainage of a large volume from her right side via a
thoracentesis and began to desat with a wet cough productive of
a small volume of frothy, blood-tinged sputum which raised
concern for re-expansion pulmonary edema. She was sent to the
unit for monitoring. She did well and was called out to the OMED
service when her above tamponade was discovered necessitating
emergent surgical intervention. On return to OMED, she had exam
and imaging finding consistent with significant re-accumulation
of her pleural effusion on the right side and underwent R-sided
pleurex placement. Her pleural fluid cultures were negative x 2.
She was followed very closely by the inteventional pulmonology
team in-house and following her Right pleurex placement, we were
very cautious to alternate the side that was drained daily. She
was drained to the point of pain, symptoms, or cough and this
was performed either by nurses or by her husband who had become
very skilled at handling the pleurex drain. She remained
persistently tachycardic in the 120's and frequently as high as
the 140's (120's seems to be her baseline per [**Hospital 191**] clinic
vitals). She maintained her sats in the mid-high 90's on 2-6LNC
(requiring a 10L facemask at one point) with her home O2 dose
being 2LNC. Throughout her admission, her blood pressure was
usually in the low 100's but she was occasionally hypotensive to
the low 80's or high 70's which responded well to 250cc boluses.
.
#Hyponatremia/Hyperkalemia/Hypothyroidism: Patient was
hyponatremic to 127 on second day of ICU course, up from most
recent Na of 133 in [**Month (only) **]. This was thought to be secondary to a
combination of SIADH in setting of metastatic cancer as well as
hypovolemia. Given K somewhat elevated, cortisol deficiency
also on differential although AM cortisol was wnl's on two
consecutive mornings. She continued to be hyponatremic and
hyperkalemic during her admission and was a difficult stick
occasionally requiring arterial sticks to check labs. The
endocrine team from [**Last Name (un) **] was consulted and recommended a
battery of tests including anti-TPO, anti-TG, serum aldosterone,
and plasma renin levesl as well as continued urine lytes
monitoring. The final assessment of her electrolyte derangement
was SIADH and she was treated with salt tabs .
.
Chronic Diagnoses:
.
# Metastatic breast cancer: Stable. She was continued on her
home Exemestane 25 mg once a day. This was held later in her
hospital course for concern that it may be interfering with her
electrolyte balance. This was ultimately not found to be related
to the patient's well-being..
.
Surgical course:
The patient showed tamponade physiology on echo and was brought
urgently to the operating room for a pericardial window with Dr.
[**Last Name (STitle) 914**]. Overall she tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for observation and recovery. Initial attempts to
wean vent were met with tachycardia and tachypnea. The vent was
weaned and the patient extubated on POD 2. The patient did
require neosynephrine for blood pressure support initially.
This was weaned and the patient was started on beta blocker for
rate control. Pericardial drain was discontinued on POD 4.
.
Transitional Issues: This patient had follow-up arranged with
her oncologist, with interventional pulmonology, with
cardiothoracic surgery, and with the endocrine team at [**Last Name (un) **].
Medications on Admission:
exemestane 25 mg once a day
gabapentin 200 mg twice a day for neuropathic pain
lorazepam 1 mg every 6-8 hours as needed for nausea
metoprolol succinate 25 mg Tablet Extended Release 24 hr
1 Tablet(s) by mouth once a day
oxycodone 5-10 mg every 4-6 hours as needed for pain
B complex vitamins [Vitamin B Complex]
calcium
cholecalciferol (vitamin D3) [Vitamin D]
diphenhydramine-acetaminophen [Tylenol PM] 500 mg-25 mg qhs
ibuprofen-diphenhydramine [Advil PM] 200 mg-38 mg daily
omega-3 fatty acids-vitamin E [Fish Oil]
Miralax daily
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for
sob,wheeze.
8. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3
times a day) as needed for pain.
9. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
10. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
11. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for insomnia.
12. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
13. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
14. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
15. sodium chloride 0.65 % Aerosol, Spray Sig: [**11-23**] Sprays Nasal
QID (4 times a day) as needed for dry nares.
16. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for thick secretions.
17. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
18. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. home oxygen
Patient needs home oxygen 3L via nasal cannula.
21. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
22. Outpatient Lab Work
Please check SMA-7 on [**2111-7-24**] and fax report to Dr. [**Last Name (STitle) **]
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Metastatic Breast Cancer
-Recurrent Malignant Pleural Effusions Bilaterally
-Recurrent malignant pericardial effusion
-Hyponatremia and hyperkalemia
-Hypothyroidism
-Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory w/ assistance or aid (walker or
cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you. You were admitted to [**Hospital1 18**]
for evaluation and treatment of shortness of breath. You were
found to have a dangerous level of fluid around your lungs as
well as your heart. As a result, you underwent thoracentesis
(needle insertion into the chest to drain fluid) and later
pleurex drain placement in the area of your right lung.
Additionally, you were transferred to cardiac surgery for a
short time to undergo emergent surgery for fluid build-up around
your heart called a pericardial window.
You were also found to have mild electrolyte disturbances
including low sodium and high potassium and were found to have
hypothyroidism. The team from [**Last Name (un) **] was consulted to help us
identify the causes of your electrolyte changes and based on the
testing they recommended we currently think you would benefit
from taking a low dose thyroid medication called Levothyroxine.
You were diagnosed with a urinary tract infection; we starting
you on ciprofloxacin for 7 days.
After an extensive discussion, you have decided that you would
not like drastic measures to prolong your life. We have given
you information on hospice care. We offered VNA services like
you had before however you opted out of this.
The following changes have been made to your medications:
-START Levothyroxine 25mcg DAILY for thyroid
-START Ciprofloxacin 250mg TWICE DAILY for UTI for 7 days. Last
of this medication will [**2111-7-28**].
-STOP Exemansthane (per Dr. [**Last Name (STitle) **]
-START Sodium chloride 1 tablet DAILY
All other meds should stay the same as before.
We wish you a speedy recovery! Please follow-up as below if you
can.
Followup Instructions:
You will need to follow up with the endocrine team at [**Last Name (un) **] for
further evaluation of your electrolyte disturbances. You are
currently scheduled for:
Department: DIV OF GI AND ENDOCRINE
When: WEDNESDAY [**2111-8-5**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1803**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Please call [**Telephone/Fax (1) 2378**] to cancel if you wish.
Also, the office of [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD (Interventional Pulmonary)
made you a follow up appointment for your drains on:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2111-7-28**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
The IP doctors are [**Name5 (PTitle) **] with your ER nurse (friend) removing your
sutures on the RIGHT drain on [**2111-7-25**], but no sooner.
Also, if that friend feels comfortable doing so, she should try
to draw blood from you at that time as well and have it sent off
for a CHEM 7 or at the very least, a sodium level. We were
unsuccessful in attaining blood ourselves today, but would like
to know if the salt tablets are working to raise your sodium
levels.
Also, an appointment was requested in the office of [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 914**], MD (Cardiothoracic Surgery) for within 1-2 weeks of
discharge ([**Telephone/Fax (1) 170**]) regarding the status of your
pericardial window. If you have not heard from them by this
Friday, please call the number above.
Your oncology follow-up is:
Department: [**Hospital 2039**] CARE CENTER
When: WEDNESDAY [**2111-7-22**] at 12:30 PM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) **], NP [**Telephone/Fax (1) 2041**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2111-8-19**]
|
[
"51881",
"5990",
"2767",
"5180",
"2449"
] |
Admission Date: [**2184-9-22**] Discharge Date: [**2184-10-1**]
Date of Birth: [**2130-12-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lisinopril / Ampicillin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
left heart catheterization, coronary angiogram
Coronary Artery Bipass Graft x1(LIMA-LAD)
History of Present Illness:
Ms. [**Known lastname **] is a 53 female s/p stenting of the proximal LAD and
s/p V.fib arrest in 11/[**2182**]. She who presented today with
substernal chest pain. The patient reports that the pain began
at 8:30PM when she stood up in her kitchen. the pain was [**6-20**]
with radiation to the left arm, mild nausea and diaphoresis. She
took a SL NTG with minimal relief. She called EMS and received
another Nitro SL in transit.
In [**Hospital1 18**] ED, initial vital signs were 98.6, 80, 110/63, 16
and100%on RA. She was given an additional two NTG and Morphine
IV which resolved the pain. EKG shows new TWI in lead V2, no
other changes. Troponins (-). Placed in observation and
underwent nuclear scan that showed a reversible distal anterior
wall and apical perfusion defect.
Given the findings on the nuclear study, the patient underwent
catheterization that revealed an osteal lesion not amenable to
intervention. CT surgery was contact[**Name (NI) **] regarding surgical
intervention.
Past Medical History:
noninsulin dependent diabetes mellitus
Dyslipidemia
hypertension
S/p Cardiac Arrest [**10/2183**]
Social History:
4th grade teacher, remote smoking history. Quit 25 years ago,
smoking [**12-14**] ppd for 5-10 years. Drinks [**12-14**] glasses of wine per
week. Denies drug use.
Family History:
Mother: Died of heart failure at age of 52 secondary to a
"virus". No history of arrythmias, syncope, or sudden death in
the family.
Physical Exam:
On Admission:
VS: 97.3 127/85 80 18 9%RA
General: Appears well and in NAD. Lying in bed.
HEENT: PERRLA, EOMI, anicteric, MMM, OP clear
CV: RRR, S1 and S2, no m/r/g
Lung: CTAB, no w/r/r
Abdomen: Soft, NT/ND, BSx4
Ext: No gross deformity or edema
Neuro: Awake, alert and oriented. CN II-XII intact. Moving all
extremeties.
Pertinent Results:
[**2184-9-23**] Nuclear Perfusion Study - IMPRESSION: 1. Reversible
distal anterior wall and apical perfusion defect. 2. Normal wall
motion with an ejection fraction of 67%.
[**2184-9-23**] Cardiac Cath - COMMENTS: 1. Single vessel coronary
artery disease 2. Ostial 80% stenosis involving the left
anterior descending coronary artery proximal to the previously
deployed stent 3. Withhold clopidogrel. 4. Cardiac surgery
consultation FINAL DIAGNOSIS:
1. One vessel coronary artery disease. 2. Ostial 80% stenosis of
the LAD proximal to the previously deployed stent.
[**2184-9-30**] 03:11AM BLOOD WBC-9.5 RBC-3.24* Hgb-10.2* Hct-29.2*
MCV-90 MCH-31.5 MCHC-34.9 RDW-11.8 Plt Ct-159
[**2184-9-22**] 09:50PM BLOOD WBC-7.3 RBC-4.36 Hgb-13.8 Hct-37.5 MCV-86
MCH-31.8 MCHC-36.9* RDW-11.9 Plt Ct-220
[**2184-9-30**] 03:11AM BLOOD Glucose-115* UreaN-7 Creat-0.6 Na-141
K-3.9 Cl-104 HCO3-29 AnGap-12
[**2184-9-22**] 09:50PM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-143
K-3.7 Cl-109* HCO3-24 AnGap-14
Intra-op TEE [**9-27**]
Conclusions
PREBYPASS: NORMAL LV SYSTOLIC FUNCTION, LVEF . 55%, NO SWMA. The
left atrium is normal in size. Left ventricular wall thicknesses
and cavity size are normal. Right ventricular chamber size and
free wall motion are normal. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to XX cm from the incisors. 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.
POST BYPASS: unchanged. Normal EF, no dissection seen after
cannula removed.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2184-9-27**] 18:16
Brief Hospital Course:
She was admitted to the floor. On [**2184-9-23**], the patient
underwent cardiac catheterization that showed an 80% stenosed
LAD ostial lesion. Plavix was held and the patient underwent
Plavix washout.
On [**9-27**] she was taken to the operating Room where single vessel
grafting was performed. She was stable, weaned from Neo
Synephrine, awoke intact and was extubated. Beta blocker was
resumed and she was diuresed towrds her preoperative weight.
Blood pressure would not tolerate resuming Diovan. This should
be addressed as an outpatient. Physical Therapy worked with her
for strength and mobility.
CTs and wires were removed without incident. Arranagements were
made for out patient follow up. Wounds were clean and healing
well at discharge on POD 4 to home.
Medications on Admission:
aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
3. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*qs 1 month ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts x1 [**2184-9-27**]
s/p coronary stenting
anxiety/depression
s/p appendectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Edema- 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**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr.[**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2184-11-3**] 1:00
Cardiologist: Dr.[**Name (NI) 13892**] office will call you with an appt.
Please call to schedule appointments with:
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 47598**] ([**Telephone/Fax (1) 9386**]in [**3-16**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2184-10-1**]
|
[
"41401",
"2851",
"25000",
"2724",
"4019",
"311",
"V4582",
"V1582"
] |
Admission Date: [**2190-8-16**] Discharge Date: [**2190-8-22**]
Service: CARDIOTHOR
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 82-year-old man
with critical aortic stenosis with a .9 cm square valve area,
mitral regurgitation, bradycardia with a pacemaker, chronic
atrial fibrillation, tricuspid regurgitation, pulmonary
hypertension and congestive heart failure. On [**2190-8-16**],
the patient underwent aortic valve replacement for critical
aortic stenosis with a 27 mm pericardial tissue valve. He
has chronic atrial fibrillation at baseline and had several
episodes of rapid atrial fibrillation in the first 72 hours
postoperatively, treated with intravenous Lopressor. He was
kept on his standing dose at home of Lopressor at 25 mg
b.i.d. At time of discharge, the patient was rate
controlled. He had an uncomplicated hospital course and
progressed well with Physical Therapy. He will be discharged
home on his usual standing dose of Coumadin 5 mg alternating
with 2.5 mg of Coumadin every other day.
PAST MEDICAL HISTORY:
1. Chronic atrial fibrillation.
2. Congestive heart failure.
3. Aortic stenosis.
4. Tricuspid regurgitation.
5. Mitral regurgitation.
6. Sick sinus syndrome, status post pacemaker.
7. Pulmonary hypertension.
8. Gastrointestinal bleeding.
MEDICATIONS AT DISCHARGE:
1. Coumadin 5 mg po each Monday, Wednesday and Friday.
2. Coumadin 2.5 mg po each Tuesday, Thursday, Saturday and
Sunday.
3. Lasix 40 mg po q.d.
4. K-Dur 20 milliequivalents po q.d.
5. Aspirin 81 mg po q.d.
6. Lopressor 25 mg po b.i.d.
7. Percocet 1-2 tablets po q. 6 hours prn.
8. Colace 100 mg po b.i.d. for seven days.
PHYSICAL EXAMINATION: Temperature 37.2. Heart rate 80.
Afebrile. Blood pressure 110/70. Respiratory rate 14.
Lungs: Clear to auscultation bilaterally. Heart:
Irregularly irregular rhythm. Normal S1, S2 with systolic
murmur. Abdomen: Soft, nontender, nondistended, no masses,
no ascites. Extremities: No peripheral edema. Wounds are
well-healed. Neurologically, completely intact, no focal
deficits.
LABORATORY VALUES AT DISCHARGE: White blood cell count 9,
hematocrit 31.0, platelet count 234,000. INR 2.6. Sodium
137, potassium 4.6, chloride 99, CO2 27, BUN 33, creatinine
1.4, glucose 121, magnesium 2.0.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To home with VNA. Patient is scheduled to
have his INR drawn the day after discharge at his [**Location (un) 47**]
facility.
DISCHARGE DIAGNOSIS: Status post pericardial aortic valve
replacement for critical aortic stenosis.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 11232**]
MEDQUIST36
D: [**2190-8-24**] 22:19
T: [**2190-8-24**] 22:19
JOB#: [**Job Number 43428**]
|
[
"4241",
"4280",
"4168"
] |
Admission Date: [**2184-5-16**] Discharge Date: [**2184-5-21**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
80 F fall from wheelchair. PMH of Multiple sclerosis, GCS 3T
on arrival in ED
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 y/o F with long history of MS [**First Name (Titles) **] [**Last Name (Titles) 68122**] was being
pushed in her wheelchair today, seatbelt off and wheels
accidently over top of stairs. Pt. fell from wheelchair and
tumbled about 2 steps onto her head. Pt. with confusion at scene
but no LOC. Pt. intubated in route by EMS without sedation, she
was unresponsive/minimally responsive at scene. In [**Name (NI) **] pt.
initially evaluated w/GCS of 3 however, once in the CT scanner
and after getting IVF the pt. opened eyes spontaneously and
would
localize to voice.
Past Medical History:
Patient has MS. [**Name13 (STitle) **] reports that at baseline she does not move
below the neck and when in a particularly good mood will speak
in full sentences.
Social History:
Husband and two sons at side
Family History:
unknown, NC
Physical Exam:
T: BP: 118/62 HR: 52 R: 18 O2Sats: 100 on vent
Gen: WD/WN, thin, NAD
HEENT: Pupils: ERRL EOMs intact
Neck: in c-collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+, ND
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, not cooperative w/exam
Motor: Pt. cannot move below the neck at baseline
Sensation: pt. no responsive at time
Reflexes: B T Br Pa Ac
Right difficult to assess, pt does not relax
Left
Toes downgoing bilaterally
Rectal exam: sphincter tone wnl
Pertinent Results:
[**2184-5-16**] 05:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2184-5-16**] 04:53PM GLUCOSE-165* LACTATE-2.4* NA+-137 K+-3.7
CL--107 TCO2-21
[**2184-5-16**] 04:50PM CK(CPK)-30 AMYLASE-61
[**2184-5-16**] 04:50PM UREA N-19 CREAT-0.7
[**2184-5-16**] 04:50PM CK-MB-NotDone cTropnT-<0.01
[**2184-5-16**] 04:50PM WBC-4.8 RBC-3.25* HGB-10.7* HCT-29.2* MCV-90
MCH-32.8* MCHC-36.5* RDW-13.2
Brief Hospital Course:
In the ED, CT scans of the cervical spine showed rotary
subluxation of C1 and C2. Pt was admitted to the hospital
DNR/DNI and Neurology was consulted. Pt was admitted intubated
with a C-collar in place. Once in house patient was extubated
and never regained her baseline mental status. Pt did not
receive code level care per the family's wishes. On HD#6 she
expired and was pronounced
Medications on Admission:
ASA
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2184-6-18**]
|
[
"5849",
"486",
"5990",
"2762"
] |
Admission Date: [**2178-11-20**] Discharge Date: [**2178-11-24**]
Service: CARDIOTHORACIC
Allergies:
Tetanus
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
[**2178-11-20**] Aortic Valve Replacement(21mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**] Porcine)
and Mitral Valve Replacement(25mm [**Company 1543**] Mosaic Porcine).
History of Present Illness:
This is an 84 year old female with known rheumatic heart
disease. In [**2178-10-8**], she presented with hemoptysis. Chest
CT scan at that time was notable for bilateral dense
cosolidations consistent with pulmonary hemorrhage. Infectious
etiology was ruled out and Methotrexate was discontinued. Serial
echocardiograms have shown progression of aortic and mitral
valve disease with severe pulmonary artery systolic
hypertension. Further cardiac evaluation included cardiac
catheterization which showed normal coronary arteries. Given new
onset hemoptysis and progression of her valvular heart disease,
she was deemed suitable for cardiac surgical intervention.
Past Medical History:
- Rheumatoid arthritis
- Osteoarthritis
- Rheumatic heart disease c/b Aortic stenosis, Aortic
insufficiency, Mitral stenosis, and Mitral regurgitation
- History of paroxysmal atrial fibrillation
- Anemia of chronic disease
- Osteoporosis
- History of scarlet fever
- s/p Cesearen section
- s/p TAH/ BSO
- Pyloric stenosis repair s/p repair
- Hemorrhoids s/p surgery
- s/p Neck surgery
Social History:
Lives in own house in senior community. Widowed. Son and
daughter supportive and nearby. No history of smoking or alcohol
abuse. Father and husband were long-time smokers. H/o blood
transfusion in [**2120**]'s.
Family History:
- Mother: ?DM, [**Last Name **] problem
- Father: emphysema
- Brother: thyroid dz, metastatic cancer, OA
- Daughter: ?RA
Physical Exam:
General: Elderly female in no acute distress
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD, transmitted murmurs noted over carotids
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, loud holosystolic murmur
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2178-11-24**] 06:30AM BLOOD WBC-8.8 RBC-3.40* Hgb-10.0* Hct-30.1*
MCV-88 MCH-29.3 MCHC-33.1 RDW-15.3 Plt Ct-257
[**2178-11-24**] 06:30AM BLOOD Plt Ct-257
[**2178-11-22**] 12:27AM BLOOD PT-14.2* PTT-28.5 INR(PT)-1.2*
[**2178-11-24**] 06:30AM BLOOD Glucose-110* UreaN-16 Creat-0.7 Na-131*
K-4.1 Cl-96 HCO3-28 AnGap-11
CHEST (PA & LAT) [**2178-11-24**] 9:31 AM
CHEST (PA & LAT)
Reason: evaluate ptx
[**Hospital 93**] MEDICAL CONDITION:
84 year old woman with s/p avr
REASON FOR THIS EXAMINATION:
evaluate ptx
HISTORY: Status post AVR, to evaluate for pneumothorax.
FINDINGS: In comparison with the study of [**11-23**], the patient has
taken a somewhat better inspiration. No definite apical
pneumothorax is appreciated on this examination. No change in
the appearance of the cardiomediastinal contours. Atelectasis,
or even pneumonia persists.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 24475**], [**Known firstname 24476**] [**Hospital1 18**] [**Numeric Identifier 24477**]
(Complete) Done [**2178-11-20**] at 10:27:44 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 1112**] W.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2094-11-1**]
Age (years): 84 F Hgt (in): 60
BP (mm Hg): 134/78 Wgt (lb): 94
HR (bpm): 67 BSA (m2): 1.36 m2
Indication: Intraoperative TEE for AVR and MVR
ICD-9 Codes: 427.31, 786.05, 440.0, 424.1, 424.0
Test Information
Date/Time: [**2178-11-20**] at 10:27 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW4-: Machine: [**Pager number 5741**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 45% >= 55%
Aorta - Annulus: 1.9 cm <= 3.0 cm
Aortic Valve - Peak Velocity: *4.7 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *89 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 68 mm Hg
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0 cm2
Mitral Valve - Mean Gradient: 8 mm Hg
Mitral Valve - Pressure Half Time: 170 ms
Mitral Valve - MVA (P [**12-9**] T): 1.2 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Moderate symmetric LVH. Normal regional
LV systolic function. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (AoVA <0.8cm2). Mild to moderate ([**12-9**]+) AR.
MITRAL VALVE: Characteristic rheumatic deformity of the mitral
valve leaflets with fused commissures and tethering of leaflet
motion. Moderate mitral annular calcification. Moderate
thickening of mitral valve chordae. Moderate valvular MS (MVA
1.0-1.5cm2) Moderate to severe (3+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2.There is moderate symmetric left ventricular hypertrophy.
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is mildly depressed (LVEF= 45 %).
3. Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis (area <0.8cm2). Mild to
moderate ([**12-9**]+) aortic regurgitation is seen.
6.The mitral valve shows characteristic rheumatic deformity.
There is moderate thickening of the mitral valve chordae. There
is moderate valvular mitral stenosis (area 1.0-1.5cm2). Moderate
to severe (3+) mitral regurgitation is seen.
7.The tricuspid valve leaflets are mildly thickened.
Post Bypass
1. Patient is being AV paced and receiving an infusion of
epinephrine and phenylephrine.
2. Left ventricular systolic function is much improved. EF 55%
3. Bioprosthetic valve seen in the mitral position. Leaflets
move well and the valve appears well seated. Trivial mitral
regurgitation. Mean gradient across the mitral valve is 4 mm Hg.
4. Bioprosthetic valve seen in the aortic position. The leaflets
move well and the valve appears well seated. No aortic
regurgitation present. Mean gradient across the aortic valve is
18 mm Hg.
5. About 20 minutes post CPB an echo dense material (about 5mm
in size) seen free floating in the left atrium. Surgeon made
aware. Did not want to go on bypass to look for it. Seemed to
subsequently disappear.
6. Aorta intact post decannulation.
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted and underwent aortic and mitral valve
replacements by Dr. [**Last Name (STitle) **]. For surgical details, please see
seperate dictated operative note. Following the operation, she
was brought to the CVICU for invasive monitoring. Within 24
hours, she awoke neurologically intact and was extubated without
incident. Routine chest x-ray was notable for a small apical
left pneumothorax. She maintained stable hemodynamics and
transferred to the SDU. She did well postoperatively, remained
in sinus rhythm and was ready for discharge home on POD #4.
Medications on Admission:
Warfarin - stopped prior to admission
Methotrexate - stopped prior to admission
Ferrous Sulfate 325 qd
Folic Acid 2 qd
MV qd
Citracal qd
Fosamax qweekly
Amoxicillin prn dental procedures
Discharge Medications:
1. Atorvastatin 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. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 * Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Citracal + D 250-200 mg-unit Tablet Sig: One (1) Tablet PO
once a day.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Mixed Aortic and Mitral Valve Disease now s/p AVR/MVR
Rheumatic Heart Disease, , Diastolic Congestive Heart Failure,
Pulmonary Hypertension, Hemoptysis, Rheumatoid Arthritis, Anemia
of Chronic Disease, History of Paroxsymal Atrial Fibrillation,
History of Scarlet Fever
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) **] in [**3-12**] weeks, please call for appt
Dr. [**Last Name (STitle) **] in [**1-10**] weeks, please call for appt
Dr. [**Last Name (STitle) **] in [**1-10**] weeks, please call for appt
Completed by:[**2178-11-24**]
|
[
"2851",
"4168",
"4280",
"42731"
] |
Admission Date: [**2172-9-17**] Discharge Date: [**2172-10-2**]
Date of Birth: [**2111-8-8**] Sex: F
Service: SURGERY
Allergies:
[**Doctor First Name **]
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
CC: Abdominal Pain, hypotension
Major Surgical or Invasive Procedure:
Hartmann's resecrion of sigmoid colon. Drainage of pelvic
abscess, Left upper quadrant colostomy, placement of pain pump
History of Present Illness:
Ms. [**Known lastname **] is a 61 year-old female with a history of
diverticulitis who presented to the emergency department with
abdominal pain and chills. She was diagnosed with diverticulitis
on CT abdomen/pelvis here at [**Hospital1 18**] on [**2172-8-4**] after presenting
to clinic with complaints of left lower abdominal pain. She was
then started on Ciprofloxacin and Flagyl, which she stopped
taking approximately one week later because of nausea. Her
symptoms had resolved at this time, but she has experienced
recurrent abdominal pain since her initial diagnosis, on
occasion treated with Maalox with minimal relief. She was
recently started on Augmentin by her PCP, [**Name10 (NameIs) 6643**] she reports
taking, with no change in her symptoms. She had been scheduled
for a colonoscopy today and began taking the Go-Lytely prep
lastnight, but while taking it became nauseous and had multiple
episodes of non-bloody, clear emesis. She also reports
experiencing chills at this time, but did not take her
temperature. She denies accompanying shortness of breath, chest
pain, diaphoresis, hematemesis, hematochezia or melena. She does
report some loose stools that have been occurring chronically
and are unchanged. She has had intermittent tolerance for PO.
She additionally denies any sick contacts, consumption of poorly
prepared food or recent travel. As a result of her chills,
nausea, vomiting and abdominal pain, she presented to the [**Hospital1 18**]
emergency department for further evaluation.
.
In the ED, her vitals were: T - 101.1, HR - 96, BP - 97/44, RR -
14, O2 - 96% RA. A CXR was unremarkable and a CT abdomen and
pelvis showed persistent and worsened diverticulitis with no
abscess or perforation. Blood cultures were drawn, she was given
Ciprofloxacin and Flagyl and Dilaudid for pain. Because of
persistent hypotension in the 80s systolic, despite 4 L of NS,
she was admitted to the ICU for further management.
Past Medical History:
Past Medical History:
HTN
Diverticulosis: Found on colonoscopy in [**2169**] with subsequent
diverticulitis since [**2172-7-12**]
Ductal Carcinoma In Situ of the right breast ([**2168**]): s/p breast
conserving therapy with wide excision and adjuvant Tamoxifen
therapy
.
Social History:
She lives in [**Location 2268**] with her husband. She denies ever using
tobacco, reports social alcohol intake and denies illicit drug
use.
Family History:
Family History: Daughter with breast cancer at age 34
Physical Exam:
PE
Vitals: T- 95.5, BP - 100/55, HR - 86, RR - 24, O2 - 96% 2L
General: Awake, alert, in mild discomfort, worsened with
examination of abdomen
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous with dry
mucous membranes
Neck: Supple, no LAD
Chest/CV: S1, S2 nl, no m/r/g appreciated, RRR
Lungs: Bilateral, dry inspiratory crackles, R>L
Abd: Mild distention, soft, tender to palpation of the LLQ with
some involuntary guarding, but no rebounding, + BS in all 4
quadrants
Rectal: Yellowish-brown stool, guaiac negative
Ext: No c/c/e
Neuro: Grossly intact
Skin: No rashes
.
Pertinent Results:
Imaging:
CT Abdomen/Pelvis ([**9-17**]):
1. Inflammation with colonic wall thickening and surrounding
fat stranding involving the distal descending and sigmoid colon
consistent with persistant diverticulitis. The degree of wall
thickening, surrounding fat stranding, involvement of adjacent
small bowel loops and length the colon involved has increased
since the previous exam, consistent with worsening disease. No
definite microperforation or abscess identified at this time.
Again given the
persistence of the inflammation in this region, followup
sigmoid/colonoscopy or CT scan is recommended after appropriate
treatment and resolution of symptoms in order ensure resolution
and exclude underlying mass.
2. Fibroid uterus.
.
CXR ([**9-17**]): The cardiac, mediastinal contours are within normal
limits. The lungs are clear. There are no pleural effusions. The
pulmonary vasculature is within normal limits. No free air is
identified under the diaphragms.
.
Colonoscopy ([**2169-9-4**]):
Diverticulosis of the sigmoid colon, descending colon and cecum
Otherwise normal Colonoscopy to cecum
.
Echocardiogram [**2172-9-22**]-Conclusions:
The left atrium is elongated. Left ventricular wall thickness,
cavity size,
and systolic function are normal (LVEF>55%). Due to suboptimal
technical
quality, a focal wall motion abnormality cannot be fully
excluded. Transmitral
Doppler and tissue velocity imaging are consistent with normal
LV diastolic
function. The aortic valve leaflets (3) are mildly thickened but
aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be
determined. There is a small (0.3 cm) pericardial effusion. The
effusion
appears circumferential. There is no echocardiographic evidence
of tamponade.
.
Pelvic ultrasound [**2172-9-30**]-IMPRESSION: 1. Mildly thickened
endometrium at 5.7mm. Reccommend further clinical evaluation and
biopsy. 2. Fibroid uterus.
Brief Hospital Course:
A/P: 61 y.o. female with PMHx of HTN, diverticulitis and DCIS
who presented with a persistent LLQ pain, fever and hypotension
in the setting of worsening diverticulitis.
.
# Sepsis: Mrs. [**Known lastname **] was admitted to the ICU sepsis with
leukocytosis, fever, and hypotension managed with fluid
administration (approximately 8 liters). She did not require
pressors. Hypotension resolved by hospital day 2.
.
# Diverticulitis: Ongoing since [**Month (only) 205**], despite antibiotics,
though patient did not take full course of Flagyl and
Ciprofloxacin and has also not been able to tolerate Augmentin.
On admission to the ICU she was started on vancomycin, zosyn
and contined on Flagyl. She was made NPO and given IV fluids.
Vancomycin was discontinued and ampicillin was later begun for
enterococcal coverage. Surgery was consulted and recommended
surgery after 5-7 days after resolution of acute inflammation.
On hospital day 9, Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a Hartmanns resection of
sigmoid colon with drainage of pelvic abscess and placement of
left upper quadrant colostomy and was as a pain pump performed
by Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]. Of note, a large multiloculated
pelvic abscess was drained. She had an estimated blood loss of
700ml. The fluid replacement was 2.4 liters of crystalloid and
2 units of packed cells.
A nasogastric tube was continued until post-operative day 2.
Her pain was managed post-operatively with her pain pump and a
PCA (very little was needed) and was gradually transitioned to
oral pain medications. Her diet was gradually advanced as
tolerated. She was seen by nutrition who recommended Ensure
supplements. She was seen by physical therapy for assistance
with ambulation and was cleared for discharge home. She was
discharged in good condition on post-operative day 7.
.
# Ostomy- Ms. [**Known lastname **] was seen by the ostomy nursing service for
education about ostomy care. She was discharged home with VNA
and a visiting ostomy nurse.
.
Dyspnea- Following fluid resuscitation, Ms. [**Known lastname **] had episodes
of dyspnea which responded to furosemide administration with
good diuresis. She was saturating well without dyspnea prior
to discharge.
.
#Anemia- Hematocrit dropped from 31.1 on admission to a nadir of
23.1 and was thought to be dilutional. Hematocrit was 35.4 on
the day of discharge.
.
# Hypertension- Ms. [**Known lastname 99884**] hypertension post-operatively was
managed with metoprolol. She was later transitioned to her home
dose of hydrochlorothiazide 25 mg PO daily per her previous
regimen. She later stated that she was also taking Lisinopril
20mg qday. Metoprolol was discontinued and she was started on
lisinopril 10mg daily and advised to follow-up with her primary
care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9006**] for further management of her
hypertension.
,
# DCIS: Ms. [**Known lastname **] stopped taking tamoxifen because of side
effects. She missed her appointment with her breast surgeon on
[**8-27**]. Tamoxifen was not restarted during this
admission. She was advised to see her breast surgeon for
further management.
.
# Vaginal bleeding- On post-operative day 6, Ms. [**Known lastname **] reported a
small amount of vaginal spotting. Gynecology was consulted and
a transvaginal ultrasound was obtained which revealed a fibroid
uterus and a 5.7 mm endometrium The bleeding was thought likely
due to the subcutaneous heparin administered post-operatively
for DVT prophylaxis. The bleeding was thought to be unlikely
from her fibroid, since
this is stable in size since last year. GYN recommended no
immediate intervention but rather an outpatient endometrial
bopsy given a slightly thickened endometrium (>4 mm for a
post-menopausal patient). An appointment was made on [**2172-11-12**] in
gynecology clinic with Dr. [**First Name (STitle) **].
Medications on Admission:
.
Medications:
Lisinopril 20 mg (not taken since [**2172-9-15**])
Tamoxifen (self d/c'd by pt. [**2-14**] side effects)
Naprosyn 500 mg [**Hospital1 **] PRN
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take this medication as prescribed by your primary care
doctor.
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: Do not drive while
taking this medication. Do not take other medications
containing acetaminophen (tylenol) while taking this medication.
Disp:*80 Tablet(s)* Refills:*0*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Talk to your primary care doctor about this medication.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Diverticulitis
Sepsis
s/p Hartmann's resection of sigmoid colon with drainage of
pelvic abscess and left upper quadrant colostomy
Vaginal Bleeding
Discharge Condition:
Good.
Discharge Instructions:
You were admitted to the hospital for diverticulitis and were
found to have low blood pressure likely due to your infection.
You were started on antibiotics and had surgical removal of part
of your colon as well as drainage of an abscess in your pelvis
and placement of a colostomy. You were given pain medications
and fluids and we able to eat prior to discharge. You were seen
by the ostomy nursing service who taught you how to change your
colostomy. You will have nurses to visit your house and help
you with this.
You were seen by the gynecology service because of some
vaginal bleeding. An ultrasound was done that showed a fibroid
in your uterus that is unchanged from before. Also, there was
mild thickening of the lining of your uterus (endometrium). The
vaginal bleeding may be due to a medication you received
(herparin) that thins your blood. However, given that you do
have mild thickening of your endometrium, you should have an
endometrial biopsy to check for endometrial cancer. This is an
office procedure and an appointment was made for you with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of gynecology.
You were re-started on your home hydrochlorothiazide and
lisinopril (Zestril) prior to discharge. You should follow-up
with your primary care doctor regarding your [**Known lastname **] blood
pressure.
You will have some abdominal pain associated with your
surgery. However, you should call your doctor or return to the
hospital for:
* Worsening of your abdominal pain
* Nausea or vomiting
* Fever, chills
* Change in color or increased pain at your ostomy site
* Increased pain, redness or drainage from your incision site
* Any other symptoms that concern
.
Please attend all follow-up appointments listed.
Followup Instructions:
Please call Dr.[**Name (NI) 12389**] office ([**Telephone/Fax (1) 22750**] to set up an
appointment in [**1-14**] weeks.
.
Please attend your appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of
gynecology on [**2172-11-12**] at 10:00 AM. Phone [**Telephone/Fax (1) 2664**]
Please call your primary care doctor at your earliest
convenience. [**Last Name (LF) 9006**], [**Name8 (MD) **] MD, MPH [**Telephone/Fax (1) 250**]
|
[
"0389",
"4019",
"2859"
] |
Admission Date: [**2176-4-3**] Discharge Date: [**2176-4-23**]
Date of Birth: [**2116-9-5**] Sex: M
Service: MEDICINE
Allergies:
Caspofungin / Levaquin
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
59 y/o man with a history of AML diagnosed [**1-21**] s/p 7+3
induction on [**2175-2-4**] with persistent blasts w/o maturation in
repeat marrow bx, s/p reinduction with HIDAC on [**2176-3-2**], now day
#215 s/p allo stem cell transplant (HLA matched sibling-brother)
in [**7-20**], presents with a 3.5 week h/o diarrhea. The pt states
the diarrhea began [**3-10**], with watery brown semi-solid to solid
BMs, up to 10-12 per day. He felt that he occasionally could
not make it to the bathroom. No blood or mucus in the stool.
He tried to limit his lactose intake, but this did not improve
his diarrhea. He has not had any sick contacts, foreign travel
(only recently went to [**Location (un) 7349**]), no camping. No changes in
medications or new antibiotics recently. He did have a "skin
rash" recently at [**Hospital **] Hospital, thought [**1-18**] levaquin. The
pt was hospitalized [**Date range (1) 61436**] at [**Location (un) **], and stated that he was
given IVF hydration, stool studies sent, he underwent flex
sigmoidoscopy showing "rectal ulcers" that were biopsied, with
path pending per pt. He says their workup was "unrevealing."
During his hospitalization, he was given flagyl and levaquin,
and hydrocortisone. His diarrhea has continued despite these
measures. He has no abd pain, no nausea or vomiting. + low
grade fevers but chills. No dark urine. No night sweats. He
notes a 13 lb weight loss since [**2-29**]. Decreased energy. Poor po
intake (b/c he fears that it will 'go right through him.'
Eating boost tid, with soups mainly. + bloating, and the
sensation of "having to have a bm" that can be as severe as a
[**5-25**], but is usually a [**1-26**]. He has not taken any meds for the
bloating or diarrhea until recently, when Dr. [**First Name (STitle) 1557**] told him to
take Imodium.
Past Medical History:
Past Oncologic History:
#. [**1-21**]: Initial presentation of malignancy: Pt had a routine
physcial at his PCP's office that showed pancytopenia. His last
CBC was one year earlier and WNL. He was admitted to [**Hospital **]
hospital where a bone marrow showed acute myelogenous leukemia.
The patient was referred to Dr. [**First Name (STitle) 1557**] for further treatment.
Prior to seeing his PCP he felt completely well. He had not
noticed any bleeding, fevers, chills, night sweats, HA, weight
loss, or shortness of breath.
.
#. AML - Hospitalization at [**Hospital1 18**]: [**Date range (1) 61437**]: Initial bone
marrow biopsy showed marrow involvement by AML evolving in a
background of myelodysplastic syndrome. 90% blasts were seen on
aspirate. Cytogenetics were abnormal with multiple structural
and numerical aberrations. Among these are a missing 7 and 21, a
deletion of 5q, additional material of undetermined origin on
17q, and 4 to 5 structurally abnormal markers. The patient was
started on 7+3 therapy on [**2-4**]. He tolerated the induction well
with only the development of fevers. However on day +13 of
induction, he underwent repeat bone marrow which demonstrated
persistent leukemia. A repeat marrow on day +20 showed a
hypocellular marrow with young cells that were thought to be of
normal maturation. His peripheral smear demonstrated few blasts,
also thought to represent early cells of normal maturation. His
peripheral smear continued to show blasts and on day +28, his
marrow was re-biopsied. This showed a increase in the number of
blast forms without maturation. He underwent reinduction with
HIDAC starting [**2175-3-3**]. He had no mucositis or CNS dysfunction
His repeat marrow on day +14 of re-induction showed 95% cellular
bone marrow comprised almost exclusively of immature cells,
consistent with myeloblasts. His counts were monitored closely
to see if he would return with MDS or persistent AML. As his
counts began to return he had noted 10% blasts in the periphery.
It was felt that this could represent persistent AML versus
early recovering marrow. He also developed a PNA during this
admission.
.
ORIGINAL CYTOGENETICS:
#. [**2175-2-17**] cytogenetics:
49,[**Last Name (LF) **],[**First Name3 (LF) **](5)(q11.2q33),-7,add(17)(q25),-21,+[**2-18**][cp19]/46,XY[1];
This abnormal karyotype shows multiple structural and numerical
aberrations. Among these are a missing 7 and 21, a deletion of
5q, additional material of undetermined origin on 17q, and 4 to
5 structurally abnormal marker
.
#. 8/22/05-10/05 Hospitalization at [**Hospital1 18**]: allo transplant from
brother, did well.
.
#. [**Hospital1 18**]: Patient was admitted [**Date range (3) 61438**] for neutropenic
fever. He was discharged from that hospitalization on
levofloxacin. No fever source was identified on that admission.
.
#. [**Date range (1) 61439**]/05: Hospitalization at [**Location (un) **]: febrile
neutropenia
.
#. [**Date range (1) 61440**]/05: Hospitalization at [**Location (un) **]: [**1-18**] ?Klebsiella
from GI tract? per pt, febrile neutropenia
.
#. end of [**2175-11-16**]: Hospitaliz. at [**Location (un) **]: Staph epi
bacteremia, on Vanco/Cefepime, febrile neutropenia
.
#. The patient had a positive CMV viral load on [**2175-10-11**] at
1,600 copies (previous negative on [**10-7**]). CMV VL on [**2176-2-29**] was
undetectable.
.
#. As of [**2-19**], the pt remains in clinical complete remission.
.
1. AML (multiple cytogentic aberrations)- diagnosed [**1-21**], S/P
2. alloSCT from sibling donor
3. Depression, well controlled on medication per pt.
4. HSV-2, only 1 flare in 3 years
5. Tonsillectomy and Adenoidectomy - [**2121**]
6. HTN, well controlled on medic per pt.
7. Pulm Aspergillus
8. CMV viremia
Social History:
no tobacco, though smoked pipes in college X 2 years,
no etoh, no IVDA. Lives in [**Location **] with wife. [**Name (NI) **] is a retired
finance professor, originally worked at [**University/College **], now working at the
[**Last Name (un) 61441**].
Family History:
No fHX of Leukemia or lymphoma. Mother- bone cancer of unknown
etiology. Father- 3 vessel bypass graft, HTN
Physical Exam:
Vitals: temp: 98.9 BP: 104/68 P: 89 RR: 14 O2sat: 99% RA. Wt 130
lbs, 66 inches.
General: Thin CM in NAD. Breathing comfortably on RA. Well
spoken. AOX3. Appropriate. + bitemporal wasting.
HEENT: PERRL EOMI. MM dry, OP clear w/o lesions
Neck: No lad, no jvd
Lungs: CTAB
CV: RRR S1 and S2 audible w/o m/r/g
Abd: Soft, NT, ND, NABS, No masses. No HSM.
P. vasc: 2+ DP pulses b/l. Dry skin. No cyanosis/clubbing.
Neuro: CN 2-12 intact. Motor [**4-19**] throughout. Sensory [**4-19**]
throughout. Gait WNL.
Pertinent Results:
MARROWS DURING INTITIAL DX:
#. [**2175-2-22**] BM Bx: Cellular myeloid-dominant marrow with markedly
left-shifted myelopoiesis and increased myeloblasts (day 20
status post myeloblative chemotherapy) Note: Although
myeloblasts appear increased on the hemodilute aspirate smear,
an accurate count can not be determined due to poor specimen
quality. Re-biopsy is recommended if clinically indicated.
.
[**2175-3-2**] BM Bx: C/W AML. Immunophenotypic findings c/w
involvement by AML w/an immature phenotype.
.
[**3-18**] BM Bx: biopsy consists of blood, cortical bone, and a few
fragments of > 95% cellular bone marrow comprised almost
exclusively of immature cells, consistent with myeloblasts.
.
MOST RECENT ECHO [**7-20**] EF >60%.
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Trace aortic regurgitation is seen.
.
Imaging:
[**2176-4-3**]: CXR
CHEST, PA AND LATERAL: An opacity is present in the left lower
lobe. The remaining lungs are clear. The mediastinal and hilar
contours are
unremarkable. The heart is normal size. No pleural effusions are
visualized. The surrounding soft tissue and osseous structures
are unremarkable.
IMPRESSION: Left lower lobe pneumonia.
.
[**2176-4-8**]:
AP CHEST RADIOGRAPH:
Left sided PICC line is seen with tip overlying the distal SVC.
Cardiac, mediastinal, and hilar contours appear unchanged.
Pulmonary vascularity remains within normal limits. Compared to
prior study, the left lower lobe opacity appears slightly worse.
There has also been interval increase in right lower lobe
opacity, consistent with pneumonia.
IMPRESSION: Bibasilar pneumonia, slightly worsened in the
interval.
.
[**4-9**] CXR
IMPRESSION: AP chest compared to [**4-4**] and 24:
Bibasilar pneumonia is clearing. Upper lungs are clear. Heart
size is
normal. There is no appreciable pleural effusion. Tip of a
left-sided
central venous line projects over the SVC. Mediastinal widening
at the thoracic inlet due to combination of adenopathy and fat
deposition and tortuous vessels is longstanding.
.
CTA [**4-9**]
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Persistent bilateral lower lobe consolidations, also with
patchy lingular
involvement. The degree of consolidation is increased at the
right base.
.
CT ABD [**4-9**]
IMPRESSION:
1. Diffuse edema of the descending colon, sigmoid colon, and
rectum with consistent with colitis. This finding is
non-specific and may represent infectious etiology. A drug
reaction if the patient is on chemotherapy could give this
appearance. Less likely is ischemia as the abdominal vasculature
is widely patent. Inflammatory bowel disease is also less
likely. Clinical correlation is recommended.
2. No evidence for pulmonary embolus. Bilateral airspace
consolidation within the lower lobes, left greater than right,
consistent with pneumonia.
3. Cholelithiasis without evidence for cholecystitis with mild
central biliary ductal dilatation.
4. Multiple rounded low-attenuation foci within the kidneys
bilaterally, which cannot be definitively characterized as
simple renal cysts. A renal ultrasound is recommended for
definitive characterization.
.
CT HEAD [**4-9**]
FINDINGS: There is no evidence of acute intracranial hemorrhage.
No mass effect. No shift of normally midline structures.
Bilateral ventricles are symmetric and not dilated. Note is made
of right carotid artery calcification. There is fluid in
bilateral ethmoid sinuses, representing sinusitis. Calcified
dural plaques are seen.
IMPRESSION: No acute intracranial hemorrhage. Ethmoid sinusitis.
.
CT CHEST [**4-19**]
IMPRESSION: Improving of the bilateral lower lobe consolidation
Brief Hospital Course:
59 y/o gentleman with h/o AML day 217 post allo SCT (HLA matched
sibling) presents with 3.5 week h/o diarrhea, 13 lb weight loss,
decr po intake. His course was complicated by bilateral lower
lobe PNA requiring an admission to the ICU.
.
#. [**Hospital Unit Name 153**] course for desaturation/acute respiratory distress: The
pt's course was complicated by PNA. On admission CXR, the pt
demonstrated a LLL infiltrate. He was started on levaquin,
however, his PNA worsened with chest CT the following day
showing bilateral lower lobe consolidations. His coverage was
broadened to include Vanco, Flagyl and Ganciclovir to cover for
CMV PNA. His voriconazole was continued throughout this time.
He did not require intubation. Pt's sats remained stable on
face mask, now weaned down to 50% Fio2, upper 90s sats. He was
suctioned and given chest PT in the ICU. His Vancomycin was
discontinued, and azithromycin was added empirically for
Legionella coverage (although urinary antigen negative). ID
consultants continued to follow pt in the [**Hospital Unit Name 153**], and recommended
sending EBV VL, 2 more sputums for PCP, [**Name10 (NameIs) **] continuing the
current regimen of Cefepime (started [**4-5**]), Flagyl (started
[**4-4**]), Azithro (added [**4-10**]) and Ganciclovir (started [**4-4**]),
keeping a low threshold for bronch. However, the pt did not
require bronchoscopy. EBV and PCP were negative. Respiratory
status improved and patient was transferred back to 7 [**Hospital Ward Name 1826**]
for further care. He was maintained on Albuterol/Atrovent nebs
and supplemental oxygen was weaned as tolerated. Repeat Chest CT
on [**2176-4-19**] showed interval improvement in pneumonia.
.
#. Bilateral lower lobe PNA: being covered with
Cefepime/Flagyl/Voriconazole. Pt most likely has bacterial PNA
given appearance with air bronchograms/consolidation seen on
Chest CT. Less likely CMV PNA or MRSA PNA, although was
recently hospitalized in [**Location (un) **], CT. Vancomycin discontinued
and added back X 2, but now discontinued. He was being covered
with Azithro for Legionella PNA though Legionella urinary ag
negative while in the ICU but this was discontinued [**4-12**] after
[**Hospital Unit Name 153**] call out. His PCP DFA was negative. His CMV VL was
negative X 3, but do not suspect CMV PNA. Serum galactomannan
negative. He was weaned from face mask to nasal cannula and
saturated well with nebs and nasal cannula. Albuterol nebs and
supplemental oxygen were weaned. Patient did well on room air
and was followed by physical therapy. At time of discharge,
patient was doing well on room air without ambulatory
desaturation below 94-95%. He was discharged home on Cefpodoxime
to complete 3 week course of antibiotics from time of clinical
improvement. Continued Voriconazole for antifungal coverage.
.
#. Diarrhea, improved: DDX includes Rotavirus in
immunosuppressed individual, GVHD, CMV colitis, other
infectious. Less likely osmotic diarrhea, medication induced,
or inflammatory. OSH report showing rectal ulcerations, biopsy:
no cytopathic effect. CMV VL at OSH neg, CMV VL here negative X
3. He was given IVIg the morning after admission. The pt was
on Ganciclovir IV for several days, however this was stopped
after he demonstrated improvement in diarrhea. GI was consulted
for possible colonoscopy with biopsy, but given improvement in
diarrhea, colonoscopy was deferred. Repeat CMV VL was sent which
was positive but not within detectable range, and patient was
re-started on Ganciclovir; he received treatment dose for 4 days
and then converted to Valganciclovir maintenance dose. At time
of discharge, patient having [**1-19**] formed BMs/day, marked
improvement from admission condition. Weaned down to Prednisone
10mg, to be tapered as outpatient.
.
# Anxiety/Depression: Continued on outpatient Ritalin,
Desipramine, and Escitilopram
.
#. HTN: Patient with long-standing history of HTN, which
improved after chemotherapy. Outpatient Metoprolol was continued
and titrated up to 25mg TID.
.
#. Incidentaloma: CT Chest on [**2176-4-19**] showed low-density right
kidney lesion which should be evaluated with ultrasound to
exclude the possibility of complex cyst or malignancy. Findings
were emailed to oncologist, to follow-up as outpatient. Patient
without flank pain or renal insufficiency.
#. FULL CODE
Medications on Admission:
1. CellCept [**Pager number **] mg b.i.d.
2. Ursodiol 300mg po bid
3. Multivitamin
4. Folic acid 800mcg po qd
5. Lopressor 12.5mg po bid
6. Lexapro 20mg po qd
7. Desipramine 100mg po qd
8. Ritalin 10mg po qAM and qNoon
9. Acyclovir 400mg po tid
10. Magnesium supplement
11. Alprazolam 0.5mg po qd prn
12. Meds he has not taken in weeks: Prep H, Peptobismol, TUMS
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
2. Methylphenidate 10 mg Tablet Sig: Two (2) Tablet PO once a
day: 1 tablet in the morning
1 tablet at noon.
Disp:*60 Tablet(s)* Refills:*0*
3. Desipramine 25 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
Disp:*100 Tablet(s)* Refills:*0*
4. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
5. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation four times a day for 10 days.
Disp:*1 trade size* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*20 Tablet(s)* Refills:*0*
8. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*14 Tablet(s)* Refills:*1*
9. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*28 Tablet(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. Flushes
Heparin and saline flushes for PICC per protocol
12. Dressing
PICC dressing care and changes per protocol
Discharge Disposition:
Home With Service
Facility:
[**Hospital 5065**] Healthcare
Discharge Diagnosis:
Bilateral lower lobe pneumonia, presumed bacterial
Diarrhea post-transplant
CMV
Hypertension
Discharge Condition:
diarrhea resolved, sat'ing well on room air
Discharge Instructions:
1. Take all medications as prescribed and make all follow-up
appointments.
2. If you experience fevers, chills, diarrhea, difficulty
breathing, or any other concerning signs/symptoms, please
contact the BMT fellow or report to the Emergency Department
Followup Instructions:
As instructed, please report to 7Feldberg on Thursday at 10 AM
to meet with Dr. [**First Name (STitle) 1557**].
Completed by:[**2176-4-27**]
|
[
"40391"
] |
Admission Date: [**2128-2-4**] Discharge Date: [**2128-2-10**]
Date of Birth: [**2070-12-6**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Aortic valve replacement with a 27-mm [**Company 1543**] Mosaic
Ultra aortic valve bioprosthesis.
2. Reconstruction of the pericardium using CorMatrix
xenograft.
[**2128-2-9**]:PPM placed for Complete heart block, [**Company 1543**]: DDD:[**Hospital1 **]-V
dual chamber PPM
History of Present Illness:
57 year old female with a history of dilated cardiomyopathy s/p
ICD implant in [**2125**], aortic insufficiency as well as chronic
kidney disease. She also has a
history of sickle cell anemia with her last crisis occurring in
[**2127-6-29**]. She has undergone yearly echocardiograms for
evaluation and follow up of her aortic insufficiency for the
past four years. Her most recent echo shows severe AI with
depressed EF. Presently, she reports she continues to feel mild
exertional dyspnea as well as occasional lightheadedness and
chest discomfort. Cardiac surgery consulted for surgical
correction.
Past Medical History:
Sickle cell anemia (last crisis in [**3-/2124**])
Nonischemic cardiomyopathy, diagnosed [**2121**]. ? Related to
recurrent sickle cell crises
AI, MR
Hypothyroidism
Renal insufficiency
s/p appendectomy
s/p oophorectomy
Social History:
Social history is significant for the absence of current tobacco
use. She quit smoking in [**2120**], smoked for 30yrs prior. There is
no history of alcohol abuse. She lives with her husband in [**Name (NI) **].
They have 3 children.
Family History:
Patient endorses a positive family history of coronary artery
disease, mother with CAD at 68. Grandparents both with MI,
unknown age.
Physical Exam:
Physical Exam
Pulse: 80 Resp: 16 O2 sat: 100%
B/P Right:140/60
Height: 5'2.5" Weight: 115 lbs
General: No acute distress, appears stated age
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [**1-4**] diastolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema - none
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: NP Left: NP
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2128-2-9**] 06:29AM BLOOD WBC-14.9* RBC-3.06* Hgb-9.1* Hct-26.7*
MCV-87 MCH-29.9 MCHC-34.3 RDW-15.8* Plt Ct-95*
[**2128-2-4**] 08:30AM BLOOD WBC-7.0 RBC-2.55*# Hgb-8.5* Hct-22.6*#
MCV-89 MCH-33.2* MCHC-37.5*# RDW-16.5* Plt Ct-69*
[**2128-2-7**] 03:16AM BLOOD PT-13.9* PTT-32.9 INR(PT)-1.2*
[**2128-2-4**] 01:50PM BLOOD PT-16.9* PTT-45.7* INR(PT)-1.5*
[**2128-2-9**] 06:29AM BLOOD Glucose-88 UreaN-26* Creat-1.2* Na-134
K-4.3 Cl-99 HCO3-27 AnGap-12
[**2128-2-4**] 03:25PM BLOOD UreaN-18 Creat-1.0 Na-138 K-4.7 Cl-108
HCO3-24 AnGap-11
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 41467**], [**Known firstname 41468**] [**Hospital1 18**] [**Numeric Identifier 41469**] (Complete)
Done [**2128-2-4**] at 3:30:32 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2070-12-6**]
Age (years): 57 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Intraoperative TEE for AVR
ICD-9 Codes: 424.1, 424.2
Test Information
Date/Time: [**2128-2-4**] at 15:30 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 17792**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Right Atrium - Four Chamber Length: *5.7 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 20% to 25% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.8 cm <= 3.0 cm
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Gradient: 16 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 9 mm Hg
Aortic Valve - LVOT diam: 2.4 cm
Findings
LEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA and extending into the RV. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV
cavity. Severely depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size. Borderline normal RV
systolic function.
AORTA: Normal ascending aorta diameter. Mildly dilated
descending aorta. Simple atheroma in descending aorta. No
thoracic aortic dissection.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Bioprosthetic aortic valve prosthesis
(AVR). AVR leaflets move normally. Moderate to severe (3+) AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate to
severe [3+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No PR.
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. Results were personally reviewed with the MD
caring for the patient.
Conclusions
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 20
%). The inferior wall hypokinesis appears most notable.
Right ventricular chamber size is normal with borderline normal
free wall function.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. No thoracic
aortic dissection is seen.
There are three aortic valve leaflets. The aortic valve leaflets
are moderately thickened, particularly at the tips. They do not
fully coapt. There is a central jet of moderate AI.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.
A moderate to severe [3+] eccentric jet of tricuspid
regurgitation is seen.
POST-CPB:
A porcine bioprosthetic aortic valve is present. The valve
appears to be well-seated. The aortic valve prosthesis leaflets
appear to move normally. There is no AI and no visible
paravalvular leak. The peak gradient across the prosthetic
aortic valve is 16mmHg, the mean gradient is 9mmHg.
The LV systolic function continues to be severely impaired with
the inferior wall appearing to be the most hypokinetic.
Estimated LV EF is 25%. (The patient is on a low dose
epinephrine infusion.)
RV systolic function appears improved. There is now severe TR,
with a similar eccentric direction as pre-bypass. This appears
to be due to failure of coaptation due to presence of pacing
wire and [**MD Number(3) 41470**].
There is no evidence of aortic dissection.
Dr.[**Last Name (STitle) 914**] was notified in person of the results at time of
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) 17792**], MD, Interpreting physician [**Last Name (NamePattern4) **]
[**2128-2-4**] 16:55
?????? [**2119**] CareGroup IS. All rights reserved.
Brief Hospital Course:
The patient was brought to the operating room on [**2-4**] where she
underwent Aortic valve replacement with a 27-mm [**Company 1543**] Mosaic
Ultra aortic valve bioprosthesis and Reconstruction of the
pericardium using CorMatrix xenograft with Dr.[**Last Name (STitle) 914**]. Please
refer to operative report for further surgical details. Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight.
Postoperatively she did experience complete heart block. An
Electrophysiology consult was obtained. Mrs.[**Known lastname **] has a history
of dilated cardiomyopathy s/p ICD implant in [**2125**], with a
single chamber ICD implanted and programmed at VVI 40 for backup
rate. Temporary Epicardial wires remained in place until
further EP eval of possible need for PPM.
She continued to progress and was transferred to the step down
unit for further recovery. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. Ep continued to follow and it was determined due to
persistant heart block, on [**2128-2-9**] Mrs.[**Known lastname **] underwent PPM
placement with the Electrophysiology team. Per EP's
recommendations, prophylaxis antibiotics were intiated post
placement. By the time of discharge on POD #6 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. PPM interrogation was performed. She was
cleared by Dr.[**Last Name (STitle) 914**] for discharge to home with VNA on POD#6 in
good condition with appropriate follow up instructions advised.
Medications on Admission:
CARVEDILOL PHOSPHATE XL 40 mg daily, DIPHENHYDRAMINE HCL 25
mgPRN, EPOETIN ALFA 20,000 unit/mL weekly, FUROSEMIDE 20 mg PRN,
LEVOTHYROXINE 75 mcg daily, LISINOPRIL 20 mg daily, MEPERIDINE
50 mg Q4 hours PRN, SPIRONOLACTONE 25 mg daily, CYANOCOBALAMIN
500 mcg daily, FOLIC ACID 0.4 mg daily, VITAMIN E 200 unit daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. meperidine 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 5 days.
Disp:*5 Tablet Extended Release(s)* Refills:*0*
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
6. Procrit 20,000 unit/mL Solution Sig: One (1) Injection QOW.
7. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA and Hospice
Discharge Diagnosis:
PREOPERATIVE DIAGNOSES:
1. Aortic insufficiency.
2. Poor left ventricular function.
3. Sickle cell anemia.
4. Thrombocytopenia.
5. Complete Heart Block post AVR placement
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
-Surgeon Dr. [**Last Name (STitle) 914**]:# [**Telephone/Fax (1) 170**]: [**2128-3-2**] at 1:45pm
-Cardiologist: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**2128-3-1**] at 3pm
-Provider DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2128-2-17**]
1:00
-Provider DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2128-2-24**]
1:30
-Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2128-2-24**] 2:00
Please call to schedule the following:
Primary Care Dr. [**Name (NI) **] [**Name (NI) 41471**] in [**3-2**] 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:[**2128-2-10**]
|
[
"2875",
"40390",
"5859",
"2449",
"4241"
] |
Admission Date: [**2137-2-6**] Discharge Date: [**2137-2-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 71511**]
Chief Complaint:
Chest discomfort and dizziness
Major Surgical or Invasive Procedure:
[**2136-2-7**] - CABGx5 (Lima->Lad, SVG->RCA-PDA, SVG->Ramus-Circumflex
artery)
[**2136-2-7**] - Urethral Dilation with Foley Catheter Placement
History of Present Illness:
Splendid 88 y/o Gentleman who recently acquired a piece of
exercise equipment
and started using it. When he was exercising and exerting
himself, he had angina. Cardiac cath demonstrated severe
three-vessel coronary artery disease. The patient was,
therefore, referred for coronary artery bypass grafting.
Past Medical History:
HTN
syncope
knee surgery in [**11/2136**](rt knee medial and lat meniscectomy)
orthostatic hypotension
glaucoma
Diverticulosis (on screening colonoscopy)
BPH
Urethral stricture
Social History:
lives with wife and [**Name2 (NI) **]. Lifetime non-smoker. Denies
alcohol or drug use.
Family History:
no history of coronary disease
Physical Exam:
Preop:
BP 131/80 HR 64 RR 18 96%RA
HEENT: pupils reactive, op clear, mmm
Neck: no JVD
Heart- RRR S1S2 no M/R/G
Lungs- CTAB
Abd- +BS, soft, ND/NT
Ext- 2+ pedal pulse b/l, 2+ femoral pulses, no varicosities
Neuro- AAO x 3
Discharge:
VS: T 99 HR 93 BP 104/56 RR 20 O2Sat 94%RA
Gen: NAD
Neuro: A&Ox3, MAE, follows commands. Non focal exam
Pulm: scattered rhonchi
CV: RRR, S1-S2. Sternum stable incision with steri strips CDI
Abdm: soft, NT,NABS
Ext: warm, well perfused. 2+ pedal edema bilat
Pertinent Results:
[**2137-2-6**] 07:14PM WBC-5.9 RBC-3.03* HGB-9.7* HCT-27.6* MCV-91
MCH-32.1* MCHC-35.3* RDW-13.5
[**2137-2-6**] 07:14PM PLT COUNT-168#
[**2137-2-6**] 03:40PM UREA N-20 CREAT-0.8 CHLORIDE-107 TOTAL CO2-23
[**2137-2-11**] 10:05AM BLOOD WBC-5.0 RBC-2.82* Hgb-9.2* Hct-26.6*
MCV-95 MCH-32.8* MCHC-34.7 RDW-13.6 Plt Ct-158
[**2137-2-11**] 10:05AM BLOOD Plt Ct-158
[**2137-2-11**] 01:05AM BLOOD Glucose-84 UreaN-33* Creat-1.1 Na-135
K-4.8 Cl-101 HCO3-26 AnGap-13
[**2137-2-11**] - CXR
The patient is status post median sternotomy and CABG.
Cardiomediastinal silhouette remains slightly widened, but not
significantly changed from previous study. Small bilateral
pleural effusions are not significantly changed from previous
study. The patient has made better inspiratory effort on current
exam, and there is better aeration of the lung bases, with
particularly less linear atelectasis demonstrated at the left
base.
[**2137-2-6**] ECHO
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2.There is mild symmetric left ventricular hypertrophy. Regional
left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal.
3.The ascending aorta is mildly dilated. There are simple
atheroma in the
ascending aorta. There are simple atheroma in the descending
thoracic aorta.
4.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-5**]+)
mitral regurgitation is seen.
6. There is no pericardial effusion.
Post Bypass
Patient is in sinus rhythm and receiving an infusion of
phenylephrine.
1. Biventricular systolic function is unchanged.
2. 1+ mitral regurgitation present.
3. Aorta intact post decannulation.
Brief Hospital Course:
Mr. [**Known lastname 13551**] was admitted to the [**Hospital1 18**] on [**2136-2-7**] for elective
surgical management of his coronary artery disease. He was taken
directly to the operating room where he underwent coronary
artery bypass grafting to five vessels. Please see operative
report for details. Of note, urology was consulted due to
difficult catheterization. A cystoscopy was performed with
dilation. Five days of ciprofloxacin was prescribed for
coverage. Postoperatively he was taken to the intensive care
unit for monitoring. By postoperative day one, Mr. [**Known lastname 13551**] had
awoke neurologically intact and was extubated. Aspirin, statin
and beta blockade were resumed. On postoperative day two, he was
transferred to the step down unit for further recovery. He was
gently diuresed towards his preoperative weight. The physical
therapy service was consulted for assistance with his
postoperative strength and recovery. On postoperative day five,
his foley catheter was removed and he voide post removal without
difficulty.
Mr. [**Known lastname 13551**] continued to make steady progress and was discharged to
rehab on postoperative day 7. He will follow-up with Dr.
[**Last Name (STitle) 914**], his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Lopressor 12.5mg [**Hospital1 **]
Lisinopril 5mg QD
Aspirin 325mg QD
TErazosin 5mg QHS
Lipitor 10mg QD
Cyanocobalamin 250mg QD
Eye drops
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Carteolol 1 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
10. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
TBA
Discharge Diagnosis:
CAD s/p CABGx5(LIMA-LAD,SVG-RCA,PDA,LCx,Ramus)[**2-6**]
Hyperlipidemia
HTN
BPH
Urethral Stricture
Diverticulosis
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeks.
6)No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Cardiologist Dr. [**Last Name (STitle) **] in [**3-9**] weeks.
Follow-up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 34561**] in [**4-7**] weeks. [**Telephone/Fax (1) 33330**]
Please call all providers for appointments
Completed by:[**2137-2-13**]
|
[
"41401",
"4019",
"2724"
] |
Admission Date: [**2183-9-1**] Discharge Date: [**2183-9-3**]
Date of Birth: [**2110-2-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
Transcutaneous pacemaker: DDD [**Company 1543**]
Permanent pacemaker
History of Present Illness:
73F w HTN HLD, retinal detachment who presented to the ED early
this morning after syncopal event at home, was admitted to the
floor and noted to have a brief episode of asymptomatic
atrioventricular conduction dissociation x2. She had returned
from [**Country 3587**] 2 days ago, noted feeling weak and fatigued
starting last night. Around 4am this morning, when patient got
up to go to bathroom at home, she started coughing, felt
increased shortness of breath, became lightheaded, vision
darkened around periphery, and she fell, losing consciousness
briefly. She awoke on the floor and called her daughter; she was
unclear of how long she was out, but she feels that it was
brief. She denied chest pain/pressure, palpitations, headache,
urinary incontinence, nausea, vomiting. She has been having
loose stools today. She has not had prior episodes of syncope.
She has had decreased po intake secondary reduced appetite. She
does not recall any sick contacts. She was in [**Country 3587**] for 5
weeks until Saturday. She denies having fevers at home, though
has had fevers on presentation to the ED this morning. She does
report fatigue and malaise for the last two days.
.
In the ED, her vital signs were as follows: T 98.8, BP 121/73,
HR 103, RR 16, and SpO2 100% on RA. Labs were notable for an
elevated WBC count of 11.0 with neutrophil predominance and
anion gap of 15. Her CXR was unremarkable. D-dimer was elevated
to 897, so CTA was done which was negative for PE and also
showed no consolidation. Head CT was negative. Patient later
spiked a fever to 102.1 in the ED with no clear source. Blood
and urine cultures were sent; no antibiotics were started
because there was no clear source of infection.
.
On the floor, patient was monitored on telemetry with heart
rates mostly in the 80s-90s. At 18:04, she was noted to have a
transient AV dissociation lasting 6 seconds with regularly
conducting p-waves and no ventricular escape, then another 4
second episode with 4 beats normal sinus rhythm in between. She
then returned to her native rhythm with rate 80s. Patient was
asymptomatic during this time and vital signs were stable.
Cardiology was consulted, and patient was transfered to CCU for
placement of temporary pacemaker wire.
.
Upon transfer to CCU, patient had a similar episode of transient
5s AV dissociation with regularly conducting p-waves and no
ventricular escape during a coughing episode. Her rhythm quickly
returned to baseline in 70s-80s. Patient complained of mild
dizziness and fatigue, denied headache or visual symptoms on
arrival to CCU. She admitted to new cough. Patient admitted to
some mild chest tightness in last week. She denied abdominal
pain, nausea, but admits to poor appetite x 1-2 days associated
with the fatigue. Daughter did note that patient may have gotten
a large bug bite on her right arm a few days ago, right before
she left [**Country 3587**]. She believes that patient may have been
worked up for hematuria as outpatient.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia - though reports of normal lipid panel recently
w/o statin
L retinal detatchment
Social History:
Originally from [**Country 3587**]. Speaks Portuguese Creole, very
limited English. She lives alone and is able to carry out her
ADLs at baseline. She has good support from her family. Her
daughter, son, and sister are present with her today. Her
daughter [**Name (NI) **] lives nearby and sees her frequently.
Tobacco: No smoking history
Alcohol: No alcohol
Family History:
No family history of seizure disorders or premature cardiac
death.
All of her siblings have diabetes.
Brother with pacemaker.
Physical Exam:
PHYSICAL EXAMINATION on Admission:
VS: T= 99.9 BP= 135/29 HR= 87 RR= 19 O2sat= 92%RA
GENERAL: WDWN elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. EOMI, mmm
NECK: JVP flat
CARDIAC: RR, normal S1, S2. [**1-25**] Early systolic murmur at USB.
LUNGS: lungs clear anteriorly bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: + very trace lower extremity edema; DP and PT
pulses intact
.
PHYSICAL EXAMINATION on Discharge:
GENERAL: WDWN elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. EOMI, mmm
NECK: JVP flat
CARDIAC: RR, normal S1, S2. [**1-25**] Early systolic murmur at USB.
LUNGS: lungs clear anteriorly bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: + very trace lower extremity edema; DP and PT
pulses intact
Pertinent Results:
[**2183-9-2**] 03:48AM BLOOD WBC-7.3 RBC-3.71* Hgb-11.1* Hct-32.7*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.2 Plt Ct-274
[**2183-9-1**] 05:10AM BLOOD WBC-11.0# RBC-4.30 Hgb-12.7 Hct-37.7
MCV-88 MCH-29.6 MCHC-33.8 RDW-14.1 Plt Ct-329
[**2183-9-1**] 05:10AM BLOOD Neuts-91.7* Lymphs-5.6* Monos-1.9*
Eos-0.4 Baso-0.4
[**2183-9-2**] 03:48AM BLOOD Plt Ct-274
[**2183-9-2**] 03:48AM BLOOD PT-14.0* PTT-32.0 INR(PT)-1.2*
[**2183-9-1**] 05:10AM BLOOD Plt Ct-329
[**2183-9-1**] 05:10AM BLOOD PT-13.1 PTT-24.6 INR(PT)-1.1
[**2183-9-2**] 03:48AM BLOOD Parst S-NEGATIVE
[**2183-9-2**] 12:39PM BLOOD Glucose-83 UreaN-11 Creat-0.7 Na-141
K-3.4 Cl-107 HCO3-24 AnGap-13
[**2183-9-2**] 03:48AM BLOOD Glucose-87 UreaN-12 Creat-0.7 Na-139
K-3.0* Cl-105 HCO3-24 AnGap-13
[**2183-9-1**] 05:10AM BLOOD Glucose-120* UreaN-23* Creat-0.9 Na-141
K-4.1 Cl-104 HCO3-22 AnGap-19
[**2183-9-2**] 03:48AM BLOOD ALT-13 AST-22 LD(LDH)-203 CK(CPK)-124
AlkPhos-54 TotBili-0.5
[**2183-9-1**] 05:10AM BLOOD CK(CPK)-246*
[**2183-9-2**] 03:48AM BLOOD CK-MB-3 cTropnT-<0.01
[**2183-9-1**] 10:55AM BLOOD cTropnT-<0.01
[**2183-9-1**] 05:10AM BLOOD cTropnT-<0.01
[**2183-9-1**] 05:10AM BLOOD CK-MB-4
[**2183-9-2**] 12:39PM BLOOD Mg-3.0*
[**2183-9-2**] 03:48AM BLOOD Albumin-3.4* Calcium-8.2* Phos-2.7
Mg-1.4*
[**2183-9-1**] 06:49AM BLOOD D-Dimer-897*
[**2183-9-1**] 05:10AM BLOOD TSH-1.4
[**2183-9-1**] 12:19PM BLOOD Lactate-1.4
[**2183-9-1**] 05:33AM BLOOD Lactate-1.6
[**2183-9-1**] 09:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.046*
[**2183-9-1**] 09:25AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2183-9-1**] 09:25AM URINE RBC-[**11-8**]* WBC-0-2 Bacteri-FEW Yeast-OCC
Epi-0-2
[**2183-9-1**] 09:25AM URINE Hours-RANDOM UreaN-555 Creat-69 Na-128
K-34 Cl-160
[**2183-9-1**] 09:25AM URINE Osmolal-694
.
Parasite Smear Negative
.
Urine and Blood cultures Pending as of [**2183-9-2**] PM....
.
ECG Study Date of [**2183-9-1**] 5:10:04 AM
Normal sinus rhythm. Left axis deviation at minus 31 degrees. Q
waves in
leads I and aVL. Poor R wave progression in leads V2-V6. Left
ventricular
hypertrophy. Intraventricular conduction delay with QRS duration
of 110 milliseconds. Compared to the previous tracing of [**2182-7-12**]
no diagnostic interval change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 188 110 368/425 70 -31 75
.
CHEST (PA & LAT) Study Date of [**2183-9-1**] 5:30 AM
FINDINGS: The lungs are clear. There are no pleural effusions or
pneumothorax. The cardiomediastinal contours demonstrate mild
tortuosity of thoracic aorta, with mild cardiomegaly. Pulmonary
vascularity is normal. Note is made of mild elevation of the
right hemidiaphragm and non-specific mildly gaseously distended
loops of small bowel in the upper abdomen.
IMPRESSION: No acute cardiopulmonary process. Mild elevation of
the right
hemidiaphragm and non-specific mildly gaseous distended loops of
small bowel in the upper abdomen.
.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2183-9-1**]
7:49 AM
FINDINGS: Non-contrast imaging demonstrates no evidence of
aortic intramural hematoma. Note is made of mild calcification
along the left anterior descending coronary artery. Following
the administration of IV contrast, opacification of the
pulmonary arterial tree is suboptimal for evaluation of
segmental and subsegmental vessels. However, the larger
pulmonary arterial branches extending to the lobar level are
well opacified without evidence of pulmonary embolism. The aorta
is normal in course and caliber without evidence of dissection
or aneurysm. There is no lymphadenopathy. The heart is normal in
size and shape.
.
Lung windows demonstrate no worrisome nodule, mass, or
consolidation.
Bibasilar areas of atelectasis are noted. The imaged upper
abdominal structures are unremarkable. No worrisome osseous
lesions are seen. A vertebral body hemangioma is noted in the
mid thoracic spine.
.
IMPRESSION: No large pulmonary embolism. Please note, evaluation
limited for subsegmental or segmental level PE.
.
Brief Hospital Course:
Pt is a 73 y/o female with HTN, HLD, retinal detachment who
presented after a syncopal event with prodrome the morning of
admission, found to have fever and paroxysmal AV disassociation.
.
# Paroxsymal AV disassociation: Etiology was unclear, but
lesion was likely infranodal as the PR intervals are not
increased and AV disassociation was complete. Temporary
pacemaker was placed. Patient was conducting normally through
native system at rate 80s. Given travel, fever and diarrhea, and
time of year infectious etiologies including Lyme, malaria and
myocarditis, were considered but infectious work-up is negative
to date. Ischemic etiology was unlikely, given troponins were
flat. Home atenolol was not likely to have contributed, as PR
intervals and RR intervals are not prolonged, just sudden
paroxysmal episodes of CHB with no ventricular escape. Based on
EKG findings, it was felt that the episode of syncope was not
vagal. Decision was made to place permanent pacemaker (dual
chamber), which was successfully placed on [**2183-9-2**]. Pt did not
experience any complications during procedure and was able to
leave ICU and got to the floor.
.
# Syncopal event:
Event was proceeded by a clear prodrome. There was conern that
this may have been vagal micturition syncope, or orthostatic
(poor PO intake and insensible losses with diarrhea). Although
this may have been an initial contributory factor, EP felt that
episode was likely due to of paroxsymal heart block that caused
her to syncopize, given similar findings seen on telemetry today
(suggestive of phase 4 block). CXR, CTA, and head CT in the ED
were all unremarkable. Unlikely seizure as there was no
post-ictal state and she has no history of epilepsy. As above,
decision was made to place a permanent dual chamber pacemaker.
.
# Fever:
Source unknown and infectious work-up was unrevealing to date.
Patient just returned from a 5 week trip to [**Country 3587**];
infectious source most likely gastroenteritis. Stool studies
were sent and are still pending; her primary care physician at
[**Name9 (PRE) **] [**Name9 (PRE) **] will have access to the [**Hospital1 18**] records online. Patient
did have new cough, but no pneumonia or cavitary lesions were
seen on CXR. UA showed hematuria but no nitrites or leukocyte
esterase. Fever curve downtrended and normalized by the time of
discharge.
.
# HTN:
HCTZ and atenolol were held on initial presentation; patient was
continued home lisinopril. She was restarted on home atenolol
dose post pacemaker.
.
# Anion gap:
Anion gap of 15 upon admission was likely due to mild lactic
acidosis in setting of syncope, fall and decreased PO intake
over past few days related to diarrhea, fever. No signs of
uremia, ETOH, DKA, or other toxic ingestion. Improved w/IVF and
supportive care.
.
# Hematuria: Likely secondary to trauma from catheterization.
UA negative for nitrites, leuk esterase. No casts.
.
Pt was full code during this admission. Pt is [**Name (NI) 67026**]
speaking and interpreter was used for consent.
.
Medications on Admission:
Aspirin 81 mg PO daily
Atenolol 25 mg PO daily
Hydrochlorothiazide 25 mg PO daily
Lisinopril 20 mg PO daily
Tylenol Arthritis 650 mg, 1-2 tabs [**Hospital1 **] PRN pain
Simvastatin 20 mg PO daily -- no longer taking regularly
Discharge Medications:
1. Tylenol Arthritis 650 mg Tablet Sustained Release Sig: [**12-21**]
Tablet Sustained Releases PO twice a day as needed for pain.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 3 days.
Disp:*24 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Paroxsymal atrio-ventricular disassociation
Bradycardia
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 1001**],
You were admitted to the hospital because you had a fainting
spell. It was determined that this was caused by an irregular
rhythm of your heart. In order to ensure that your heart
maintained a normal rate and rhythm, it was determined that you
needed a permanent pacemaker placed. You underwent placement of
a dual chamber pacemaker without any complications during the
procedure. You were able to be discharged in stable condition to
complete your recovery at home.
.
The following changes were made to your medications:
- Please START taking the antibiotic Clindamycin 300mg (2
tablets, 150mg each) every 6 hours x 3 days
- Please STOP taking hydrochlorothiazide until seen by your
primary care physician who can restart it as appropriate
- Please continue to take all of your other home medications as
prescribed
Please be sure to take all medication as prescribed.
.
Please be sure to keep all follow-up appointments with your
primary care physician and other healthcare providers.
If you continue to have fevers or diarrhea, please contact your
primary care physician.
.
It was a pleasure taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please be sure to keep all follow-up appointments with your
primary care physician and other [**Name9 (PRE) 67027**] providers.
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2183-9-10**] at 10:30 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: MONDAY [**2183-10-13**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital1 7975**] ST. HLTH CTR-KCSS
When: WEDNESDAY [**2183-11-12**] at 10:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7980**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
.
.
Department: [**Hospital3 1935**] CENTER
When: MONDAY [**2183-11-17**] at 1:45 PM
With: EYE IMAGING [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: WEDNESDAY [**2183-9-10**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Completed by:[**2184-1-19**]
|
[
"2762",
"4019",
"2724"
] |
Admission Date: [**2141-5-22**] Discharge Date: [**2141-6-8**]
Date of Birth: [**2098-11-18**] Sex: F
Service: MEDICINE
Allergies:
Cefepime
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
endotracheal intubation
nasointestinal tube placement
Bronchoalveolar Lavage
History of Present Illness:
This patient is a 42 year old female with a history of
hypertension, seizure disorder, alcohol abuse, who complains of
abdominal pain associated with n/v. Patient was brought in by
[**Location (un) 86**] med flight from [**Hospital6 302**] emergency Department
with a history of abdominal pain, hypotensive to 80/P which
improved after fluid resusitation with NS (5L) to SBP of 120's,
but still had poor urine output. Patient got fentanyl 100mg IV
for pain and zofran for nausea. Initial workup notable for free
fluid in the abdomen seen on CT scan (in [**Location (un) 6813**] pouch),
without any free air, positive fast exam. On arrival to [**Hospital1 18**],
she is awake alert and oriented, and complaining of abdominal
pain, worse on the left lower quadrant. She admits to drinking
alcohol regularly. She denies any trauma preceding the abdominal
pain. Patient reports that she had a two day history of N/V/D
with worsening epigastric/periumbilical pain. Denies any fevers,
chills.
.
In the ED, initial vs were: 95/71 93 30 100% RA. Patient was
given additional IVF, vanc/zosyn, 4g of mag, 2 calcium, 30 of
phos, got fentanyl IV for pain control. Lab was notable for
leukocytosis with bandemia, CT c/w pancreatitis. Liver US w/o
stones. Exam was notable for periumbilical / LLQ TTP, guiaic
neg. Patient has 2 PIV 18g and 20g.
.
On the floor, patient is in mild distress no other complains.
Past Medical History:
alcohol abuse
seizure disorder
hypertension
anxiety
depression
LMP 2wks ago
Social History:
drinks at most a pint a day (last use was 2 weeks ago), ever
since [**2127**], usually drinks 3 drinks of bourbon, last drink was 5
days ago. Self dc'd BP meds around 3 days ago. denies smoking or
drug use, on disability.
Family History:
father with history of pancreatits
Physical Exam:
Admission:
Vitals: T: 97.2 BP: 82/56 P: 63 R: 22 O2: 98%
General: Alert, oriented, no acute distress
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Chest: Clear to auscultation, bilaterally, no wheezes, rales,
rhonchi
Cardiovascular: Regular Rate and Rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Abdominal: soft, mildly distended, with tenderness to palpation
mainly in the left lower quadrant but diffusely tender,
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Pertinent Results:
Admission labs
[**2141-5-21**] 07:30PM BLOOD WBC-14.4* RBC-4.55 Hgb-13.0 Hct-36.9
MCV-81* MCH-28.7 MCHC-35.3* RDW-21.4* Plt Ct-103*
[**2141-5-21**] 07:30PM BLOOD Neuts-67 Bands-20* Lymphs-13* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2141-5-21**] 07:30PM BLOOD PT-11.8 PTT-30.3 INR(PT)-1.0
[**2141-5-21**] 07:30PM BLOOD Glucose-97 UreaN-9 Creat-0.7 Na-130*
K-4.3 Cl-100 HCO3-17* AnGap-17
[**2141-5-21**] 07:30PM BLOOD ALT-51* AST-118* AlkPhos-58 TotBili-0.7
[**2141-5-21**] 07:30PM BLOOD Lipase-1380*
[**2141-5-21**] 07:30PM BLOOD Calcium-4.3* Phos-0.8* Mg-1.2*
[**2141-5-21**] 07:30PM BLOOD Triglyc-2536* LDLmeas-LESS THAN
[**2141-5-21**] 07:42PM BLOOD Lactate-1.6
[**2141-5-22**] 06:56AM BLOOD freeCa-0.67*
CTA Abd/Pelvis [**5-22**]
1. Marked peripancreatic free fluid, which may be secondary to
acute
pancreatitis. Correlation with lab values is recommended.
2. Marked duodenal edema and mucosal hyperenhancement, could be
reactive to the adjacent acute pancreatitis.
3. Uterine fibroid.
4. Fatty liver.
CTA Torso [**5-24**]
1. Extensive peripancreatic fluid is unchanged since prior
study, consistent with history of acute pancreatitis.
2. Interval development of extensive consolidation and
ground-glass opacity in both lungs, most likely due to ARDS or
aspiration.
CTA Abdomen [**6-1**]
1. In this patient with acute pancreatitis, the extensive
peripancreatic
fluid in the anterior pararenal space extending inferiorly into
the pelvis, appear similar in size and appearance compared to
the prior study. No vascular complications are seen. No evidence
of pancreatic necrosis.
2. Improvement in the edema/ARDS and consolidative changes in
both lung
bases.
3. Mild narrowing of the origin of the celiac trunk, likely due
to
compression by the median arcuate ligament.
4. Multiple uterine fibroids.
5. Previously post-pyloric feeding tube has withdrawn, with tip
now within
the stomach.
CT ABDOMEN W/CONTRAST Study Date of [**2141-6-4**] IMPRESSION:
1. Stable extensive peripancreatic fluid collections extending
inferiorly
into the pelvis, which are unchanged in size and appearance
compared to the
prior study, likely representing pseudocysts. No evidence of
pancreatic
necrosis, hemorrhage, or vascular complication.
2. Improvement in bibasilar opacities within the lung bases.
3. Stable enlargement of the left ovary.
.
VitB12-1591*
.
UA [**5-26**]: Sp [**Last Name (un) **]-1.020 Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-1 pH-5.5 Leuks-MOD
URINE RBC-24* WBC->1000* Bacteri-MANY Yeast-NONE Epi-0
Micro:
[**2141-6-5**] Blood Culture, Routine-PENDING INPATIENT
[**2141-6-4**] URINE CULTURE-mixed flora, contaminated
[**2141-6-4**] Blood Culture, Routine-PENDING INPATIENT
[**2141-6-2**] FECAL CULTURE-negative; CAMPYLOBACTER
CULTURE-negative
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative
[**2141-6-2**] CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative
[**2141-5-31**] CATHETER TIP-negative
[**2141-5-31**] URINE CULTURE-FINAL {YEAST} 10,000-100,000
ORGANISMS/ML
[**2141-5-31**] Blood Culture, Routine-negative
[**2141-5-30**] Blood Culture, Routine-negative
[**2141-5-28**] RESPIRATORY CULTURE-
NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Unable to grow for ID&sensitivities.
CHRYSEOBACTERIUM INDOLOGENES
|
AMIKACIN-------------- 32 I
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>32 R
CEFTRIAXONE----------- 32 I
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
IMIPENEM-------------- 4 S
LEVOFLOXACIN---------- <=1 S
MEROPENEM------------- 2 S
PIPERACILLIN/TAZO----- <=8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- <=2 S
[**2141-5-27**] URINE CULTURE- >100,000
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMPICILLIN------------ 4 S 4 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
[**2141-5-26**] RESPIRATORY CULTURE-
HAEMOPHILUS INFLUENZAE. HEAVY GROWTH.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
[**2141-5-24**] Respiratory Viral Culture-negative
Respiratory Viral Antigen Screen-uninterpretable
[**2141-5-24**] BRONCHOALVEOLAR LAVAGE
RESPIRATORY CULTURE (Final [**2141-5-26**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Final [**2141-5-31**]): NO LEGIONELLA
ISOLATED.
Immunoflourescent test NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR: NO ACID FAST BACILLI SEEN ON CONCENTRATED
SMEAR.
ACID FAST CULTURE (Preliminary):
[**2141-5-23**] URINE CULTURE-negative
[**2141-5-22**] MRSA SCREEN-negative
[**2141-5-22**] Blood Culture, Routine-negative
[**2141-5-21**] CULTURE-negative
[**2141-5-21**] Blood Culture, Routine-negative
.
DISCHARGE LABS:
Na 138, K 3.4, Cl 103, HCO3 22, BUN 3, Cr 0.3
ALT-81* AST-48* AlkPhos-72 TotBili-0.3
Hct 22.8, WBC 22.9, plts 394
Triglycerides 225
Reticulocytes 3.2
Brief Hospital Course:
42 F with Hx of etoh abuse, hypertension, possible seizure
disorder presented with findings c/w severe pancreatitis and
hypotension. Her pancreatitis was severe and complicated by ARDS
requiring intubation. She developed a multifocal PNA, fevers,
and severe metabolic derangements. She improved rapidly and was
extubated on [**6-1**]. She remained stable and was transferred to
the medical floor for ongoing care.
.
# Pancreatitis, Severe without Necrosis
The cause of her pancreatitis was most likely alcohol, although
she was noted to have hypertriglyceridemia which may cause
pancreatitis as well. Her course was complicated by ARDS and
severe calcium, magnesium and phosphorous derangements requiring
aggressive repletion (~20 grams of calcium gluconate in 24
hours). She was treated initially with bowel rest and later with
a nasojejunal tube for feeds and, when that clogged, two days of
parenteral feeding before which she was started on a diet. She
was counselled extensively on the hazards of her alcoholism, and
social work was consulted for further counselling and
information on community resources.
Patient currently abdominal pain-free.
.
# Acute Respiratory Distress Syndrome and Multifocal Bacterial
Pneumonia
On day two of hospitalization, Ms. [**Known lastname 45935**] developed extreme
respiratory distress. A CXR revealed bilateral inifiltrates. She
was promptly diuresed but the infiltrates persisted which was
attributed to ARDS. She was intubated. She received a BAL that
yielded H. Flu bacterium. In 2 days, her ARDS improved briskly
however intubation was deferred secondary to oversedation. By
day 3, she had developed new infiltrates, fever while growing h.
flu and, later, CHRYSEOBACTERIUM INDOLOGENES. She was treated
initially with cipro/cefepime and later switched to bactrim, as
per sensitivities. Her antibiosis was complicated by a
maculopapular rash that later became confluent on the back and
left forearm. Cipro/Cefepime was then changed to bactrim.
Bactrim was then d/c'd d/t concern of high fevers and worsened
rash.
Pt was changed to levofloxacin with plans for total of 14 day
course of appropriate coverage.
.
# Anemia, NOS
Pt was noted to have significant anemia, with fluctuating HCT.
A CT of the abdomen was obtained due to clinical concern of
possible hemorrhagic pancreatitis, however the CT remained
stable without e/o hemorrhage. Hct still remained low at
discharge, with no evidence of acute bleeding. She will be
supplemented with iron, thiamine and folate. Reticulocyte count
was 3.2. Anemia likely due to acute inflammation and illness.
.
# Severe Malnutrition; Protein-Energy and complex
mineral/vitamin deficiencies
Hypocalcemia
Hypophosphatemia
Anemia with very wide RDW; presumed Folate and Iron Deficiency
Thrombocytopoenia responsive to etoh abstinence
EtOH abuse
The patient had refractory hypocalcemia which was partly
malnutritional and partly due to pancreatitis and severe
refractory hypophosphatemia both which required aggressive
repletion. She had anemia with a normal MCV and RDW > 22
indicating two distinct populations of red cells, presumably
related to etoh abuse, folate deficiency and iron deficiency.
These were repleted empirically, given her etoh abuse. She had
thrombocytopoenia that improved steadily over admission,
presumably with abstinence from etoh. She was given tube feeds
and PPN while intubated and her diet was advanced after
extubation. Pt is at risk for other nutritional deficiencies as
well, thus she was also treated with a multivitamin. Her B12
level was tested and was WNL.
.
# Transaminitis with fatty infiltration on CT
Likely Alcoholic Steatohepatis
Transaminitis on admission: AST/ALT > 2 (50/22) with normal
bilirubin and alkaline phosphatase. She had diffuse fatty
infiltration of her liver on CT. Presumably she had Alcoholic
Steatohepatitis vs NASH with fibrosis. Her enzymes fell over the
hospitalization until they abruptly rose. She had a rash develop
at that time and the second peak had ALT>AST with values in the
100's. This was presumed related to medications; her antibiotics
were changed at that time, as she also had a rash (see below).
.
# Anxiety
She was maintained on her home regimen of clonazepam and
required large doses of versed while intubated. Continued
clonazepam and paxil.
.
# Alcohol abuse
Patient was counseled extensively regarding her alcohol abuse,
and social work provided additional counseling and resources.
.
# Rash
During her ICU stay, she developed a severe whole body rash,
likely due to medication. Considering the fact that she had been
on multiple new medications, it is difficult to pinpoint which
medication caused the reaction, however, I suspect that the
initial reaction was due to cefepime. Her Cefepime and cipro
were exchanged for bactrim, however this was subsequently
exchanged for levofloxacin after she developed a high fever and
worsened rash after a dose of bactrim. She tolerated the
levofloxacin without difficulty, and her rash continued to
improve.
.
KEY FOLLOW UP:
PCP FOLLOW UP SCHEDULED FOR [**6-13**]. Will need CBC and
trigylcerides checked at that time.
Alcohol cessation. She was counseled extensively.
Medications on Admission:
amlodipine 5mg daily (not taking)
ascorbic acid 500 mg daily
carvedilol 6.25mg twice a day (not taking)
clonidine 0.1 mg twice a day (not taking)
ferrous sulfate 325mg Twice a day
folic acid 1mg once a day
keppra 500mg Twice a day (not taking)
zestril(lisinopril) 10mg once a day (not taking)
MVI once a day
paxil 20mg once a day
thiamine 100mg once daily
trazodone 100mg QHS
klonopine 1mg TID
Discharge Medications:
1. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Outpatient Lab Work
CBC, triglycerides [**2141-6-13**], results to NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 72313**] Phone:
[**Telephone/Fax (1) 9674**]
Discharge Disposition:
Home
Discharge Diagnosis:
# Pancreatitis, Severe without Necrosis
# Acute Respiratory Distress Syndrome/Acute respiratory failure
# Multifocal Bacterial Pneumonia
# Severe Malnutrition; Protein-Energy and complex
mineral/vitamin deficiencies
# Hypocalcemia
# Hypophosphatemia
# Anemia with very wide RDW
# Thrombocytopoenia responsive to etoh abstinence
# Severe alcohol abuse
# Transaminitis with fatty infiltration on CT
# Anxiety
# Severe rash, presumed medication related (possibly Cefepime,
but unclear)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a severe episode of pancreatitis due to
your alcohol consumption. You were VERY sick, and developed
breathing problems that required intubation, pneumonia, and a
urinary tract infection. It is extremely important that you do
not drink alcohol anymore. You have been provided resources to
assist you in quitting drinking.
It is also very important that you take all of your medications
as prescribed.
.
Complete the course of antibiotics for pneumonia.
LEVOFLOXACIN 500 MG FOR 7 DAYS. IF YOU HAVE TROUBLE FILLING THIS
PRESCRIPTION, CONTACT ME AT [**Telephone/Fax (1) 86498**].
.
Go to your primary care appointment on [**2141-6-13**]. They will
recheck your blood counts and your trigylcerides.
Followup Instructions:
Dr. [**Last Name (STitle) **] is not taking new patients.
This is with a nurse practitioner in his office:
With: NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 86499**]
Location: [**Last Name (un) **], [**Location 21487**] [**Numeric Identifier **]
Phone: [**Telephone/Fax (1) 9674**]
Appointment: [**2141-6-13**]:00am
|
[
"51881",
"2761",
"2762",
"5990",
"2875",
"4019"
] |
Admission Date: [**2199-1-1**] Discharge Date: [**2199-1-3**]
Date of Birth: [**2159-1-24**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 39 year-old
male with a history of known coronary artery disease status
post non Q wave myocardial infarction previously in [**2197-9-10**] status post cardiac catheterization over at [**Hospital1 2025**], which
revealed disease in the left anterior descending coronary
artery, diagonal and the right coronary artery. It was felt
at that time the patient would be best managed medically in
the interim. However, he continued to experience substernal
chest pain, which had radiated to his neck and arms after
walking approximately 100 to 150 steps. He underwent an ETT
on [**10-12**] where he exercised for 7.5 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
protocol with ST depressions along with MIBI showing moderate
to severe perfusion defects in the distal anterior wall and
apex. He was seen by his cardiologist who had recommended a
relook catheterization. The patient was admitted for cardiac
catheterization to the [**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Coronary artery disease status post myocardial infarction
in [**9-11**].
2. History of HIV with last CD4 count of 15 in [**11-12**].
3. History of pancreatitis.
4. History of cryptococcal meningitis.
5. History of elevated cholesterol.
6. History of pancreatitis in [**2196-1-11**] secondary to
HAART.
ALLERGIES: Status post desensitization to Bactrim.
FAMILY HISTORY: Mother with a history of hypertension.
SOCIAL HISTORY: The patient lives with his wife. [**Name (NI) **] has a
twenty pack year history of smoking. He quit one year ago.
MEDICATIONS ON ADMISSION:
1. Abacavir 300 mg po b.i.d.
2. Atorvastatin 10 mg po q day.
3. Azithromycin 1200 mg po q week.
4. Didanosine 400 mg q day.
5. Fluconazole 400 mg q day.
6. Fortivase 200 mg po take four by mouth twice a day.
7. Lisinopril 5 mg q day.
8. Metoprolol 50 mg po b.i.d.
9. Plavix 75 mg po q.d.
10. Ritonavir 100 mg po b.i.d.
11. Tenofovir 30 mg po q day.
12. Tricor 54 mg po q.d.
13. Ursodiol 300 mg po b.i.d.
PHYSICAL EXAMINATION: The patient's temperature is 97.5.
Heart rate 93. Blood pressure 107/52. Respirations 22.
Sating 100% on room air. In general, he is a tired appearing
male in no acute distress, thin, cachectic. HEENT pupils are
equal, round and reactive to light. Sclera anicteric.
Oropharynx is clear with moist mucous membranes. Neck was
supple. No JVD or bruits. Heart was regular rate and
rhythm. Normal S1 and S2. No murmurs, rubs or gallops.
Lungs clear bilaterally. Abdomen soft, nontender,
nondistended with good bowel sounds. Extremities no edema.
Alert and oriented times three. Extraocular movements
intact. Moving all extremities. Sensation to light touch
intact in all four extremities.
LABORATORY DATA ON ADMISSION: The patient's white blood cell
count was 3.1, hematocrit 27.1, hemoglobin 9.0, platelets 95.
INR 1.0, PTT 38.8, PT 12.4. Urinalysis had a specific
gravity of greater then 1.035 with negative nitrate and
negative leukocyte esterase. Chem 7 sodium was 133,
potassium 3.3, chloride 103, bicarb 22, creatinine 0.7, BUN
17, glucose 163, cholesterol 145, triglycerides of 180, HDL
29 and LDL of 80.
HOSPITAL COURSE: The patient is a 39 year-old male with a
history of HIV/AIDS and coronary artery disease status post
cardiac catheterization. The patient initially underwent a
cardiac catheterization, which was notable for the left main
with no significant obstructive coronary artery disease. The
left anterior descending coronary artery had a mid to
proximal 95% vessel true bifurcation lesion and to a diagonal
branch. The left circumflex had a serial 70% stenosis and
the right coronary artery had a proximal serial 40 to 50%
stenosis. The initial hemodynamics revealed normal filling
pressures and a calculated ejection fraction of 65%. The
patient on the following day had undergone interventional
cardiac catheterization where he underwent drug eluding stent
placement in the circumflex and left anterior descending
coronary artery. This catheterization was notable for 20%
distal stenosis in the left main. Left anterior descending
coronary artery had approximately 20% with 90% bifurcation
lesions involving diagonal branch along with a more distal
70% lesion and the left circumflex had a 70% serial lesion.
The procedure had been notable for successful percutaneous
transluminal coronary angioplasty and stenting of the mid
left circumflex along with percutaneous transluminal coronary
angioplasty and stenting of the mid left anterior descending
coronary artery with jailing of the D1. However, during this
procedure the patient had dropped his blood pressure to the
70s initially. This may have also been secondary to large
vagal maneuver as well. He was transferred to the Coronary
Care Unit for further hemodynamic monitoring.
The patient had responded to dopamine. The patient's
baseline blood pressures had been in the 90s. He tolerated
his wean from Dopamine during this hospital course.
Otherwise the patient had an decrease in his hematocrit from
admission of 27.1 to 22.5. He had been transfused 2 units of
packed red blood cells with an appropriate bump in his
hematocrit. His other white blood cells and platelets were
at his baseline values.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post myocardial infarction
in [**2197**].
2. Status post cardiac catheterization with intervention to
the circumflex and left anterior descending coronary artery
with stent placement.
DISCHARGE MEDICATIONS: Same as those on admission.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Last Name (NamePattern1) 49318**]
MEDQUIST36
D: [**2199-1-3**] 11:32
T: [**2199-1-8**] 07:53
JOB#: [**Job Number 49319**]
|
[
"41401",
"412"
] |
Admission Date: [**2195-4-30**] Discharge Date: [**2195-5-20**]
Date of Birth: [**2167-5-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
[**2195-4-30**] Wound washout
[**2195-5-13**] wound washout
[**2195-5-18**] PICC line placement
[**2195-5-19**] Initiation of packing of occipital wound / needs to be
done daily
History of Present Illness:
HPI:27 year old found down at the bottom of stairs with GCS 6.
He was intubated at the OSH and given 50 of mannitol as well as
cerebrex. His head CT showed ?EDH and skull fractures. The
patient was medflighted here and neurosurgery was called for
evaluation.
Past Medical History:
PMHx:drug and ETOH abuse per brother
Social History:
Social Hx:per OSH records patient has h/o drug and ETOH abuse
Family History:
Family Hx:unknown
Physical Exam:
PHYSICAL EXAM:
T:97.6 BP: 131/86 HR:84 RR:22 O2Sats:100% vented
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:2mm, non-reactive bilaterally
Open occipital wound palpated.
EOMs-unable to test
Neck: In cervical collar.
Lungs: On ventilator.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: GCS 3. Patient has no corneals, no gag, no cough.
Cranial Nerves:
I: Not tested
II: Pupils equally round but nonreactive.
III-XII: unable to test
Motor: No movement to deep noxious stimuli in any extremity.
Sensation: Does not appear to feel pain.
Toes mute bilaterally
ON DISCHARGE
Awake alert oriented x 3, speech clear, CN II-XII intact, tongue
ML, trace left pronator drift, motor full otherwise, sensation
intact.
Pertinent Results:
CT head from OSH:
No hemorrhage appreciated. There are multiple areas of skull
fracture in the occipital region.
Repeat CT at [**Hospital1 18**]: tiny SDH along tentorium, fractures are
again
noted. No epidural hematoma is seen.
MRV HEAD W/O CONTRAST Study Date of [**2195-5-1**] 12:27 AM
FINDINGS: There is no acute infarct seen. Hemorrhagic contusions
are
identified involving both cerebellar tonsils with increased
signal seen within both cerebellar tonsils, which are displaced
inferiorly to the upper cervical region. Additionally, foci of
hemorrhage are seen in the left cerebellar hemisphere along the
vermis and also along the lateral aspect of the cerebellum
adjacent to the left occipital bone fracture. Blood is
visualized in the subarachnoid space as well as in the occipital
horns of both lateral ventricles. There is no hydrocephalus
seen. There is no midline shift. Mucosal changes are seen in the
sinuses.
IMPRESSION:
1. Left occipital bone deformity identified with hemorrhagic
contusions in
the left cerebellar hemisphere and also involving both
cerebellar tonsils. The cerebellar tonsils appear herniated
below the foramen magnum.
2. Focus of increased signal around the fourth ventricle on
FLAIR with
involvement of the left facial colliculus. This could also
reflect edema from contusion.
3. Subarachnoid hemorrhage with blood within the lateral
ventricles. No
evidence of hydrocephalus.
MRV OF THE HEAD:
The head MRV demonstrates normal flow in the superior sagittal
and right
transverse sinus. The left transverse sinus demonstrates
narrowing in its
midportion at the site of fracture. However, continuous flow
signal is
identified indicating patency. No collateral vessels are
identified.
IMPRESSION: No evidence of sinus thrombosis. The left transverse
sinus
appears compressed and narrowed in the mid portion. The superior
sagittal and right transverse sinuses are normal.
MR BRACHIAL PLEXUS W/O CONTRAST Study Date of [**2195-5-1**] 6:05 PM
MR BRACHIAL PLEXUS: For the purposes of this study due to the
fact that the patient was intubated and with an A-line in place,
the right arm was imaged up and the left arm down. Allowing for
this difference both brachial plexi morphologically appear
normal without evidence of adjacent hematoma or avulsion.
Comparison with the most recent MR [**Name13 (STitle) 2853**] confirms these
findings.
There is striking edema within the cerebellar tonsils as well as
the left
cerebellar hemisphere. Cerebellar tonsils appear slightly
inferiorly
herniated which is better evaluated on a prior MRI/MRA brain.
There is edema within the left occipital bone. Note is made of
consolidation at the left lung base, which is likely due to
aspiration and/or contusion. There is prominent edema throughout
the left paraspinal muscles, particularly involving the
semispinalis capitis and splenius capitis with edema approaching
the lower cervical spinal nerve roots but not abutting them.
IMPRESSION:
1) Normal MR appearance of the brachial plexi.
2) Extensive left paraspinal muscle injury as above.
3) Left cerebellar hemisphere and cerebellar tonsillar
contusions; please see prior MRI brain for better assessment.
4) Left lung base consolidation, which in this setting is likely
due to
aspiration and/or contusion.
CT HEAD W/O CONTRAST Study Date of [**2195-5-2**] 9:42 AM
FINDINGS: Similar appearance to subdural blood layering along
the tentorium bilaterally. Subarachnoid blood in the posterior
horns of lateral ventricles and interpeduncular cistern is
unchanged. Frontoparietal subarachnoid blood layering in the
sulci towards the vertex is similar to prior (series 2, image
23). Punctate foci consistent with contusion are again seen in
the
cerebellum.
Again seen is diffuse sulcal effacement consistent with mild
global edema.
There is persistent mild effacement of the fourth ventricle. The
third and
lateral ventricles appear unchanged. Caudal displacement of the
tonsils
appear similar to prior. There is no shift of normally midline
structures and no evidence of major vascular territorial
infarct.
Again seen is an extensively comminuted left occipital bone
fracture extending into the skull base (for details see the CT
of [**2195-4-30**]). There is subcutaneous emphysema in the left
occipital subgaleal tissues with overlying skin staples,
unchanged from prior. Mucosal thickening is again seen in the
ethmoidal, sphenoidal and bilateral maxillary sinuses with
circumferential thickening on the right.
IMPRESSION:
1. Stable appearance of subdural hemorrhage layering along the
tentorium and stable appearance of subarachnoid hemorrhage
including layering in the lateral ventricles and interpeduncular
cistern.
2. Cerebellar contusion. Mild global edema persists with mild
effacement of the fourth ventricle, but no midline shift and no
interval change in
ventricular size.
3. Unchanged displacement of the cerebellar tonsils inferiorly,
better
assessed on the prior study of [**2195-5-1**].
CT HEAD W/O CONTRAST Study Date of [**2195-5-8**] 8:08 AM
IMPRESSION:
1. Interval improvement in diffuse sulcal effacement as well as
mass effect on the fourth ventricle.
2. Interval evolution of subdural hematoma and cerebellar
contusion,
with resorption of subarachnoid and intraventricular hemorrhage.
CT HEAD W/ & W/O CONTRAST Study Date of [**2195-5-11**] 3:41 PM
IMPRESSION:
1. Thick rim-enhancing subcutaneous fluid collection abutting
the fracture
site and extending inferiorly which appears to be increasing in
size.
Assessment for change and enhancement is not possible given lack
of any prior contrast-enhanced studies. Given the clinical
symptoms, it is worrisome for superinfection.
2. Regions of enhancement surrounding the previously described
hemorrhagic
contusions within the left cerebellar tonsil and left cerebral
hemisphere.
While this finding can be seen in noninfected hematomas, given
the overlying suspicious fluid collection, additional foci of
infection cannot be excluded by imaging.
[**Last Name (LF) 82567**],[**Known firstname **] [**Medical Record Number 82568**] M [**2106-5-24**]
Radiology Report CT HEAD W/ & W/O CONTRAST Study Date of
[**2195-5-11**] 3:41 PM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2195-5-11**] 3:41 PM
CT HEAD W/ & W/O CONTRAST Clip # [**Clip Number (Radiology) 82569**]
Reason: eval for infection / pt with left occipital open skull
fract
Contrast: OPTIRAY Amt: 90
[**Hospital 93**] MEDICAL CONDITION:
27 year old man with left occipital sk fx.
REASON FOR THIS EXAMINATION:
eval for infection / pt with left occipital open skull
fracture s/p washout and
closure without [**Last Name (un) 2043**] repair...now with bump in WBC from 14
to 20 without
obvious source...
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: JKPe MON [**2195-5-11**] 8:06 PM
There is interval increase in size to a rim-enhancing left
posterior occipital fluid collection tracking from the bony
fracture site inferiorly which is suspicious for superinfection.
Additional smaller foci of enhancement involving the left
cerebellum and left cerebellar tonsil are noted at the site of
prior hemorrhagic contusions and likely relate to enhancement
around the hematoma although superinfection cannot be excluded
by imaging.
Final Report
HISTORY: Rising white cell count with known left occipital open
skull
fracture status post washout and closure.
Comparison is made to [**5-2**] and [**5-8**] CT examinations as
well as [**5-1**] MRI examination.
TECHNIQUE: Axial acquired images were obtained through the brain
prior to and
after the administration of intravenous contrast.
CT OF THE HEAD WITHOUT AND WITH INTRAVENOUS CONTRAST: Unenhanced
images of
the brain display hypodensity at the patient's known sites of
prior
hemorrhagic contusions within the left cerebellar tonsil and
left cerebellar hemisphere. The brain parenchyma appears
otherwise normal with no new regions of hemorrhage noted.
A 13 x 27 mm (AP and TR) thick rim-enhancing fluid collection is
noted to
extend craniocaudally from the fracture site inferiorly along
the left
occipital bone. Its size as well as the degree of internal fluid
content
appears predominantly new from the [**5-2**] exam and increased
from the [**5-8**] exam. Mild induration of the adjacent subcutaneous fat is
noted along
this collection. Additional non-liquified enhancing components
are also
present more inferiorly within the posterior musculature.
Additionally,
adjacent to the fracture site, there is mild enhancement noted
along the
previously demarcate hemorrhagic left cerebellar contusions, the
one more
laterally is less conspicuous than the 9 x 11 mm more medial
collection.
Additional smaller foci of enhancement are noted within the left
cerebellar tonsil which was also noted to have a hemorrhagic
contusion on prior MR. The degree of mass effect within the
posterior fossa appears slightly improved with post-surgical
changes from prior suboccipital craniotomy again noted.
There is increased opacification involving the right maxillary
sinus with
remaining paranasal sinuses displaying minimal mucosal disease.
Mild
opacification of both of the mastoid air cells bilaterally is
also unchanged.
IMPRESSION:
1. Thick rim-enhancing subcutaneous fluid collection abutting
the fracture
site and extending inferiorly which appears to be increasing in
size.
Assessment for change and enhancement is not possible given lack
of any prior contrast-enhanced studies. Given the clinical
symptoms, it is worrisome for superinfection.
2. Regions of enhancement surrounding the previously described
hemorrhagic
contusions within the left cerebellar tonsil and left cerebral
hemisphere.
While this finding can be seen in noninfected hematomas, given
the overlying suspicious fluid collection, additional foci of
infection cannot be excluded by imaging.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 82568**] M [**2106-5-24**]
Radiology Report CT HEAD W/ & W/O CONTRAST Study Date of
[**2195-5-18**] 4:07 PM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2195-5-18**] 4:07 PM
CT HEAD W/ & W/O CONTRAST Clip # [**Clip Number (Radiology) 82570**]
Reason: eval for possible abcess in left cerebellar region /
eval po
Contrast: OPTIRAY Amt: 90
[**Hospital 93**] MEDICAL CONDITION:
28 year old man with open skull fracture - with wound
infection s/p wash out...
REASON FOR THIS EXAMINATION:
eval for possible abcess in left cerebellar region / eval
postop wound
washout.... thank you
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Provisional Findings Impression: JKPe MON [**2195-5-18**] 7:44 PM
PFI: Marked interval decrease in size of rim-enhancing posterior
subcutaneous
fluid collection with small approximately 9 x 25 mm
rim-enhancing collection
noted to persist inferiorly. The regions of intraparenchymal rim
enhancement
surrounding the prior sites of hemorrhagic contusions are less
conspicuous on
today's exam which suggests no underlying parenchymal infection.
Final Report
HISTORY: Open ankle fracture status post debridement of
superinfected
subcutaneous collection.
Comparison is made to [**2195-5-1**] MRI and [**2195-5-11**] head
CT.
TECHNIQUE: Axial contiguous images were obtained through the
brain without
and with intravenous contrast.
CT OF THE BRAIN WITHOUT AND WITH INTRAVENOUS CONTRAST:
Unenhanced images of
the brain demonstrate no evidence of acute intracranial
hemorrhage, mass
effect, shift of midline structures, hydrocephalus, or acute
major vascular
territorial infarct. Regions of low attenuation within the left
cerebellar
hemisphere and vermis persist and correlate to the sites of
prior
intraparenchymal hemorrhagic contusions.
Post-contrast administration there is better identification of
improvement of
the previously identified large thick rim-enhancing subcutaneous
fluid
collection which has underwent interval evacuation. There is
some persistent
fluid noted about the skull fracture site with subcutaneous
emphysema;
however, the rim-enhancing component has decreased with only a
small pocket
noted to persist inferiorly measuring 9 x 25 mm (series 3 image
5). Additional
post-surgical changes involving the suboccipital craniotomy are
stable as is
the overall appearance of the minimally displaced left occipital
skull
fracture. There is no finding to suggest underlying
osteomyelitis. The
regions of intraparenchymal contusion again display very mild
rim enhancement;
however, this is less conspicuous than the most recent enhanced
examination of
[**5-11**] suggesting evolving intraparenchymal hematomas.
Moderate-to-severe
chronic mucosal thickening involving the right maxillary sinus
and right
[**Doctor Last Name 13856**] bullosa are again noted. The remaining paranasal sinuses
and mastoid
air cells are well aerated. There is partial opacification noted
to persist
involving the right mastoid air cells.
IMPRESSION:
1. Significant interval decrease in size to the known
superinfected
subcutaneous fluid collection abutting the fracture site. Only a
small pocket
remains which displays rim enhancement more inferiorly.
2. Decreased rim enhancement surrounding the hemorrhagic
intraparenchymal
contusions involving the left cerebellar hemisphere with no new
regions of
intraparenchymal enhancement or extra-axial fluid collections to
suggest
subdural/epidural empyema.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **],[**Known firstname **] [**Medical Record Number 82568**] M [**2106-5-24**]
Radiology Report [**Numeric Identifier 76392**] EXCH PERPHERAL W/O PORT Study Date of
[**2195-5-18**] 5:09 PM
[**Last Name (LF) **],[**First Name3 (LF) 742**] NSURG FA11 [**2195-5-18**] 5:09 PM
PICC LINE PLACMENT SCH Clip # [**Clip Number (Radiology) 82571**]
Reason: right picc up the neck. needs repo
[**Hospital 93**] MEDICAL CONDITION:
28 year old man with new picc placmt
REASON FOR THIS EXAMINATION:
right picc up the neck. needs repo
Provisional Findings Impression: JXXb MON [**2195-5-18**] 9:00 PM
Repositioning of PICC line with tip of the PICC line in SVC and
the line is
ready to use.
Final Report
CLINICAL INFORMATION: The patient is an 28-year-old man who had
infection and
needed PICC line placed for antibiotics. The existing PICC line
was misplaced
and needed to be repositioned by IR.
OPERATORS: Dr. [**First Name8 (NamePattern2) 82572**] [**Name (STitle) **] and Dr. [**First Name (STitle) 4685**] [**Name (STitle) 4686**], the
attending
radiologist who was present and supervised during the whole
procedure.
PROCEDURE: PICC line reposition.
ANESTHESIA: Lidocaine was used for local anesthesia.
PROCEDURE AND FINDINGS: After the risks and benefits of the
procedure as well
as local anesthesia were explained, the patient was brought to
the angiography
suite and placed supine on the imaging table. The right arm and
the existing
PICC line was prepared and draped in the usual sterile fashion.
A scout image
was taken which demonstrated the PICC line tip was located in
the right IJ. A
decision was made to reposition the existing PICC line. The PICC
line was
then pulled back under fluoroscopic guidance with the tip
located in the right
brachiocephalic vein and then the PICC line was advanced forward
with the tip
lodged into the SVC. The wire was then removed. The PICC line
was aspirated
and flushed easily. The PICC line was secured to the skin and
sterile
dressing was applied.
The patient tolerated the procedure well, and there were no
immediate
complications.
IMPRESSION: Repositioning of PICC line with the tip of PICC line
in SVC and
the catheter is ready to use.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
DR. [**First Name (STitle) **] [**Name (STitle) **]
Approved: WED [**2195-5-20**] 8:23 AM
Brief Hospital Course:
Pt was admitted to the neurosurgery service after eval in the ED
for depressed skull fracture. He was taken to the OR where
under general anesthesia he underwent a wound washout with
minimal elevation of depressed skull fracture. He tolerated
this well and was transferred to TICU. On exam he was found to
have left upper extremity weakness. He underwent CT c-spine
that showed no fracture and cervical MRI which showed no
ligamentous injury. His hard collar was removed. He also had
brachial plexus MRI which showed no injury. He also had MRV
which showed the left transverse sinus demonstrating narrowing
in its midportion at the site of fracture and therefore was
started on aspirin. EEG testing was completed which showed Left
slowing, no seizure foci. He was kept NPO until formal swallow
eval copuld be done [**12-29**] absent gag reflex.
On [**5-5**] he was transferred out of the Intensive Care Unit to
[**Hospital Ward Name 2982**] Step down. Speech and swallowing evaluation was done and
he was started on a regular; dysphagia diet with no difficulty.
On [**5-7**] in the evening Mr. [**Known lastname 48036**] fell to the floor striking his
head as he was trying to get out of bed. CT of the head was
negative for new findings.
He remained stable over the weekend. It was noted that his WBC
count jumped from 14 - 20 in 24 hours. A contrasted head CT was
ordered as well as a UA. His urine and sputum cultures were
negative. His wound looked clean with a small area of scabbing
vs necrosis and was without drainage. A contrasted head CT was
obtained [**12-29**] to increased WBC. His CT revealed thick rim
enhancing subcutaneous fluid collection abuting fracture site
with enhancement surrounding the site was concering for
infection, wound was aspirated and sent for cultures. The
following day, patient had a nonfocal exam and recieved a lumbar
puncture to rule out central nervous system infection.
He was brought to the OR on [**2195-5-13**] after bedside eval of wound
revealed active exudative drainage. He was closed with
interrupted sutures. ID consult was obtained the day prior and
recs were followed. He was started on Nafcillin and Micafungin
IV for definative treatment.
A PICC line was placed on [**2195-5-18**] for abx use. Contrast CT of
the brain was obtained for re-eval of possible intracranial
abcess vs infarct (enhancement eval).
The results showed interval improvement. No plan for re-wash
out at this time. ID continue's to follow. Posterior wound
remains with element of serous drainage. Wound packed with
Idodiform gauze and will be re-packed daily.
CSW eval obtained for clarity of use of IV drug use history. Pt
denies use of drugs outside of marijuana and alcohol at this
time.
Rehab screening is in progress. He and his father agree to
[**Name (NI) **] rehab. He is to be discharged today [**2195-5-20**]
Medications on Admission:
Medications prior to admission:
Received Cerebrex and 50 of mannitol at OSH.
Also received intubation medication.
Discharge Medications:
1. Outpatient Lab Work
PLEASE HAVE THESE LEVELS DRAWN WEEKLY AND FAX'D TO THE FOLLOWING
NUMBER: [**Telephone/Fax (1) **] ATTN: DR.[**Last Name (STitle) **]
CBC WITH DIFFERENTIAL
CHEM 10
LFT'S
ESR
CRP
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-28**]
Tablets PO Q4H (every 4 hours) as needed for headache.
10. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itcing.
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
12. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed) as needed for sore throat.
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. Nafcillin 2 g IV Q4H Duration: 4 Weeks
at this pt [**2195-5-18**], pt will require 4 weeks of nafcillin IV from
start date...thanks
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. Micafungin 100 mg Recon Soln Sig: One (1) Intravenous once
a day for 6 weeks: 6 WEEK COURSE TOTAL / STARTED ON [**2195-5-15**].
17. Nafcillin 2 gram Piggyback Sig: One (1) Intravenous every
four (4) hours for 6 weeks: 6 WEEKS TOTAL / STARTED ON [**2195-5-15**].
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 6978**] House of [**Hospital1 **]
Discharge Diagnosis:
Open depressed skull fracture
MSSA infection in scalp wound
left transverse sinus stenosis
dysphagia
Yeast infection / scalp tissue cx.
Discharge Condition:
Stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
YOUR SUTURES SHOULD REMAIN IN PLACE UNTIL [**2195-6-2**] (TOTAL OF
20 DAYS)
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 2WEEKS WITH A CONTRASTED CT SCAN
OF THE BRAIN.
THE APPOINTMENTS LISTED BELOW ARE TO SERVE AS A REMINDER. THEY
WERE POSTED IN OUR SYSTEM
PLEASE CALL THESE PROVIDERS IF YOU CANNOT MAKE THESE
APPOINTMENTS....HOWEVER IT IS IMPORTANT THAT YOU ATTEND THESE
APPOINTMENTS. THANK YOU
Provider: [**Name10 (NameIs) 12082**] CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2195-6-17**]
3:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2195-8-19**] 10:30
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2195-5-20**]
|
[
"3051"
] |
Admission Date: [**2181-2-26**] Discharge Date: [**2181-3-14**]
Date of Birth: [**2113-1-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Aortic valve replacement (21mm CE Magma Tissue) [**2181-3-8**]
Cardiac cath [**2181-3-2**]
History of Present Illness:
Ms. [**Known lastname 1683**] is a 68 year-old woman who was transferred from an
outside hospital with dyspnea and a chronic obstructive
pulmonary disease exacerbation. Work-up for this complaint
revealed moderate to severe aortic stenosis, moderate aortic
regurgitation, moderate mitral regurgitation, severe pulmonary
hypertension, and an ejection fraction of 55% by echocardiogram.
She was referred to cardiac surgery for repair of her aortic
valve pathology.
Past Medical History:
Aortic Stenosis, congestive heart failure Hypertension, h/o
breast cancer s/p left mastectomy and XRT, Hyperthyroidism -
multinodular goiter, Noninsulin dependent diabetes mellitus,
Chronic obstructive pulmonary disease, Hyperlipidemia, s/p non
ST elevation mycardial infarction
Social History:
Works in electronics company as tester. Denies alcohol use. 20
pack year, quit 20 years ago.
Family History:
No valvular disease, no sickle cell.
Physical Exam:
VS: 80 20 138/57 5'5" 69kg
Skin: Left breast removed (well-healed), multiple bruises on
arms
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Decreased breath sounds bilat. bases
Heart: Irregular rhythm with 3/6 systolic murmur radiating to
carotids
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused, 2+ edema
Neuro: Alert and oriented x 3, grossly intact
Pertinent Results:
[**3-2**] Cath: 1. Selective coronary angiography of this right
dominant system revealed no angiographically apparent flow
limiting disease. 2. Resting hemodynamics demonstrated moderate
pulmonary artery hypertension (PA 49/13 mm Hg), elevated left
sided filling pressures (LVEDP 47 mm Hg), and systemic arterial
hypertension (central aortic pressure 147/42 mm Hg. 3. Aortic
valve calculated at 0.9 cm2, with cardiac output/index 4.37
l/min and 2.39 l/min/m2, mean gradient 21.7 mm Hg, systolic
ejection period 23.8, valve flow 183.65 ml/sec. 4. Wide pulse
pressure indicative of significant aortic insufficiency. FINAL
DIAGNOSIS: 1. Coronary arteries are normal. 2. Moderate aortic
mixed stenosis and regurgitation. 3. Severe diastolic
ventricular dysfunction.
[**3-1**] CNIS: 1. No significant interval change and no evidence of
significant ICA stenosis on either side. 2. Antegrade flow in
both vertebral arteries.
[**3-8**] Echo: PRE-CPB:1. The left atrium is moderately dilated. No
spontaneous echo contrast is seen in the body of the left atrium
or left atrial appendage. No thrombus is seen in the left atrial
appendage. No thrombus is seen in the right atrial appendage No
atrial septal defect is seen by 2D or color Doppler. 2. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is mildly dilated. 3. Right ventricular chamber size and
free wall motion are normal. 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 severely
thickened/deformed. The annulus measures 21 mm. There is
moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Mild
(1+) aortic regurgitation is seen. 6. The mitral valve leaflets
are moderately thickened. There is severe mitral annular
calcification. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Moderate (2+) mitral regurgitation is seen at a
systolic pressure of 130 that is 1+ at a systolic pressure of
100 mmHg. Drs [**First Name (STitle) 6507**], [**Name5 (PTitle) 3318**] and [**Name5 (PTitle) 5209**] were in the OR to
discuss the findings with Dr. [**Last Name (STitle) **].
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusions of epinephrine, phenylephrine. AV pacing.
Well-seated bioprosthetic valve in the aortic position. No AI.
Gradient now 34 peak, 20 mean on inotropic support. MR is now
trace. Preserved biventricular systolic function. Aortic contour
is normal post decannulation.
[**2181-2-26**] 04:27PM BLOOD WBC-13.3*# RBC-3.20* Hgb-10.1* Hct-29.8*
MCV-93 MCH-31.5 MCHC-33.8 RDW-17.1* Plt Ct-115*#
[**2181-3-7**] 06:04AM BLOOD WBC-7.9 RBC-2.65* Hgb-8.4* Hct-26.3*
MCV-99* MCH-31.5 MCHC-31.8 RDW-16.0* Plt Ct-167
[**2181-3-13**] 06:01AM BLOOD WBC-10.7 RBC-2.84* Hgb-9.1* Hct-27.1*
MCV-96 MCH-31.9 MCHC-33.4 RDW-16.9* Plt Ct-110*
[**2181-2-26**] 04:27PM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.2*
[**2181-3-7**] 06:04AM BLOOD PT-14.1* PTT-110.9* INR(PT)-1.2*
[**2181-3-14**] 05:58AM BLOOD PT-29.1* PTT-33.4 INR(PT)-3.0*
[**2181-2-26**] 04:27PM BLOOD Glucose-167* UreaN-76* Creat-1.3* Na-147*
K-3.3 Cl-103 HCO3-34* AnGap-13
[**2181-3-7**] 06:04AM BLOOD Glucose-84 UreaN-37* Creat-1.0 Na-147*
K-3.5 Cl-105 HCO3-37* AnGap-9
[**2181-3-13**] 06:01AM BLOOD Glucose-95 UreaN-50* Creat-1.3* Na-138
K-3.6 Cl-99 HCO3-32 AnGap-11
[**2181-3-3**] 06:14AM BLOOD ALT-47* AST-16 LD(LDH)-318* AlkPhos-42
TotBili-1.0
Brief Hospital Course:
Upon admission to the medicine service, Ms. [**Known lastname 1683**] was treated
with a Solu-Medrol taper for a resolving chronic obstructive
pulmonary disease exacerbation. She was then transferred to
cardiology for cardiac catheterization in preparation for an
aortic valve repair. On [**2181-2-28**] she was intubated for
respiratory distress and hypoxemia and was transferred to the
cardiac care unit. She was diuresed and extubated by the
following day. She was seen in consultation by cardiac surgery
to evaluate her for aortic valve replacement. Her subsequent
cardiac catheterization on [**3-3**] revealed no significant coronary
artery disease. She was diuresed with a Lasix drip. She was
also seen in consultation by endocrinology for a nodule on her
thyroid. It was recommended that after her heart surgery, this
nodule be ablated.
On [**2181-3-8**] she was taken to the operating room and underwent an
aortic valve replacement with a CE magna tissue valve. Please
see operative report for surgical details. Following surgery she
was transferred to the CVICU for invasive monitoring in stable
condition. She did require blood transfusions due to low HCT.
Within 24 hours she was weaned from sedation, awoke
neurologically intact and extubated. But shortly after she had
increased rhonchi with respiratory acidosis and need to be
re-intubated. She was again weaned and extubated the following
day. she remained int he CVICU for several mores days while
receiving aggressive pulmonary toilet and diuresis. On post-op
day three chest tubes were removed. Post-operatively she
continued to have arrhythmias which were also seen upon
admission. Therefore she was started on Coumadin with heparin
bridge. Electrophysiology was eventually consulted. Epicardial
pacing wires were removed on post-op day four and she was then
transferred to the telemetry floor for further care. She
continued to slowly recover over the next several days while
awaiting for her INR to be therapeutic ([**2-20**]). She worked with
physical therapy and appeared ready for discharge on post-op day
five.
Medications on Admission:
Imdur 60 mg, Methimazole 5 mg MTWTFS, Verapamil 240 mg daily,
Lasix 40 mg daily, Guafenesin 600 mg [**Hospital1 **], Ecotrin 325 mg daily,
Levaquin 750 mg daily,
Dyazide 50/25mg? (patient unsure of dose)
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: As instructed based on INR Tablet
PO DAILY (Daily): Goal INR 2.0-3.0. Dose coumadin accordingly.
Likely dose 1mg alternating with 2mg.
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day):
Take with lasix and stop when lasix stopped.
3. Furosemide 40 mg IV TID
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
5. Zocor 80 mg Tablet Sig: One (1) Tablet PO QHS.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months: Or while taking narcotics.
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Methimazole 5 mg Tablet Sig: One (1) Tablet PO QMOTUWETHFRSA
().
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb IH
Inhalation Q6H (every 6 hours).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day): 1 INH
IH [**Hospital1 **] .
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB IH Q6H Inhalation Q6H (every 6
hours): NEB IH Q6H
.
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Acute on chronic congestive heart failure
Acute Renal Failure
Atrial Fibrillation
Pneumonia
Secondary: Hypertension, h/o breast cancer s/p left mastectomy
and XRT, Hyperthyroidism - multinodular goiter, Noninsulin
dependent diabetes mellitus, Chronic obstructive pulmonary
disease, Hyperlipidemia, s/p non ST elevation mycardial
infarction
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] ([**Telephone/Fax (1) 6699**]) in [**1-19**] weeks
Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 27174**]) in 2 weeks
Please call for appointments
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2181-3-14**]
|
[
"5849",
"486",
"51881",
"2762",
"4168",
"4019",
"25000",
"2724",
"412",
"42731",
"4280"
] |
Admission Date: [**2139-7-14**] Discharge Date: [**2139-7-19**]
Date of Birth: [**2069-6-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 yo F h/o previously healthy presented to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**]
hospital with SOB and weekness for a couple weeks. The pt was
recently able to walk a flight of stairs and go to the gym
without any SOB. Over the last couple weeks, the pt has declined
to the point where she can hardly walk out of the bedroom
without become dyspneic. The pt denies CP, although she
occasionally has noted palpitations. She has noted weight loss
of 14 lbs. The pt has also been evaluated recently for early
satiety and decreased apetite. She has nausea with eating, no
vomiting, no sensation of food getting stuck. No choking on
food.
On the day PTA, the pt went to PCP to discuss the results of
a swallow study to evaluate the dysphagia. The PCP was concerned
about the SOB, sent the pt to ED where she was found to be in
wide-complex tachycardia thought to be rapid A-fib with aberrant
conduction, rate 116-150's. BP 111/74. She was given dilt 20mg x
2, Lasix 40 IV, and started on Dilt gtt. She subsequently
developed hypotension and recieved IVF boluses and tranferred to
[**Hospital1 18**]. Amio bolus and gtt started en route.
.
In ED wide-complex tachycardia was noted at 120's-150's. BP
109/59. Heparin anti-coagulation was started. Metoprolol x 1 was
given for rate control. BP dropped to 80's systolic, the pt was
started on levophed. There was concern that there were periods
of V-tach. Levophed was d/c'ed.
The pt was tranferred to the CCU with the plan for amio and dig
for rate control.
Past Medical History:
No significant past medical history
Social History:
Drinks a small bottle of wine per day. No EtOH or drug use.
Lives on [**Hospital3 4298**].
Family History:
non-contributory
Physical Exam:
Physical Exam:
Vitals: Tm 95.5 p 73-75 BP 135/71(115-142/54-72) rr 24 sats
94-100 on 4L NC
I/O 1st shift: 100/300
Tele: NSR 65-75. Although several episodes of [**2-20**] beats of
regular wide complex rhythm at 150, likely NSVT
Neck: no JVD.
Chest: clear
CV: RRR, no murmurs
ABD: Abd NT/ND. NABS
Ext: no edema. distal pulses present.
Pertinent Results:
[**2139-7-14**] 07:00PM cTropnT-0.02*
[**2139-7-14**] 07:00PM CK-MB-NotDone
[**2139-7-14**] 07:00PM PLT SMR-NORMAL PLT COUNT-299
[**2139-7-14**] 07:00PM PT-14.6* PTT-28.1 INR(PT)-1.4
[**2139-7-14**] 07:00PM WBC-12.10* RBC-4.32 HGB-12.6 HCT-37.4 MCV-87
MCH-29.3 MCHC-33.8 RDW-14.0
[**2139-7-14**] 07:00PM NEUTS-74* BANDS-0 LYMPHS-14* MONOS-11 EOS-0
BASOS-1 ATYPS-0 METAS-0 MYELOS-0
[**2139-7-14**] 07:00PM TSH-1.6
.
BARIUM ESOPHAGRAM [**2139-7-17**]: Barium passes freely through the
esophagus. There are normal primary peristaltic contractions.
There is no aspiration, and no retention in the valleculae or
piriform sinuses. No structural abnormalities are detected in
the region of the pharynx or cervical esophagus. When the
patient was prone, she became short of breath, and therefore
full evaluation for gastroesophageal reflux and hiatal hernia
was not completed. The stomach empties promptly, and no gross
abnormality is detected within the stomach.
.
IMPRESSION: Findings to explain the patient's symptom of
dysphagia. Normal barium esophagram.
.
R groin ultrasound [**2139-7-18**]:
IMPRESSION:
1. Hematoma in the medial right thigh.
2. No evidence of arteriovenous fistula or pseudoaneurysm.
.
Head CT [**2139-7-14**]:
IMPRESSION:
1. No intracranial hemorrhage or mass effect.
2. No enhancing brain lesions.
.
Chest CT [**2139-7-14**]:
IMPRESSION:
1. No pulmonary embolism detected.
2. Large bilateral pleural effusions with associated bilateral
lower lobe atelectasis.
3. Small amount of pericardial fluid, which is within the
physiologic range.
4. No para-esophageal mass detected. However, direct copmarison
with the outside study is recommended for full assessment. See
comment above.
5. Scattered ground-glass opacities in the upper lobes and
lingula, of uncertain clinical significance.
.
Echocardiogram [**2139-7-15**]:
Conclusions:
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. There is severe global
left ventricular hypokinesis. No masses or thrombi are seen in
the left ventricle. Right ventricular systolic function appears
depressed. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
.
IMPRESSION: Severe, dilated (non-ischemic) cardiomyopathy.
Moderate valvular regurgitation.
.
[**2139-7-15**] abdominal ultrasound:
.
IMPRESSION:
1. No evidence of intra or extrahepatic biliary dilatation. The
gallbladder is normal.
2. Echogenic areas within the liver adjacent to the gallbladder
consistent with focal fat infiltration.
3. Right-sided pleural effusion.
Brief Hospital Course:
A/P:
70 yo F h/o previously healthy presented to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**]
hospital with SOB and weekness for a couple weeks, found to be
in rapid A-fib with aberrant conduction. Her BP has been low but
stable off pressors.
.
1. Rapid A-fib/hypotension.
In the CCU, the pt spontaneously converted to sinus rhythm while
on the amiodarone and digoxin therapy. The hypotension from the
prior evening was assessed to have resulted mainly from the dilt
and metoprolol doses that the pt recieved in the setting of
severely depressed systolic function. The rapid rate was also
contributing. The amiodarone was stopped on the morning of HD #1
because of liver enzyme elevation. The plan was to continue dig
for rate control and start metoprolol. A repeat echocardiogram
to assess cardiac function was obtained.
Rate control with dofetilide was considered, since amiodarone
was contraindicated with the elevated liver enzymes. However,
the QT interval was found to be prolonged on the ECG taken prior
to the dose of dofetilide was given. The plan for dofetilide was
changed. Anticoagulation with IV heparin was started on HD#1.
Coumadin was started for anti-coagulation on HD #4 once the
transaminases were trending down for a couple of days. The pt
was discharged with a plan for outpatient follow up.
.
2. Congestive Heart failure:
The pt was found to have an EF 15-20% on echocardiogram at
[**Hospital1 18**]. This represented a new diagnosis of heart failure. The
dysfunction was global, indicating a liekly non-ischemic
cardiomyopathy likely from EtOH, viral/idiopathic, or possibly
with some reversible component of tachycardia induced
cardiomyopathy. CXR here showed pulmonary edema. She had SOB,
and an oxygen requirement, satting 88-90% on RA.
-she received lasix diuresis to relieve the volume overload.
-metoprolol, ACE-inhibitor, ASA were started. statin was held
off in setting of elevated transaminases.
.
2. Dysphagia/early satiety/wt loss/guiaic positive stool:
The pt stated that she had already initiated a plan for the
work-up of these findings with another physician. [**Name10 (NameIs) **] CT at
[**Hospital1 18**] showed no evidence of para-esophageal mass by chest CT.
Upper GI/SBFT study was obtained with the plan for further
work-up to continue as an outpatient with the patient's primary
physician. [**Name10 (NameIs) **] exam revealed a Normal barium esophagram.
.
3. Severe transaminase elevation.
On the morning of HD #1, the pt's liver transaminases were found
to be elevated to 1500 range. ALk phos is normal. The
differential diagnosis was shock liver vs hepatitis vs
idiosyncratic reaction to amiodarone vs portal vein or IVC
thrombosis.
The pt had a liver son[**Name (NI) **] which was normal.
.
Medications on Admission:
aspirin
Discharge Medications:
1. Outpatient [**Name (NI) **] Work
PT/INR to be drawn on Tuesday, [**2139-7-21**]. We will follow up the
results and adjust coumadin as needed.
2. Outpatient [**Name (NI) **] Work
PT/INR to be drawn on [**2139-7-28**].
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*6*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*6*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
8. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Your
dose will be adjusted depending on the INR.
Disp:*30 Tablet(s)* Refills:*2*
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
Discharge Disposition:
Home
Discharge Diagnosis:
Cardiomyopathy
Atrial fibrillation
Shock Liver
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed. You will have labs drawn on
Tuesday, [**2139-7-21**] (here at [**Hospital1 18**] in [**Hospital Ward Name 23**] 6) and then Tuesday,
[**2139-7-28**] (either here or in MV). Continue to take coumadin (blood
thinner) at 5 mg each night. This dose will be adjsted based on
your labs (INR). For now, you should have your INR checked
weekly until you are on a stable coumadin regimen.
Followup Instructions:
You have an appointment in [**Hospital **] clinic ([**Telephone/Fax (1) 1954**]) with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**7-29**] at 1:20 PM in [**Hospital Ward Name 23**] 7. Please be sure to
call up in advance to go over insurance info and demographics.
.
You should find a primary care physician in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] and
he will continue to check your INR levels and dose your
coumadin. Goal INR is [**12-18**].
.
You should follow up with a cardiologist (Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) 11679**], office phone, [**Telephone/Fax (1) 5455**]). Please call to schedule
an appt within 2-4 weeks.
|
[
"4280",
"42731",
"4240",
"5849"
] |
Admission Date: [**2115-4-29**] Discharge Date: [**2115-5-10**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
ICD firing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is an 85 yo M with a history of Type 2 DM, paroxysmal
afib, Chronic systolic CHF, severe LV dysfuntion (EF 20-25%),
s/p BiV ICD placment in [**2108**], and VT s/p amiodarone and
dofetilide who was transferred from an OSH on [**2115-4-29**] to the
Cardiology service [**1-21**] to recurrent VT on mexilitine,
transferred to CCU for further monitoring after VT x 2
terminated by ICD firing.
Recently, he was admitted to an OSH ([**2115-4-9**] through [**2115-4-22**]) and
his ICD was reprogrammed to treat Vt/VF with atp x 1 followed by
1 shock. On this admission he was started on mexelitine and sent
home.
The patient returned to the OSH [**2115-4-28**] with slow VT (rate of
120s - 130s) on the Mexilitine with pre-syncopal symptoms. The
dizziness lasted several minutes while lying in bed. He denied
chest pain, palpitations, shortness of breath. He was referred
to [**Hospital1 18**] for further EP evaluation and possible VT ablation.
Past Medical History:
1. CARDIAC RISK FACTORS: hyperlipidemia
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS:none
-PACING/ICD: BiV ICD placed in [**2108**]. This was a
[**Company 1543**] Concerto.
3. OTHER PAST MEDICAL HISTORY:
Chronic systolic congestive heart failure (EF 20%).
Ventricular tachycardia treated with dofetilide.
s/p BIV ICD
Atrial fibrillation
Chronic back pain
Mild dementia with short-term memory deficits
bladder CA, s/p tumor excision
dyslipdiemia
chronic venous insufficiency
Social History:
-Tobacco history: patient smoked 1.5ppd x 50 years. Quit 20
years ago.
-ETOH: No alcohol.
-Illicit drugs: None.
Family History:
NC
Physical Exam:
VS: 96.8, 76 bpm, 93/82, 19, 100% on 2 L nc
GENERAL: WDWN 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 at clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Distant heart sounds. RR, normal S1, S2. No m/r/g.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Patient has an
umbilical hernia. Easily reducible.
EXTREMITIES: Chronic venous stasis bilaterally. Minimal ankle
edema bilaterally. 2+ PT pulses bilaterally.
PULSES:
Right:DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
C. Cath [**2115-5-1**]
no coronary artery disease
PCW mean 26
RA 14
.
EKG [**2115-5-1**]
The tracing is marred by baseline artifact. The rhythm appears
to be atrial sensed and ventricular paced with occasional
ventricular ectopy as recorded on [**2115-4-30**] without diagostic
interim change. There is occasional intrinsic A-V conduction.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
81 136 24 [**Telephone/Fax (3) 6513**]62 -98
.
2D-ECHOCARDIOGRAM: 5/`14/09
The left atrial volume is markedly increased (>32ml/m2). Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is severe global left
ventricular hypokinesis (LVEF = 20-25 %). The estimated cardiac
index is depressed (<2.0L/min/m2). There is no left ventricular
outflow obstruction at rest or with Valsalva. The right
ventricular cavity is dilated with depressed free wall
contractility. The aortic root is moderately dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Dilated, LV with severe global hypokinesis. The
lateral wall has relatively better function.The RV is not well
seen but is probably mildly dilated/depressed. Mild mitral and
aortic regurgitation.
Compared with the report of the prior study (images unavailable
for review) of [**2110-12-2**], the findings are similar. The degree
of mitral regurgitation and ventricular dilatation are slightly
less on the current study.
[**2115-4-29**] 07:30PM BLOOD WBC-5.7 RBC-4.36* Hgb-12.8* Hct-38.1*
MCV-87 MCH-29.2 MCHC-33.5 RDW-15.1 Plt Ct-187
[**2115-5-4**] 06:18AM BLOOD WBC-5.0 RBC-3.89* Hgb-11.3* Hct-34.0*
MCV-87 MCH-29.0 MCHC-33.3 RDW-15.0 Plt Ct-144*
[**2115-5-8**] 06:50AM BLOOD WBC-4.6 RBC-4.22* Hgb-12.7* Hct-36.8*
MCV-87 MCH-30.0 MCHC-34.4 RDW-15.9* Plt Ct-141*
[**2115-5-8**] 06:50AM BLOOD Plt Ct-141*
[**2115-5-8**] 06:50AM BLOOD PT-14.1* PTT-74.5* INR(PT)-1.2*
[**2115-4-29**] 07:30PM BLOOD PT-21.7* PTT-29.1 INR(PT)-2.1*
[**2115-4-29**] 07:30PM BLOOD Glucose-151* UreaN-37* Creat-1.7* Na-136
K-3.8 Cl-96 HCO3-28 AnGap-16
[**2115-5-4**] 06:18AM BLOOD Glucose-151* UreaN-41* Creat-1.9* Na-132*
K-4.0 Cl-95* HCO3-27 AnGap-14
[**2115-5-8**] 06:50AM BLOOD Glucose-134* UreaN-48* Creat-2.0* Na-133
K-4.2 Cl-95* HCO3-27 AnGap-15
[**2115-5-3**] 04:58PM URINE Hours-RANDOM UreaN-392 Creat-86 Na-42
[**2115-5-3**] 04:58PM URINE Osmolal-351
[**4-30**] CXR
FINDINGS: In comparison with the study of _____, there is
continued
enlargement of the cardiac silhouette in a patient with a
dual-channel
pacemaker defibrillator device. The pulmonary vascularity is
difficult to
evaluate, but is essentially within normal limits. Mild
elevation of the left
hemidiaphragmatic contour with atelectatic changes at the bases
and blunting
of the costophrenic angle. The upper lungs are essentially
clear.
[**5-1**] C. Cath
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
no obstructive coronary artery disease. The LMCA was normal. The
LAD had
minor luminal irregularities. The LCX had minor luminal
irregularities.
The RCA was a large dominant vessel, without angiographically
apparent
stenosis.
2. Resting hemodyanamics demonstrated elevated left and right
sided
filling pressures, with a LVEDP and RVEDP or 26mm HG and 17m Hg,
respectively, with a mean PCWP of 26 mm Hg. There was mild to
moderate
pulmonary arterial hypertension with a pressure of 48/24 mm Hg,
likely
secondary to the elevated PCWP. There was no evidence of
restrictive or
constrictive physiology. There was no evidence of an
intracardiac shunt
by oximetry. There was no significant gradient across the aortic
valve
on carefull pullback of the catheter from the left ventricle to
the
aorta. Systemic arterial pressures were in the normal range.
FINAL DIAGNOSIS:
1. No obstructive coronary arteries disease.
2. Elevated left and right sided filling pressures consistent
with
congestive heart failure.
Brief Hospital Course:
At [**Hospital1 18**], he had cardiac cath evaluation on [**5-1**] that revealed
clean coronaries and elevated left and right sided filling
pressures. On the floor he underwent agressive diuresis. On the
night of [**5-1**] he had an episode of VT/VF which was terminated w/
ATP followed by shock (ICD).
On [**5-1**] mexilitine and dofetilide were stopped with plan to
start amiodarone after wash out and plan of VT ablation on [**5-6**].
Patient was to be continued on heparin gtt and agressive
diuresis. On [**5-2**] patient had a run of VT/VF w/ resultant ICD
firing. EP was called and pt. was given 150mg IV bolus of
amiodarone. Following amiodarone bolus, pt. transiently became
hypotensive to the 70's, but returned to baseline w/o
intervention. Again 45 minutes later, pt. had a run of VT w/
resultant shock. He was transferred to the CCU for observation
and for further management.
.
In the CCU, patient was continued on amiodarone and lidocaine
gtt. On [**5-4**] he was started on amiodarone 400mg po bid. He was
diuresed wtih IV lasix, with goal I/Os even. On [**5-5**] the patient
was started on Mexelitine 150mg po tid. Lidocaine gtt and
amiodarone gtt stopped.
On discharge patient was maintained on mexelitine and amiodarone
po. EP recommeded tapering amiodorone to 300 mg daily.
# h/o atrial fibrillation: Coumadin was stopped. Patient was
placed on heparin gtt temporarily in anticipation of potential
EP ablation, which was not required in the end. Patient
restarted on Coumadin prior to discharge.
.
# PUMP: Chronic systolic heart failure with EF 20%, s/p BiV ICD
placement. Repeat TTE on this admission shows unchagned EF
20-25% dilated, LV with severe global hypokinesis. Mild signs of
fluid overload on exam, including ankle edema and elevated JVD.
Cath revealed elevated markedly elevated right (RA = 14 mm Hg)
and left heart (PCWP = 26mmHg) filling pressures consistent with
CHF. Patient was diuresed with lasix 80mg po daily with goal
I/Os even to negative 500cc. Continued on Carvedilol 6.25mg po
daily, Spironolactone 12.5mg po daily.
.
# Renal failure: Cr up to 2.3. Apparent baseline 1.5 to 1.7.
Likely due to DM and HTN. Also rising in the setting of
diuresis. Urine lytes were consistant with pre-renal failure.
Patient was discharged with plan to hold Lasix for 2 days and
then resume at a lower dose. He should continue to have regular
renal labs checked.
Medications on Admission:
Coumadin 5 mg daily
Metolazone 2.5 mg twice a week
Lasix 80 mg daily
Lidoderm 700 mg 5% patch daily
Imdur 7.5 mg daily
Spironolactone 25 mg daily
allopurinol 100 mg daily
Dofetilide 0.25 mg daily
Zocor 40 mg daily
carvedilol 12.5 mg b.i.d.
tramadol 50 mg t.i.d. PRN back pain
Glyburide
lantus 12 units daily
albuterol nebulizer p.r.n. cough
Discharge Medications:
1. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
2. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
9. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Twelve (12)
units Subcutaneous once a day.
10. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please take the dose that you were taking prior to admission.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
12. Outpatient Lab Work
Please have INR, BUN/Cr checked in 3 days. Please fax results to
PCP.
13. Amiodarone 100 mg Tablet Sig: 3-6 Tablets PO once a day: 600
mg per day for 7 days, then 300 mg daily.
Disp:*180 Tablet(s)* Refills:*2*
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: Start
on [**5-13**].
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6514**] Nursing Home
Discharge Diagnosis:
Primary diagnosis:
Ventricular tachycardia
Discharge Condition:
Stable. Normal sinus rhythm.
Discharge Instructions:
You were admitted with ventricular tachycardia, and your ICD
firing as a result. Your medications were changed, and currently
you are on Amiodarone and Mexiletene. You were briefly in the
CCU because of your fast heart rate and low blood pressure. This
was controlled with the above medications.
If you have worsening chest pain, shortness of breath,
palpitations, lightheadedness or any other symptoms please call
your primary care doctor or go to the emergency department.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Followup Instructions:
You have the following appointments
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2115-7-30**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2115-7-30**] 12:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2115-5-24**] 2:40
Completed by:[**2115-5-11**]
|
[
"5849",
"25000",
"42731",
"4280",
"2724"
] |
Admission Date: [**2195-2-24**] Discharge Date: [**2195-3-6**]
Date of Birth: [**2136-3-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
fever and MS change
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
This is a 58yoW with h/o end-stage multiple sclerosis, s/p total
colectomy [**11/2194**], transferred from [**Hospital3 2558**] with mental
status change, tachycardia 140bpm, and T 102. She is non-verbal
at baseline but communicates by head nod. On arrival to [**Hospital1 18**]
ED vitals 101.8, 139, 130/70, 22, 95%RA. Initial lactate 3.0.
She received 6L NS and LR in the ED and was treated with
levofloxacin/vancomycin/metronidazole. She c/o abdominal pain
that was sharp and constant (with prompting in questioning).
She c/o nausea but denied vomiting. CT abdomen/pelvis showed no
acute intraabdominal pathology. BP normalized with SBP 120s,
and she was admitted to the floor.
.
Soon after arrival to the medical floor her SBP dropped to 80s,
HR 110s. She received additional 3L NS. ABG 7.39/40/74 with
lactate 0.8. She continued to c/o abdominal pain, pointing to
pelvic region. Blood pressure normalized 120s/70s, however, she
became more tachycardic with HR 120s. She was transferred to the
unit where she was treated with aztreonam for urosepsis.
.
On presentation she nods yes to abdominal pain, denies headache,
chest pain, shortness of breath.
Past Medical History:
# Multiple sclerosis, dx [**2176**]. Her decline has only been in the
past 18 months. She went from fully communicative before to
nonverbal now. She was ambulating independently but started
using a cane, then a walker, and is now bedbound.
# s/p total colectomy + colostomy for "compaction and
infection," [**11/2194**] (at [**Hospital1 756**] and Women Hospital)
# UTI [**10/2194**]
# depression/mood disorder
# anxiety
# hepatitis C
# hepatitis B
# optic neuritis
# dysphagia
.
Social History:
lives at [**Hospital3 2558**]. Friends in the community serves as her
HCP
Family History:
not known (patient nonverbal)
Physical Exam:
VITALS: Tm/c 99.3 HR 109 BP 91/61 SBP 91-113 RR 24 97%RA
GEN: anxious, grimacing at times during PE, nodding
appropriately to yes/no questions
Skin: no rashes, + RLE heel skin breakdown
HEENT: PERRL, anicteric, OP clear, MMM
Neck: supple, no LAD, JVP flat
CV: tachy, regular, no mrg
Resp: CTAB, no crackles, sl [**Month (only) **] at bases, transmitted upper
airway sounds
Abd: +BS, soft, + ttp suprapubically, no rebounding/guarding,
G-tube, ileostomy bag
Ext: warm, well-perfused, contracted arms and legs, no edema,
1+ DP pulses B/l
Neuro: alert, appropriate, CN II-XII intact, can move BUE/BLE
with min arm movement and minimal toe wiggling, contracted with
increased tone, 2+-3 B/l biceps reflexes. + pain with leg
movement b/l (stable per nurse)
Pertinent Results:
[**2195-2-24**] 02:52AM LACTATE-3.0*
[**2195-2-24**] 03:00AM PLT COUNT-473*
[**2195-2-24**] 03:00AM NEUTS-65.7 LYMPHS-26.1 MONOS-5.9 EOS-0.2
BASOS-2.1*
[**2195-2-24**] 03:00AM WBC-17.2* RBC-4.62 HGB-15.1 HCT-45.5 MCV-98
MCH-32.7* MCHC-33.2 RDW-13.3
[**2195-2-24**] 03:00AM LIPASE-18
[**2195-2-24**] 03:00AM ALT(SGPT)-32 AST(SGOT)-44* ALK PHOS-72
AMYLASE-59 TOT BILI-0.4
[**2195-2-24**] 03:00AM GLUCOSE-105 UREA N-24* CREAT-0.4 SODIUM-140
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-25 ANION GAP-18
[**2195-2-24**] 04:03AM PT-11.8 PTT-24.7 INR(PT)-1.0
[**2195-2-24**] 04:43AM URINE RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE
EPI->50
[**2195-2-24**] 04:43AM URINE BLOOD-TR NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2195-2-24**] 04:43AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2195-2-24**] 06:51AM URINE MUCOUS-FEW
[**2195-2-24**] 06:51AM URINE 3PHOSPHAT-MOD AMORPH-FEW
[**2195-2-24**] 06:51AM URINE RBC-[**7-12**]* WBC-[**4-6**] BACTERIA-MOD
YEAST-NONE EPI-<1 RENAL EPI-[**4-6**]
[**2195-2-24**] 06:51AM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-MOD
[**2195-2-24**] 06:51AM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.028
[**2195-2-24**] 09:15AM NEUTS-58.7 LYMPHS-36.9 MONOS-3.6 EOS-0.3
BASOS-0.5
[**2195-2-24**] 09:15AM WBC-11.9* RBC-3.46*# HGB-11.7*# HCT-34.0*#
MCV-98 MCH-33.8* MCHC-34.4 RDW-13.6
[**2195-2-24**] 09:23AM LACTATE-1.4
.
CXR [**2-24**]: Right diaphragmatic elevation with bibasilar
atelectasis. An underlying consolidation is not excluded, and
dedicated PA and lateral chest x-ray is recommended.
.
CXR [**2-25**]: unchanged from prior
CXR [**3-1**]: Some right basilar atelectasis is demonstrated, but
no definite new infiltrate is seen. Fluid status is within
normal limits and unchanged. Cardiac silhouette is normal.
.
[**2-24**] CT Abd/Pelvis:
IMPRESSION:
1. No evidence of acute inflammatory process within the abdomen
or pelvis. Status post total colectomy with right lower quadrant
ileostomy.
2. Bibasilar airspace disease, likely atelectasis.
3. Left adrenal nodule, not completely characterized on this
examination, further evaluation with dedicated adrenal CT or MRI
is recommended.
4. Right hepatic hypodense lesion, too small to characterize.
.
LE USN: No evidence of lower extremity deep vein thrombosis,
bilaterally.
.
RUQ USN: Sludge and stones identified within the gallbladder. No
evidence of cholecystitis or biliary dilatation.
.
[**2-27**] Abd/Pelvic CT: 1. No significant change from study
performed three days prior, with no new acute inflammatory
process within the abdomen or pelvis identified.
2. Small bilateral pleural effusions with associated segmental
atelectasis, right greater than left.
3. Nodular appearance of left adrenal gland again not completely
characterized on this CT.
4. Unchanged small hypoattenuating lesion within the liver.
5. Tiny pulmonary nodule within the right lung. In the absence
of malignancy, followup imaging within a year would be
recommended to document stability.
.
abd XR:No evidence of obstruction or free intraperitoneal air.
Left basilar atelectasis.
Brief Hospital Course:
This is a 58yo woman with end stage multiple sclerosis
presenting with hypotension, tachycardia, fever, abdominal pain,
and mental status change which was diagnosed as urosepsis who is
s/p MICU stay, now on meropenem.
.
1. Fever, hypotension, and MS change: The patient's fever,
hypotension, and MS change were thought to be secondary to
urosepsis given her + UA. She had an elevated lactate on
admission and quickly became hypotensive. She was transferred to
the MICU, fluid resuscitated, and continued on
levofloxacin/vancomycin/metronidazole which was then changed to
Aztreonam given her allergy history when her UA came back
positive for proteus. A CXR was obtained and was concerning for
pneumonia vs atelectasis. However, given no h/o cough, sputum
production, chest pain, or SOB, or oxygen requirement, this
finding was attributed to atelectasis. The ddx also included
adrenal insufficiency since patient likely treated with steroids
for MS flares, and autonomic disregulation given h/o central
neurologic degenerative disease. A cortisol stimulation test was
preformed with a bump in cortisol level of only 6. However, at
this point the patient's hypotension had improved while on
empiric antibiotics. Urine and blood cx were negative. The
patient was hemodynamically stable with decreasing leukocytosis
and was transferred to the floor. She spiked with a bump in her
WBC ct and her coverage was broadened to meropenem and
vancomycin. She subsequently defervesced and her leukocytosis
resolved. She remained afebrile for > 48 hrs and vanco was
discontinued. She remained afebrile for an additional 48 hrs and
the patient was deemed well enough to be discharged on an
additional 7 day course of IV meropenem. The PICC line is ready
to use and may be pulled after completion of her 7 day course of
meropenem.
.
2. Tachycardia: the patient remianed in sinus tachycardia
througout the duration of her hospitalization. The differential
included anxiety, pain, resolving hypotension/infection, and PE.
Given the patients abd pain, pain seemed a plausible etiology.
LENIs were obtained which were neg for PE and the pt did not
have an O2 requirement. Her tachycardia improved during the
duration of her hospitalization.
.
3. Abd pain: The patient complained of persistent abdominal
pain throughout the course of her hospitalization. She had two
CT of abd/pelvis which were negative for obstruction, colitis,
pancreatitis, or abcess. Her LFTs were unremarkable. She was
stooling well through her ostomy. C diff was negative x 2. As
the patient had some skin breakdown around her ostomy site, this
was proposed to be the cause of her pain. She was also started
on Reglan with the thought that gastric motility may have been
affected, causing her abdominal pain and nausea. Also, the
epigastric location of her pain makes PUD a possible etiology.
Her PPI was increased to [**Hospital1 **] and her abdominal pain resolved
despite continued TTP upon exam.
.
4. MS: The patient has end stage MS. she was continued on
Copaxone and Baclofen per her outpt regimen.
Medications on Admission:
amitrytyline 50mg HS
calcium
vitamin D
fluticasone 50mcg 2 sprays daily
mvi
valproic acid 250mg/5mL syrup, 13mL [**Hospital1 **]
colace 100 [**Hospital1 **]
neurontin 300 tid
metoprolol 12.5 tid
tylenol 650 q6
baclofen 5 qhs
oxycodone 5 q6H prn
prilosec 20mg daily
Copaxone 20mg SC daily
Discharge Medications:
1. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY
(Daily).
6. Valproate Sodium 250 mg/5 mL Syrup Sig: Thirteen (13) ml PO
Q12H (every 12 hours).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
8. Gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO TID (3 times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours.
11. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO QHS (once a day (at
bedtime)).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
14. Glatiramer 20 mg Kit Sig: One (1) Kit Subcutaneous DAILY
(Daily).
15. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous every six (6) hours for 7 days.
16. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
urosepsis
Discharge Condition:
Improved. BP stable and pt afebrile.
Discharge Instructions:
Please return to the ER or call your PCP if you experience
increasing temperatures, change in mental status, or any other
symptoms that are of concern.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5351**] [**Telephone/Fax (1) 608**] upon
discharge.
Completed by:[**2195-3-6**]
|
[
"5990",
"2762",
"99592"
] |
Admission Date: [**2191-3-18**] Discharge Date: [**2191-3-25**]
Date of Birth: [**2191-3-18**] Sex: F
Service: NB
[**Known lastname **] [**Known lastname **] is the 1611 gram product of a 33 [**2-11**] week gestation
born to a 31-year-old G3, P2 now 3 mother. Prenatal screens:
A positive, antibody negative, hepatitis B surface antigen
negative, Rubella immune, GC negative, Chlamydia negative,
GBS negative. The infant was born in a car due to precipitous
delivery. EMT's arrived within a few minutes of life and
found the infant pink and vigorous. He was brought to the
[**Hospital 8641**] Hospital Emergency Department for stabilization. Of note,
mother has an admitted history of substance abuse but denied
recent history. In the emergency department the infant was noted
to be hypothermic, temperature 92.5, and hypoglycemic,
D-stick 30. He was warmed and given intravenous glucose with good
effect. He was started on CPAP for persistent grunting, chest x-
ray showed ground glass opacities. He was intubated with
improvement in aeration. He received morphine for intubation. He
had a CBC and blood culture drawn prior to receiving antibiotics.
The infant was transported to [**Hospital3 **] via the [**Hospital3 18242**] Transport Team on low vent settings in room air to 40
percent without incident.
PHYSICAL EXAMINATION: Anterior fontanel open and flat.
Clear breath sounds with good aeration. Regular rate and
rhythm. No murmur. Good femoral pulses. Abdomen soft,
nondistended. Positive bowel sounds, no hepatosplenomegaly,
patent anus, moves all extremities well.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Infant arrived to the Newborn Intensive Care
Unit intubated on vent support of 16/5, rate of 14 in room air.
He was extubated within 12 hours to CPAP. He remained on CPAP
for a total of 24 hours at which time he transitioned to room air
and remained stable in room air with occasional apnea and
bradycardia of prematurity. No methylxanthine therapy has been
required.
Cardiovascular: No cardiovascular incidents.
Fluid and Electrolytes: Birth weight was 1611 grams.
Initially he was started on 80 cc's per kilo per day of D10-W.
Enteral feedings were started on day of life one. He progressed
to full enteral feedings by day of life six and is currently
taking 150 cc's per kilo per day of Special Care 20. He
is tolerating feeds well. His discharge weight is 1500 grams.
GI: Peak bilirubin was 9.1/0.4 on day of life three. He
received phototherapy for a total of three days. Rebound
bilirubin was 5/0.3.
Hematology: Hematocrit on admission is 52, infant has not
received any blood products during this hospitalization.
Infectious disease: CBC and blood culture obtained on transport.
CBC was benign. Antibiotics were discontinued after 48 hours
negative blood culture.
Neurology: Has been appropriate for gestational age.
Sensory: Audiology: Hearing screen has not been performed
but should be done prior to discharge.
Psychosocial: [**Hospital3 **] Social Worker has been involved
with this mother. The contact social worker name is [**Name (NI) 36526**]
[**Name (NI) 6861**]. She can be reached at [**Telephone/Fax (1) 8717**]. A 51A has
been filed in light of concerns of history of drug abuse,
mother's refusal of a urine toxic screen on this infant and
previous two children not in custody of mother. [**Known lastname **] has
not demonstrated signs of neonatal abstinence. DSS has taken
custody of the infant. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 59150**] is the DSS supervisor involved
in the case. The mother has visited and is allowed to
continue visiting. She is currently homeless and trying to
obtain a place at the [**Last Name (un) 4114**] Family Shelter as well as entry
into a drug rehabilitation program.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To [**Hospital3 **] Special Care Nursery.
Name of primary pediatrician - not yet identified.
CARE AND RECOMMENDATIONS: Continue 150 cc's per kilo per day
of Special care 20. Advance in calories as required for
weight gain.
MEDICATIONS: Not applicable.
Car seat position screening has not been performed but should
be done prior to discharge. State Newborn Screens have been
sent per protocol.
IMMUNIZATIONS: The infant has not received any
immunizations.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet any
of the following three criteria.
1. Born at less than 32 weeks.
2. Born between 32-35 weeks with two of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
sibling.
3. With chronic lung disease.
Influenza immunizations 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 childs life
immunization against influenza is recommended for household
contact and out of home care givers.
DISCHARGE DIAGNOSIS:
1. Premature infant born at 33-1/7 weeks.
2. Mild respiratory distress syndrome.
3. Sepsis ruled out with antibiotics.
4. Mild hyperbilirubinemia, treated.
5. Apnea and bradycardia of prematurity.
6. Social Issues, in DSS custody.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern4) 55464**]
MEDQUIST36
D: [**2191-3-24**] 19:53:49
T: [**2191-3-24**] 20:42:09
Job#: [**Job Number 59151**]
|
[
"7742",
"V290"
] |
Admission Date: [**2111-10-11**] Discharge Date: [**2111-10-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Right hand numbness, dysarthria, chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 87 y/o woman with PMH notable for hypertension,
prior TIA, and paroxysmal atrial fibrillation (on coumadin) who
presents following several hours of right hand numbness and one
episode of aphasia earlier today. Patient notes first episodes
of right hand numbness last Thursday. Lasted several hours and
resolved on its own. This morning, woke up with right hand
numbness which eventually resolved over several hours. Then,
when the patient went to get iced coffee with her daughter, she
could not speak her intended words. At that time, her daughter
took her to [**Hospital3 **]. There, she had a head CT which
demonstrated acute on chronic SDH with mass effect. Though we do
not have records from [**Hospital1 5075**] ED, she was treated with
decadron and then transferred to [**Hospital1 18**] due to patient family
preference.
In our ED, the patient's initial vitals were T 96.7, BP 185/76,
HR 68, RR 16, 97% on RA. NSG was contact[**Name (NI) **]. She was given 1 U
FFP (infusing when brought up to floor). She was ordered for
hydralazine to be given as needed for SBP > 180 but this was not
given. At about 1430, she complained of [**6-13**] chest pressure
which did not radiate. This lasted about 2 minutes. EKG was
obtained, and she was given nitroglycerin and the pain resolved.
1st set of cardiac enzymes was negative.
On arrival to the MICU, the patient is without complaint. She
denies any numbness of the right arm or hand. She denies any
chest pain, difficulty breathing, or nausea. She denies any
current difficulty with speech or headache though does endorse
frontal bilateral headache for the past 5 days, intermittent in
nature, which is not typical for her. Denies any head trauma or
headache.
She is not particularly active at baseline; she walks at her
house and then around in the backyard. She is able to do this
without any shortness of breath or chest pain. She has had
several episodes of chest pain in the past few weeks, similar in
character, lasting minutes which resolve without intervention.
She does not report any dyspnea, diaphoresis, or nausea with
these episodes. She reports that the pain has come on at rest
and not with exertion per se.
Past Medical History:
* Hypertension
* s/p pacemaker ("passing out" spells, not sure indication)
* TIA in [**11-10**]
* Paroxysmal atrial fibrillation (on Coumadin)
Social History:
Patient lives with daughter. Previously worked as homemaker & in
her family's sub [**Location (un) 6002**] shop. No h/o smoking. Drinks one
alcoholic beverage per week. No illicit drug use.
Family History:
Mother and brother with "heart problems," thinks CHF. Son died
in 30s from brain tumor
Physical Exam:
VS - Temp 97.4 F, BP 152/77,HR 73, R 10, O2-sat 97% RA
GENERAL - alert, pleasant female, lying in bed in no distress
HEENT - PERRL, EOMI. MMM, tongue midline, symmetric palate
elevation.
NECK - no lymphadenopathy, JVP at 7 cm
LUNGS - clear bilaterally without any wheezes, crackles, or
rhonchi
HEART - RRR, systolic murmur at the LLSB
ABDOMEN - soft, normoactive bowel sounds, nontender to palpation
EXTREMITIES - 1+ pitting edema bilaterally, DP pulses 2+
bilaterally
NEURO - A&O X 3. CN II-XII intact. Strength 5/5 bilateral
biceps, triceps, hand grip, intrinsic hand muscles, hip flexors,
ankle dorsiflexion & plantarflexion. DTRs 2+ bilaterally at
biceps. Sensation to light touch intact bilateral upper & lower
extremities. No pronator drift. Finger to nose testing intact.
Pertinent Results:
<b>[**2111-10-11**] HEAD CT</b>
IMPRESSION: Predominantly chronic left subdural hematoma
measuring up to 1.8 cm from the inner table with mild associated
mass effect and midline shift. There is no evidence of
herniation.
<br>
<b>[**2111-10-12**] HEAD CT</b>
IMPRESSION: No significant change in chronic left subdural
hematoma. No
evidence for new hemorrhage or worsening of associated mass
effect.
<br>
<b>[**2111-10-13**] HEAD CT</b>
IMPRESSIONS: No change in extent of chronic left subdural
hematoma. However, foci of increased attenuation along its
inferior extent may represent a small amount of acute on chronic
bleeding. No change in mass effect on the left frontal cortex.
NOTE ADDED AT ATTENDING REVIEW: The slight apparent increase in
density within the inferior portion of the left subdural
hematoma may be due to changes in head position within the
scanner, rather than real appearance of new hemorrhage.
<br>
<b>[**2111-10-14**] HEAD CT</b>
IMPRESSION: No significant change in the extent or appearance of
the left
subdural hematoma. No increase in mass effect, midline shift, or
associated edema.
<br>
<b>EKGs</b>
[**2111-10-11**] 1400: A-V paced, no acute ST changes
[**2111-10-11**] 1635: sinus rhythm at 70, LAD, LVH, diffuse symmetric T
wave inversions in V3-6, biphasic T wave in V2, inverted T waves
in II, III, aVF
[**2111-10-11**] 2200: sinus rhythm at 80, LAD, symmetric inverted T
waves in V3-6, biphasic T wave in V2, inverted T waves in II,
III, aVF0
<br>
<b>[**2111-10-12**] TRANSTHORACIC ECHOCARDIOGRAPHY</b>
CONCLUSIONS:
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-10mmHg. Left ventricular wall thicknesses
and cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with near akinesis of the
distal half of the left ventricle. Basal segments contract well
(LVEF 30%). The apex is aneurysmal, but no masses or thrombi are
seen(but images quality is suboptimal). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened. No aortic stenosis is seen. Mild to moderate ([**2-4**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**2-4**]+) mitral regurgitation
is seen. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Extensive regional left ventricular systolic
dysfunction c/w multivessel CAD. Mild-moderate mitral
regurgitation. Moderate pulmonary artery systolic hypertension.
Mild-moderate aortic regurgitation.
<br>
<b>CARDIAC ENZYMES</b>
[**2111-10-11**] 02:30PM BLOOD cTropnT-<0.01
[**2111-10-11**] 09:25PM BLOOD cTropnT-0.08*
[**2111-10-12**] 03:55AM BLOOD cTropnT-0.09*
[**2111-10-13**] 04:12AM BLOOD cTropnT-0.15*
[**2111-10-13**] 04:45PM BLOOD cTropnT-0.10*
<br>
<b>MISCELLANEOUS LABS</b>
BASIC COAGULATION PT PTT Plt Ct INR(PT)
[**2111-10-17**] 09:20AM 13.8* 24.4 1.2*
[**2111-10-13**] 04:12AM 16.1* 26.6 1.4*
<br>
HEMATOLOGIC calTIBC Ferritn TRF
[**2111-10-11**] 09:25PM 352 34 271
<br>
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2111-10-12**] 03:55AM 161 721 49 3.3 98
Brief Hospital Course:
87 y/o woman with presenting complaint of right hand clumsiness
and dysarthria initially admitted to the MICU with an acute on
chronic subdural hematoma whit sequelae of TIA vs. seizure. Also
suffered an NSTEMI and a short period of pulmonary edema in
setting of systolic heart failure.
<br>
<i>## Acute on chronic subdural hemorrhage:</i>
Imaging at admission revealed small area of acute on chronic
subdural hemorrhage. Consulted neurology who felt that the
transient right hand clumsiness and dysarthria may have been the
result of a left pontine lacunar infarct/TIA, due to the SDH
directly or because of simple partial seizure caused by the SDH.
Neurosurgery was also consulted and initially felt that a Burr
hole would be indicated. While in the ED, she developed chest
pressure later found to be the sentinel symptom for NSTEMI.
Given the intervening NSTEMI, neurosurgery felt that although
she needed surgical drainage of her SDH, her cardiac issues
should be dealt with first and she was thus transferred to the
MICU. All anticoagulation was held and because she was treated
with coumadin at baseline, she was given vitamin K and received
a total of 5 units FFP with a goal of reducing INR below 1.4.
Her INR stabilized at approx 1.2 during the admission. Also,
because of her SDH, she needed permissive hypertension.
Originally, goal was systolic blood pressures to 160s-180s,
using pressors if needed. However, given her cardiac issues, it
was decided to make her goal 140s-160s and to avoid pressors. In
order to attempt optimal medical management of her NSTEMI,
aspirin was initiated at full dose 325 mg on morning of
[**2111-10-14**] with a 12 hour follow-up head CT showing possibility
of small new focus of acute bleeding. Aspirin was discontinued
and patient was transfused with two units of platelets. During
these interventions and studies, her mental status and neuro
exam was unchanged. On [**2111-10-16**] another Head CT was performed
and showed no concern for expanding size of SDH.
<br>
<i>## Seizure prophylaxis for SDH:</i>
She was loaded with dilantin and then given daily dilantin for
prophylaxis in setting of SDH. As her dilantin level was not
therapeutic (6.3) on the day prior to discharge, she received a
dilatin bolus and her maintenance dose was increased to 200 mg
in the morning and 250 mg in the evening. She was given
instructions upon discharge to have her dilanin level measured
on [**2111-10-20**].
<br>
<i>## NSTEMI:</i>
Patient had chest pain upon presentation to the ED with a
troponin zenith of 0.15 and question of EKG changes when
non-paced rhythm was present. Management was severely limited by
SDH in that there were restrictions on use of anticoagulation
and antiplatelet agents. Aspirin was initiated at full dose 325
mg on morning of [**2111-10-14**] and was then discontinued with no
plan to reinitiate antiplatelet therapy for reasons shown in the
"Acute on chronic subdural hemorrhage" section above. Patient
was placed on beta blocker and an ACE-inhibitor as her blood
pressure allowed. Patient was instructed to follow-up on her
hospitalization with her home cardiologist. Between outpatient
cardiology and outpatient neurosurgery, the indications and
risk/benefit ratio of futher anti-platelet therapy and
anticoagulation will need to be assessed.
<br>
<i>## Systolic Heart Failure:</i>
After talking to outpatient cardiology office, apperas to be
first documentation of this problem. ECHO on [**2111-10-12**] showed
extensive regional left ventricular systolic dysfunction c/w
multivessel CAD, mild-moderate mitral regurgitation, moderate
pulmonary artery systolic hypertension, mild-moderate aortic
regurgitation. She developed pulmonary edema while in the MICU.
After several days of gentle diuresis, patient was liberated
from supplemental oxygen and had not experienced symptoms of
dyspnea for 3 days prior to discharge. She was discharged on a
home regimen of furosemide with instructions to consult with a
physician if she had weight gain greater than 3 pounds from her
baseline.
<br>
<i>## Anemia:</i>
Baseline HCT unknown. Iron studies showed ferritin of 34, TIBC
of 352, and ferritin of 271, which is inconsistent with iron
deficiency. HCT at discharge on [**2111-10-17**] was 30.3 and had been
stable for approximately 5 days.
Medications on Admission:
fosinopril 40 mg daily
atenolol 50 mg daily
diovan 320 mg daily
isosorbide 30 mg daily
lasix 40 mg daily
nexium 40 mg daily
vesicare 5 mg daily
verapamil 180 mg daily
fosamax 70 mg weekly
coumadin 5 mg daily
lipitor 40 mg daily
calcium 600 mg [**Hospital1 **]
MVI daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week.
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One and a half Tablet Sustained Release 24 hr PO once a
day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Phenytoin 50 mg Tablet, Chewable Sig: 4 in morning and 5 at
night Tablet, Chewables PO twice a day: Please take 4 tablets in
the morning and 5 tablets at night.
Disp:*270 Tablet, Chewable(s)* Refills:*2*
7. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Acute on chronic subdural hematoma
Transient ischemic attack
Non ST elevation myocardial infarction
Paroxysmal atrial fibrillation
Acute systolic heart failure
Discharge Condition:
Stable, with no neurological sequelae.
Discharge Instructions:
You originally presented to an outside hospital with concern
about right hand clumsiness and difficulty speaking. You were
discovered to have an acute bleed in your head. You were then
transferred to our hospital. In the emegency department you had
chest pain and were later discovered to have an elevation in
some of your labs that indicated there had been damage to your
heart muscle. We monitored your heart rhythm, but saw no
concerning changes. You had no additional chest pain after your
episode in the emergency department.
Concerning your head bleed. We followed the severity of your
head bleed with serial head CTs. You had one concerning head CT
after starting aspirin and you were given a transfusion of
platelets. A repeat head CT was unconcerning for any changes
from the day prior. You should no longer take aspirin or
warfarin (coumadin) until you are cleared by neurosurgery to do
so. You will need to follow-up with Dr. [**Last Name (STitle) **] in neurosurgery the
week following discharge. You should call [**Telephone/Fax (1) 1669**] to set up
appointment for either [**2111-10-22**] or [**2111-10-23**].
Concerning your medications, we have made several changes. Due
to your recent head bleed, we stopped several of your
medications.
You should no longer take the following medications:
aspirin, warfarin (coumadin), fosinopril, atenolol, valsartan,
isosorbide, and verapamil
For your blood pressure, you are now taking:
lisinopril, metoprolol, furosemide
To prevent seizures related to the blood in your head, we
started you on a medication called phenytoin. You will have a
home health service visiting you to check on the levels of this
medication on [**2111-10-19**].
You may continue to take the nexium, multivitamins, calcium, and
fosamax as you were prior to hospitalization.
You need to follow-up with your primary care physician and your
cardiologist.
You have an appointment with Dr. [**Last Name (STitle) 48579**] on [**2111-10-26**]
10:15 A.M.
You have an appointment with Dr. [**First Name (STitle) **] Phone [**Telephone/Fax (1) 80081**] [**11-16**], [**2111**] 4:30 PM.
You need to follow-up with Dr. [**Last Name (STitle) **] in neurosurgery the week
following discharge. You should call [**Telephone/Fax (1) 1669**] to set up
appointment for either [**2111-10-22**] or [**2111-10-23**].
Should you have any chest pain, shortness of breath, fainting,
loss of consciousness, difficulty with speech or coordination,
severe headaches, visual changes, or other concerning symptoms,
please contact your doctor immediately or report to the
emergency department.
Followup Instructions:
APPOINTMENTS:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 48579**]
[**2111-10-26**] 10:15 A.M.
[**Location (un) 1121**] Physicians Group - 331 Highland, [**Hospital1 3597**]
[**Street Address(2) 80082**], [**Hospital1 3597**], [**Numeric Identifier 20777**]
Phone: ([**Telephone/Fax (1) 80083**] Fax: ([**Telephone/Fax (1) 80084**]
Cardiology: [**Last Name (LF) **],[**First Name3 (LF) **] C
Phone [**Telephone/Fax (1) 80081**]
[**2111-11-16**] 4:30 PM
Neurosurgery: Dr. [**Last Name (STitle) **]
Phone [**Telephone/Fax (1) 1669**]
Need to call to set up appointment for either [**2111-10-22**] or
[**2111-10-23**]
Completed by:[**2111-10-20**]
|
[
"41071",
"4280",
"42731",
"V5861",
"53081",
"4019"
] |
Admission Date: [**2138-11-14**] Discharge Date: [**2138-11-20**]
Date of Birth: [**2054-4-12**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9454**]
Chief Complaint:
PCP: [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 21883**], MD
.
CHIEF COMPLAINT: s/p mechanical fall
REASON FOR MICU ADMISSION: GI bleed
Major Surgical or Invasive Procedure:
EGD and colonoscopy on [**2138-11-17**]
History of Present Illness:
Ms. [**Known lastname **] is an 84 y.o. F with h/o falls, atrial
fibrillation on coumadin, chronic kidney disease stage IV, HTN,
and T2 DM, who presents s/p mechanical fall day prior to
admission. Pt fell down 1 step and slid down to her knees as she
was holding on to the door. Denied neck and back pain. Denies
loss of consciousness. She was ambulatory after the fall and
drove herself home, but the pain increased this AM in her left
knee. She complained of bilateral knee pain, L > R, and thus,
presented to the ED. She has noted darker colored stools for the
last 1-2 months, but denies BRBPR, hemorrhoids. Has 1 BM per
day. Denies lightheadedness, dizziness. Last colonoscopy > 10
years ago and reportedly negative.
.
In the ED, initial VS: T 97.5 HR 109 BP 162/62 RR 16 O2 100%RA.
VS in ED: 134-162/44-60, HR 88-109. Labs drawn, significant for
Hct 22 and INR 4.3. Knee X-rays and EKG performed. Rectal
performed by GI showed reddish tinged, dark brown, guiaic
positive. NG lavage negative. GI consulted. Pt given
oxycodone-acetaminophen 5/325 po x 1, pantoprazole 40 mg IV x 1,
Vitamin K 10 mg IV x 1, 2 L NS. Active T&S. Ordered for 2pRBC,
not hung. 2 large bore PIVs placed. Physical Therapy consulted
in ED and recommended home with PT.
.
Currently, she has L > R knee pain, [**6-22**], aching.
.
ROS: Denies fever, chills, cough, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria. + dark stools
Past Medical History:
- Type 2 Diabetes Mellitus
- Atrial Fibrillation on Coumadin
- Hypertension
- Hyperlipidemia
- Pulmonary arterial hypertension
- Chronic kidney disease
- Anemia
- Hyperparathyroidism s/p parathyroidectomy [**6-21**]
- Pelvic fracture lateral compression type I and a left proximal
humerus fracture [**10-21**]
- s/p Hysterectomy
Social History:
She never smoked. Last drink [**2-14**] glass of wine 1 week ago. Lives
with sister, walks on her own.
Family History:
Her mother had hypertension, died at 89. Her father had lung
cancer, died at 74. Denies colon cancer, colon polyps in family.
Physical Exam:
Vitals - T: 96.6 BP: 151/41 HR: 102 RR: [**9-28**] 02 sat: 96% RA
GENERAL: pleaseant, elderly female in NAD
HEENT: EOMI, anicteric, conjunctivae pink, MMM, no cervical LAD
CARDIAC: irreg irreg, no m/r/g
LUNG: CTAB, no w/r/r
ABDOMEN: NDNT, soft, 2 ecchymoses 3x3 cm on R mid abdomen and L
mid abdomen, NABS
EXT: no c/c/e, 2+ DP, L knee with inner ecchymoses and
ballotable swelling, R knees with ballotable swelling
NEURO: A&O x 3
DERM: no rashes
Pertinent Results:
Labs on admission:
LABS:
WBC 9.6
h/h 8.6/25 --> s/p 2U PRBC's
plts 228
INR currently 1.5 <-- 4.3 on presentation
Chems significant for glucose 53, BUN/Cr 106/3.6
.
B12 normal
.
Iron 58 (30-160)
TIBC 242 (260-470)
Ferritin 430 (13-150)
Transferrin 186 (200-360)
.
UA with negative blood, negative nitrites Lg LE, 168 WBC's, mod
bacteria, however was asymptomatic
.
By discharge
Hct had stabilized in the high 24's.
WBC 5.8
Plts 179
INR had decreased to 1.2
BUN/Cr was within baseline 63/2.8
Digoxin level normal 0.8
MICROBIOLOGY: None.
BILATERAL KNEE XRAYS (WET READ): No acute fracture or
dislocation. Unchanged calcinosis in bilateral compartment.
Subchondral cyst in superior pole of patella. Vascular
calcifications again noted. No large joint effusions.
.
[**2138-11-17**] GI Bx's
Colonic polypectomies:
A. Hepatic flexure:
Adenoma.
B. Transverse, polyp:
Sessile serrated adenoma.
Brief Hospital Course:
84 y.o. F with h/o falls, atrial fibrillation on coumadin,
chronic kidney disease, HTN, and T2 DM, who presents s/p
mechanical fall day prior to admission, incidentally found to
have worsening anemia with guiaic + stools in setting of
supratherapeutic INR.
1. GIB: Given negative NG lavage, guiaic positive reddish brown
stools on rectal, likely lower GI bleed; however, may also be
oozing from upper GI tract given supratherapeutic INR of 4.3.
Hemodynamically stable in ED. Pt received vitamin K IV 10 mg x 1
in ED. Patient received a total of 3U PRBC's. Hct remained
stable for >48 hours in the high 24's by the time of discharge.
No gross bleeding was seen after admission, no worrisome changes
in vitals signs. On [**2138-11-17**] the pt went for EGD/colonoscopy
which showed diverticuloses in colon and two polyps which were
removed with pathology as above. The prep was considered limited
and GI recommended a repeat colonoscopy for further evaluation
as well as a capsule endoscopy to evaluate the small bowel in
the near future. These procedures were deferred to the outpt
setting, and will need to be followed up on by the pt's PCP.
2. S/p mechanical fall--Pt had plain films showing no fracture.
She did have large effusions on the medial aspect of her
chronically arthritic knees. Pain was only an occasional
complaint during admission and was relieved with small amts of
narcotics, lidocaine patches, and Tylenol. Physical therapy came
to work with her both while she was in the unit, at which time
they cleared her for home with PT services, and also while she
on the floor, at which time they recommended the same. The pt
was seen to be ambulating the halls with a walker and able to
climb stairs without difficulty.
3. HTN--All HTN meds were held on admission. Subsequently
Propanolol and Valsartan were added back. However, other bp meds
Lasix, Hydralazine, and Nifedipine continued to be held and this
will need to be addressed by PCP. [**Name10 (NameIs) **] was ranging between
120-150 on the day of discharge.
4. Type 2 DM: Pt was seen to have 2 episodes of symptomatic
hypoglycemia which resolved with juice and crackers. Her insulin
regimen was made less aggressive on admission to the floor with
an regimen of NPH [**12-2**] in the am/pm and sliding scale insulin
as well. She felt that she was not eating as much as she does at
home. After this change she did not have any more episodes of
hypoglycemia. On discharge, we lowered her home regimen of
Humalog 75/25 from its original dose of 25/40 in the am/pm to a
lower dose of 15/30 in the am/pm. She stated she checks her
finger sticks often and would continue to do so until follow up.
This is another aspect of her care that will need to be followed
in the outpt setting.
5. [**Name (NI) 100757**] pt was maintained on Digoxin. A level was measured
at 0.8. Rate was also controlled with Propanolol which was added
back when her Hct was stable and it was clear she was not
bleeding. The patient had excellent heart rate control and no
episodes of RVR while admitted.
The pt's Coumadin was also held in the setting of active
bleeding, and was not restarted while admitted. Her INR was 4.3
on admission and 1.2 by discharge. This is another issue that
will need to be addressed by pt's PCP. [**Name10 (NameIs) **] has a high risk for
stroke according to CHADS2 and will likely need to be restarted,
however as was discussed, she also has a h/o falls. Therefore
risks/benefits will need to be weighed when restarting
anticoagulation. Currently the risks of a recurrent GIB and fall
appear to outweight the risk of stroke. This was discussed with
the patient and the patient agreed with the management.
6. [**Name (NI) 94062**] pt was seen to be chronically anemic, with a
picture consistent with anemia of chronic disease and was given
a dose of erythropoietin on the advice of her nephrologist. She
was NOT given a prescription for this on discharge and this will
need to be followed up, likely by her nephrologist or PCP.
7. Acute on Chronic Renal [**Name (NI) 94059**] pt's Cr on transfer from
the ICU was within limits of her baseline and by discharge was
also within limits of baseline. This was not an acute issue
while on the floor.
8. Hyperlipidemia--Continued home atorvastatin.
9. Hyperparathyroidism--Followed by Dr. [**Last Name (STitle) 13059**] at [**Hospital1 18**].
Continued Calcium and Vitamin D supplementation
# CODE: DNR/DNI (confirmed with patient)
IN CONCLUSION: For the outpt provider, [**Name10 (NameIs) **] are several
considerations after discharge.
1. We stopped her Coumadin in the setting of bleed, she has high
CHADS2 and will likely need to be restarted soon, but with the
understanding that she has now had at least 2 falls.
2. She had a GI bleed and her Hct was stable on d/c, please
check a Hct and make sure it is steady.
3. We have her back on 3 of her 5 home HTN meds (Valsartan and
Propanolol) but Lasix, Nifedipine, and Hydralazine were not
added back, please check her bp.
4. We changed her original insulin regimen as above to a less
aggressive regimen. Please follow up her finger sticks and
adjust accordingly.
5. She received Epogen while in house, may want to consider
continuing
Medications on Admission:
Atorvastatin 20 mg po daily
Digoxin 125 mcg po daily
Folic acid 1 mg po daily
Lasix 60 mg po daily
Hydralazine 67.5 mg po BID
Hydralazine 50 mg po qhs
Humalog 75-25 - 25 units q AM, 40 units q PM
Nifedipine ER 60 mg po daily
Propanolol SR 80 mg po daily
Valsartan 320 mg po daily
Coumadin 2.5 mg po daily or directed by [**Hospital **] Clinic
Calcium carbonate 1000 mg po QID
Tylenol OTC
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Suspension
Sig: One (1) injection Subcutaneous twice a day: Take 15U every
morning and 30U every evening.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*5*
7. Propranolol 80 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
8. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) dose
Injection QMOWEFR (Monday -Wednesday-Friday).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
CareGroup
Discharge Diagnosis:
Anemia due to acute blood loss, likely from GI tract
Trauma to knees due to mechanical fall without loss of
consciousness
AFib
Hypertension
Chronic Renal Insufficiency
Diabetes type 2
Hyperlipidemia
Discharge Condition:
By the time of discharge, the pt's Hct was stable, was not
losing blood from any source, vital signs were stable, pt was
taking good PO food and liquids, was ambulating with a walker,
and was medically clear for discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after a fall in which you injured
your knees. During your evaluation you were noted to have a drop
in your blood level and were also noted to have blood coming
from your GI tract. You were admitted to the intensive care unit
and given some blood products. After you stabilized, you
underwent a procedure to visualize your GI tract. The bowel prep
was poor and your GI tract was not properly visualized, however
your colon was seen to have diverticuli and also several polyps
were removed. The GI doctors [**Name5 (PTitle) 2985**] a repeat colonoscopy with a
better prep was warranted in the future.
CHANGES TO YOUR MEDICATIONS:
1. While you were admitted, your anticoagulation medicine
Coumadin was held because it can aggravate bleeding problems.
2. [**Name2 (NI) **] of your blood pressure meds were also held due to
concern of low blood pressures. You were kept on Digoxin,
Propanolol, and Valsartan, but Lasix, Hydralazine, and
Nifedipine were all held. You will need to follow up with your
primary care physician (PCP) to asssess your blood pressure and
whether you need to restart these meds.
3. Your insulin regimen was also made less aggressive as it was
seen that your blood sugars were occasionally too low. After
discharge, you should temporarily lower your insulin regimen to
Humalog Mix 75/25 --> 15 units in the morning and 30 units in
the evening. You should continue to monitor your blood sugars
and follow up with your PCP to evaluate your sugars--they may
need to be increased or decreased accordingly.
4. You were started on Erythropoietin shots, which will help
your bone marrow make more blood.
5. You were started on Vitamin D which contributes to bone
health
6. You were started on oral Pantoprazole which makes your
stomach less acidic
Please return to the hospital if you experience any fevers,
chills, night sweats, continued blood loss from your GI system,
or any blood loss anywhere, abdominal pain that does not
resolve, shortness of breath, chest pain, dizziness, new pain in
your knees or pain that is not resolved with medications, or any
other concerns.
Followup Instructions:
Please follow up with:
1. [**Company 191**] discharge clinic, [**Hospital Ward Name 23**] Building, [**Location (un) **] in [**Hospital Ward Name 5074**], [**Hospital1 18**]
Tuesday [**11-25**], 2:50pm
Have your hematocrit checked --> This is VERY IMPORTANT. Make
sure your healthcare provider knows what your hematocrit level
is. During this appointment please have them schedule you an
appointment with your PCP [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 21883**] who is also at [**Hospital **].
2. Dr. [**First Name8 (NamePattern2) 437**] [**Last Name (NamePattern1) 20540**]
GI fellow who performed your colonoscopy
Wednesday [**11-26**], at 3pm.
[**Location (un) 453**] [**Hospital Unit Name **] on [**Initials (NamePattern4) 1388**] [**Last Name (NamePattern4) **]
4. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] [**Name8 (MD) 20868**], NP in Nephrology
[**12-5**], at 10am
[**Last Name (un) **] Diabetes Center
Completed by:[**2138-11-20**]
|
[
"5849",
"2851",
"40390",
"42731",
"V5861",
"4168",
"2724",
"V5867"
] |
Admission Date: [**2182-2-1**] Discharge Date: [**2182-2-13**]
Service: MEDICINE
Allergies:
Gentamicin
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Aspiration
Major Surgical or Invasive Procedure:
Endotracheal intubation
IJ central line
PICC line placement
Blood transfusion x 2
History of Present Illness:
83 year old male with end stage parkinson's disease on 2L O2 at
baseline admitted with aspiration PNA. At the time of admission
the patient was a DNR/DNI. The plan was discussed with the
family, and the decision was made for intubation and full
treatment, everything short of CPR and shocks. He was
subsequently intubated. Sputum subsequently grew proteus and he
is being treated with a 10 day course of Zosyn (last day
[**2182-2-13**]). He was also diuresed while in the ICU. On the day of
transfer out of the ICU he was felt to be at well diuresed (and
bicarb rising) and his lasix was stopped. Of note, while in the
ICU he was noted to have bilateral red legs and LENI's were
performed. He was found to have a left DVT. A heparin drip was
started. He got his first dose of coumadin on [**2182-2-7**]. His
hemotocrit slowly trended down and he required 2 transfusions
during his ICU stay. His hct was stable at the time of transfer
to the medical floor.
Past Medical History:
Parkinson's disease/multisystem atrophy
Contracture of multiple joints
h/o blood clots
Mild heart arrhythmia
Dementia, likely Alzheimer
Depression
Bilateral heel ulcers
Benign prostatic hypertrophy
Social History:
He formally worked as an engineer and has a Master's Degree. He
has never smoked and rarely drinks alcohol. Lives in a NH at
baseline non-verbal and bed ridden.
Family History:
His parents died in their 80's of "natural
causes". His son has factor 5 mutations and a history of blood
clots.
Physical Exam:
GEN: NAD, lying in bed, non-verbal, appears chronically illl
HEENT: PERRL, anicteric, dry MM, op without lesions, poor
dentition
NECK: no LAD, no jvd
RESP: bronchial breathsounds throughout
CV: distant heart sounds difficult, no murmur appreciated
ABD: nd, +b/s, soft, G tube in place
EXT: pitting edema bilaterally, lower extremities wrapped in
bandages
SKIN: Stage 4 decubitus on sacrum
NEURO: severe contractions in all joints. non-verbal
Pertinent Results:
[**2182-2-1**] 09:10AM BLOOD WBC-5.7 RBC-2.78* Hgb-9.2* Hct-28.9*
MCV-104* MCH-33.2* MCHC-31.9 RDW-14.5 Plt Ct-283
[**2182-2-1**] 02:44PM BLOOD WBC-12.3*# RBC-2.84* Hgb-9.4* Hct-29.1*
MCV-103* MCH-33.2* MCHC-32.4 RDW-15.0 Plt Ct-327
[**2182-2-1**] 11:08PM BLOOD WBC-8.7 RBC-2.63* Hgb-8.5* Hct-26.1*
MCV-99* MCH-32.4* MCHC-32.6 RDW-15.9* Plt Ct-231
[**2182-2-11**] 06:14AM BLOOD WBC-10.6 RBC-2.86*# Hgb-9.2*# Hct-27.3*
MCV-96 MCH-32.3* MCHC-33.9 RDW-15.4 Plt Ct-294
[**2182-2-12**] 07:10AM BLOOD WBC-11.3* RBC-2.88* Hgb-9.7* Hct-28.0*
MCV-97 MCH-33.7* MCHC-34.7 RDW-16.0* Plt Ct-334
[**2182-2-1**] 11:08PM BLOOD Neuts-64 Bands-20* Lymphs-7* Monos-8
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2182-2-12**] 02:56PM BLOOD PT-15.0* PTT-63.9* INR(PT)-1.3*
[**2182-2-1**] 02:44PM BLOOD Glucose-125* UreaN-88* Creat-2.3* Na-139
K-4.5 Cl-103 HCO3-20* AnGap-21*
[**2182-2-2**] 04:57AM BLOOD Glucose-105 UreaN-80* Creat-1.7* Na-139
K-3.9 Cl-108 HCO3-23 AnGap-12
[**2182-2-2**] 06:36PM BLOOD Glucose-130* UreaN-77* Creat-1.4* Na-140
K-3.8 Cl-111* HCO3-22 AnGap-11
[**2182-2-9**] 05:35AM BLOOD Glucose-118* UreaN-27* Creat-1.0 Na-141
K-4.4 Cl-103 HCO3-31 AnGap-11
[**2182-2-10**] 06:47AM BLOOD Glucose-91 UreaN-26* Creat-1.2 Na-139
K-4.3 Cl-102 HCO3-34* AnGap-7*
[**2182-2-11**] 06:14AM BLOOD Glucose-179* UreaN-24* Creat-1.1 Na-134
K-3.8 Cl-96 HCO3-32 AnGap-10
[**2182-2-12**] 07:10AM BLOOD Glucose-115* UreaN-28* Creat-1.3* Na-138
K-3.9 Cl-100 HCO3-32 AnGap-10
[**2182-2-1**] 02:44PM BLOOD ALT-11 AST-25 LD(LDH)-153 AlkPhos-57
Amylase-53 TotBili-0.7
[**2182-2-12**] 07:10AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.2
[**2182-2-2**] 06:36PM BLOOD Ferritn-556*
[**2182-2-1**] 09:10AM BLOOD Cortsol-76.1*
[**2182-2-1**] 09:10AM BLOOD CRP-GREATER TH
[**2182-2-4**] 07:08PM BLOOD Vanco-12.5
[**2182-2-1**] 09:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2182-2-7**] 02:03PM BLOOD Lactate-2.0
.
CXR 1/18:1. Airspace opacities in the mid- and lower lungs,
bilaterally, likely represent pneumonic consolidation, possibly
due to aspiration.
2. Tip of endotracheal tube is 5 cm from the carina, in standard
position.
.
GTube check: There is a gastrojejunostomy tube seen projecting
over the mid lower abdomen with contrast being injected into the
jejunal loop.
.
CXR [**2-3**]: The ETT and CVL remain in place. There is no
pneumothorax. Stable appearance of bilateral infiltrates with no
significant interval change.
.
CXR [**2-7**]: In comparison to previous radiograph, the central
venous access line right has been removed. Both lungs show
slightly better transparency than yesterday, this is more
obvious on the right than on the left side. No evidence of newly
appeared pneumonia. No signs of cardiac decompensation. No newly
appeared opacities.
IMPRESSION: Status post removal of the central venous access
line right. Slight improvement of parenchymal consolidations.
.
CXR [**2-8**]: Compared to [**2182-2-7**]. Left-sided central venous line
tip remains in the proximal SVC without evidence of
pneumothorax. No significant change in bilateral parenchymal
opacities and likely left pleural effusion.
.
Sputum culture [**2-2**]
PROTEUS MIRABILIS. MODERATE GROWTH. PRESUMPTIVE
IDENTIFICATION.
YEAST. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- 2 I
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
MRSA nasal swab screen: pending at discharge
Urnialysis + for blood, but no infection. Culture pending.
Brief Hospital Course:
83M h/o end-stage Parkinson's presenting with sepsis likely from
aspiration PNA. He was admitted to the MICU. He was treated
with broad spectrum antibiotics, intubated, and given aggressive
IVF resuscitation. He improved on that treatment in the MICU,
and was extubated [**2182-2-8**]. He had sputum cultures that grew
P.mirabilis, that was sensitive to zosyn. He was transferred to
the medical [**Hospital1 **] that day after extubation. He was continued on
antibiotics and intermittent nasal and then oral suctioning.
Details are as follows:
# Respiratory failure. This was felt to be due to aspiration
pneumonia. As mentioned, he was treated with broad spectrum
antibiotics, and then narrowed to zosyn when culture were
positive, and he completed a 10 day course. He was treated
with as well while in the MICU with furosemide drip, and then
transitioned to PO oral lasix while on the medical [**Hospital1 **]. He was
given a face mask with humidified oxygen. He will need a follow
up xray in one month to assess interval change. He was
continued on his nebulizers.
# Anemia. His hematocrit was drifting down during his ICU stay,
with no clear cause. He was hemoccult negative. He had no
imaging studies consistent with a new bleed. There was concern
of bleeding while on the heparin gtt, but none was found. He
received two transfusions of PRBC without complications. His
hemolysis workup was negative. His hematocrit was stable upon
discharge.
# DVT: He was found to have a left sided LE DVT, and started on
heparin gtt with transition to warfarin. At the time of
discharge, he was trandsitioned to lovenox [**Hospital1 **] while continuing
the warfarin. His goal INR is [**2-17**], and he should be treated for
6 months.
# Rash: He developed a diffuse macular erythematous rash ,
blanching, by the time he was leaving the MICU. It was
suspected to be a drug rash, with Zosyn as the likely offender.
His Abx were scheduled to stop that day, and the rash started to
improve after that.
# Pressure ulcers: This was a CHRONIC problem. Wound care
consulted, Kinair bed was supplied, ensure adequate nutrition.
Zinc and ascorbic acid were given.
# Dementia: CHRONIC. Continue home dose of memantine 10mg daily
. He appeared to be back at his baseline by discharge.
# Parkinson: CHRONIC. Continuee home dose of Carbidopa-Levodopa
(Sinemet) and baclofen (to avoid baclofen withdrawal)
#FEN: He was fed via GJ tube. He had two studies done to ensure
proper placement.
#Prophylaxis: Bowel regimen, pantoprazole, heparin gtt until
therpeautic on coumadin.
#Access: Left PICC line.
#Code Status: DNR not DNI. Family would like to continue
intubation/treatment for two weeks, then reassess status. Son
confirms that if pt is extubated and needs reintubated (as long
as in two week period) would re-intubate. He does not want to
be shocked.
#Communication: Son [**Name (NI) 429**] [**Name (NI) 7229**], cell [**Telephone/Fax (1) 7230**], home
[**Telephone/Fax (1) 7231**]. [**Hospital3 2558**] 4floor nurses [**Doctor First Name 2013**] and [**Doctor First Name 7232**],
[**Telephone/Fax (1) 7233**].
Medications on Admission:
Polysporin powder topical
Hyoscamine prn for secretions
Morphine SL prn for pain
Acetaminophen prn
BIsacodyl 10mg pr prn
Mild of magnesia 30ml on Saturday
Namenda 10mg Daily
Prilosec 20mg Qdaily
Calcium carbonate 500mg Qdaily
Vitamin C
Baclofen 5mg TID
Carbidopa/Levodopa 25/100mg 2 tables TID
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Docusate Sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1) PO BID (2
times a day).
3. Thiamine HCl 100 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
5. Carbidopa-Levodopa 25-100 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO
TID (3 times a day).
6. Baclofen 10 mg Tablet [**Telephone/Fax (1) **]: 0.5 Tablet PO TID (3 times a day).
7. Memantine 5 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO daily ().
8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. Senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: 8.8 MLs PO BID (2 times a day)
as needed for constipation.
10. Ascorbic Acid 90 mg/mL Drops [**Last Name (STitle) **]: Five (5) ml PO BID (2
times a day) for 5 days.
11. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily) for 5 days.
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
13. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours).
14. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY16 (Once
Daily at 16): Please titrate to INR [**2-17**].
15. Furosemide 20 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO DAILY
(Daily): Please hold if SBP < 100.
16. Enoxaparin 80 mg/0.8 mL Syringe [**Month/Day (3) **]: One (1) injection
Subcutaneous Q12H (every 12 hours): Please continue while
transitioning to warfarin; overlap three days with therapeutic
INR.
17. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN
10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aspiration pneumonia
Respiratory failure
Sepsis
Acute renal failure
Drug rash (? zosyn)
Parkinson's disase
DVT
Discharge Condition:
Stable, requiring less suctioning, afebrile
Discharge Instructions:
You were admitted with aspiration pneumonia. You had a central
line placed, were intubated, and started on broad antibiotics.
You have recovered from the pneumonia. You were also found to
have a LE DVT (blood clot) and were started on coumadin and
heparin.
You should seek immediate medical attention if you experience
any concering symptom, such as shortness of breath, high fever,
chest pain.
You should continue the lovenox injections twice daily until
your INR is [**2-17**] for three days.
Followup Instructions:
Please follow up with the doctors at your rehab. You should
also see your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5351**] and [**Doctor Last Name **], as soon as possible
while at [**Hospital3 2558**].
|
[
"0389",
"5070",
"51881",
"5849",
"78552",
"99592",
"2859"
] |
Admission Date: [**2180-9-28**] Discharge Date: [**2180-10-3**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 84699**] is an 89 yo woman, normally independent, who was
found down by a friend the morning of [**9-28**]. She was found
responsive, but non-verbal and unable to move her right side.
Per her son, she was found lying in bed, shaking (there was an
apparent loss of consciousness). She was brought to an outside
hospital where a L frontal IPH with mm shift and a questionable
L
occipital bleed were seen. She was given 10mg IV labetalol and
transferred to [**Hospital1 18**] for further evaluation and treatment.
Since admission, she has been hemodynamically stable. She
underwent an MRI and repeat CT this AM. Per her nurse, she had
not had any witnessed movement of her right side. She was able
to state her name today but has not had spontaneous speech.
Past Medical History:
1. Hypertension
2. Hyperlipidemia
3. Anxiety
4. Hard of hearing (wears hearing aids)
Social History:
Widowed, lives alone in [**Hospital3 **].
Family History:
Father deceased in 50s from CAD. 2 Children deceased
from Lymphoma and Brain Tumor.
Physical Exam:
T= 97.5 BP= 107-139/45-62 HR= 72-95 RR=[**1-15**] O2= 100% on RA
PHYSICAL EXAM
GENERAL: NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. MMM. OP clear. Neck Supple. No nuchal
rigidity.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 3/6 SEM
best
at apex but referred throughout.
LUNGS: CTAB, good air movement bilaterally anteriorly.
ABDOMEN: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
EXTREMITIES: 1+ edema of the right foot, 2+ dorsalis pedis/
posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
Neurologic:
-Mental Status: Alert, responds to verbal stimuli. Answers some
but not all questions:
Are you [**Known firstname **]? "Yes"
Are you home? no response, facial gestures
Are you in a hospital? "yes"
Are you a Man? "yes"
Am I a boy? "no"
Unable to name low frequency objects such as pen or key.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk bilaterally. Unable to have patient
fixate for funduscopic exam.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Pt unable to report sensation.
VII: No facial droop, facial musculature symmetric.
VIII: unable to assess, no hearing aids in place.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: unable to assess
XII: Tongue protrudes in midline.
-Motor: Normal bulk, diminished tone on right. Moves left arm
without difficulty. No tremors. Moves left arm to command,
touches nose with left hand, does not move right arm or leg to
command. Sticks out tongue.
-Sensory: Grimaces to pain on right, withdraws on left.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 0 0
R 2 2 2 0 0
Plantar response was extensor on right, down on left.
-Gait: Deferred.
Pertinent Results:
[**2180-10-2**] 04:09AM BLOOD WBC-8.6 RBC-3.95* Hgb-11.3* Hct-35.0*
MCV-89 MCH-28.5 MCHC-32.1 RDW-15.0 Plt Ct-172
[**2180-9-29**] 02:59AM BLOOD Neuts-84.7* Lymphs-9.6* Monos-5.5 Eos-0.1
Baso-0.2
[**2180-10-2**] 04:09AM BLOOD Plt Ct-172
[**2180-10-1**] 06:50AM BLOOD PT-12.2 PTT-28.9 INR(PT)-1.0
[**2180-10-2**] 04:09AM BLOOD Glucose-144* UreaN-27* Creat-0.7 Na-142
K-3.6 Cl-107 HCO3-22 AnGap-17
[**2180-10-2**] 04:09AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.3 Cholest-198
[**2180-10-2**] 04:09AM BLOOD %HbA1c-6.3*
[**2180-10-2**] 04:09AM BLOOD Triglyc-118 HDL-55 CHOL/HD-3.6
LDLcalc-119
[**2180-9-29**] 02:59AM BLOOD CRP-22.4*
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2180-9-28**]
2:53 PM
REASON FOR EXAM: Intracranial bleed.
COMPARISON: CT from outside hospital from [**2180-9-28**].
TECHNIQUE: Multidetector CT images of the head were obtained
without
administration of IV contrast.
FINDINGS: Again seen there is intraparenchymal hemorrhage within
the
parasaggital aspect of the left frontal lobe, in the
distribution of the left
anterior cerebral artery, with no change in size. There is
surrounding
hypodensity extending to cortex, compatible with cytotoxic
edema. There is a
small area of hypodensity within the left occipital lobe, likely
encephalomalacia secondary to an old infarct, unchanged since
prior exam.
Extensive areas of white matter hypodensity, in the subcortical
and
periventricular regions of both cerebral hemispheres, likely
represent severe
chronic microvascular ischemic changes. Again seen there is
minimal rightward
shift of midline structures by approximately 2 mm. There is no
depressed skull
fracture. The visualized paranasal sinuses demonstrate air-
fluid level within
the left sphenoid sinus. The visualized mastoid air cells are
grossly clear.
The visualized orbits are grossly unremarkable. Incidental note
of a cavum
septum pellucidum is noted.
IMPRESSION:
Left frontal intraparenchymal hemorrhage with adjacent cytotoxic
edema, not
changed since the prior outside CT exam. Findings are likely
secondary to a
hemorrhagic infarct in the left anterior cerebral artery
distribution. MRI of
the brain is recommended for further evaluation, and to exclude
an underlying
mass.
Brief Hospital Course:
Ms. [**Known lastname 84699**] is an 89 yo woman, normally independent, who was
found down by a friend the morning of [**9-28**].
1. Stroke/IPH. The patient was initially seen by neurosurgery
for evaluation of IPH. This was found to be stable, and
non-surgical. She was evaluated by the Neurology service, and
it was suspected that she had an ACA infarction, with
hemorrhagic conversion. She had a CTA of the head which showed
no sign of vascular occlusion, and carotid dopplars, which
showed <40% stenosis. She had a TTE which showed mild HOCM, but
no evidence of thrombus or PFO. Her hemorrhage was evaluated
with serial CTs, and found to be stable, and she was started on
a full dose of aspirin. Repeat CT on the day of discharge
revealed stable and expected evolution of the hemorrhage without
evidence for extension following initiation of aspirin. She had
an A1C of 6.3%, total cholesterol of 198, with an LDL of 119.
Exam on discharge was notable for abulia. Pt was mute without
any verbal utterances. She was able to mimmick simple commands
such as lifting her left arms. Her right arm and leg are plegic.
Her left arm is full strength. She is able to dorsiflex her left
ankle with 4/5 strength, but unable to hold her left leg
antigravity. She grimaces to pain throughout.
2. Code status: DNR/DNI, confirmed with patient's children,
[**Last Name (un) 57792**] and [**Doctor First Name **].
Medications on Admission:
1. Lorazepam 0.5mg [**Hospital1 **]
2. Zocor 20mg PO Daily
3. Verapamil 240mg QD
4. Trazadone 50mg PO QHS
6. ASA 81mg Daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Verapamil 40 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
5. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: for positive UA in setting of foley
catheter.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34004**] Nursing Facility
Discharge Diagnosis:
Left frontal ACA stroke with hemorrhagic conversion.
Hypertension
Hyperlipidemia
Discharge Condition:
Non-fluent aphasia. Will nod and shake head in response to
questions. Holds left arm antigravity. Right arm is plegic.
Dorsiflexes left foot. Unable to hold left leg antigravity.
Right leg is plegic.
Discharge Instructions:
You were admitted because of right sided weakness and inability
to speak. You were found to have a left frontal stroke. You
were started on a full dose of aspirin to help prevent further
strokes. You had an ultrasound of the vessels in your neck,
which showed no sign of stenosis. You had an echocardiogram of
your heart which showed normal ejection fraction and an
indication to continue to control your blood pressure. Your
cholesterol is well controlled, and you should continue on
simvastatin.
If you notice worsening weakness, difficulty speaking, headache,
or any other new or concerning symptoms, please go to the
nearest ED for further evaluation.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] in the stroke neurology division at
[**Hospital1 18**].
Date/Time:[**2180-11-6**] 1:30
Phone:[**Telephone/Fax (1) 44**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"5990",
"4019",
"2724"
] |
Admission Date: [**2118-7-5**] Discharge Date: [**2118-7-10**]
Date of Birth: [**2039-11-2**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
male with aortic stenosis referred for further evaluation and
possible surgery. He was noted to have had dyspnea on
exertion for several months now with a positive stress test
that showed dyspnea and 2-mm ST segment depressions in leads
V4 through V6. Negative for chest pain, however. His ejection
fraction was noted to be was noted to be 63% at this time. He
did have a catheterization due to exertional symptoms and an
abnormal stress test in [**2114**]. It revealed a 40% mild LAD
lesion prior to the first diagonal and a 40% ostial D1 of
20%, D2 of 40%, RCA distally. The patient reports that he has
been having progressive dyspnea with exertion now for 2 years
and shortness of breath when shoveling snow or pushing a
lawnmower. It also occurs when he walks about 1 block. He has
not had any chest pain. He also has not had any claudication,
orthopnea, edema, PND or lightheadedness. No fevers, chills,
nausea or vomiting.
PAST MEDICAL HISTORY: Significant for hypertension,
hypercholesterolemia, and diabetes mellitus in addition to
benign prostatic hyperplasia, right DVT, hip arthritis, hard
of hearing. He has had an appendectomy in the past and a
circumcision as an adult and esophageal narrowing for which
he undergoes dilations every 6 months. No history of TIAs or
CVAs.
ALLERGIES: No known allergies.
PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile
with all vital signs stable. He was in no apparent distress
and comfortable in bed. Neuro revealed was alert and oriented
x 3 and following all commands. Pupils were equally round and
reactive to light, and he was anicteric. The neck was supple
with no lymphadenopathy or thyromegaly. Carotids were noted
to have a radiating murmur typical of aortic stenosis. The
lungs were clear to auscultation bilaterally. Heart was in a
regular rate and rhythm with a 4/6 systolic ejection murmur.
The abdomen was soft, nontender and nondistended with normal
active bowel sounds. The extremities were warm and well
perfused throughout. There was no clubbing, cyanosis or
edema. The pulses were 2+ throughout.
HOSPITAL COURSE: Thus, at this time the patient was admitted
for aortic valve replacement with Dr. [**Last Name (STitle) **] to take place
on the morning of [**7-5**]. This proceeded without any
issues, and the patient was brought to the CSRU afterwards.
He was noted to have some atrial fibrillation at this time.
He was on beta blockade again, Lopressor 12.5 b.i.d., and the
rest of his home medications were started. He was noted to
not require anticoagulation at this time as his rhythm
quickly returned to sinus. The patient was followed by
physical therapy as well who evaluated the patient and found
him to be fit for discharge to home when he was medically
cleared, and on postoperative day 3 the patient continued to
progress well with his pacer wires discontinued at this time.
His Lopressor was increased to 50 p.o. b.i.d. to control
rate, and he was noted to be increasing his activity with
physical therapy. His creatinine was 1.7 at this time, so his
Lasix was held. By the time of discharge it returned to
baseline at 1.3, and Lasix was restarted. On postoperative
day #5, the patient was deemed fit for discharge to home
without services, and there was noted some ankle swelling,
and so his Lasix dose was increased to 40 p.o. b.i.d. with
his creatinine now normalized.
DISCHARGE INSTRUCTIONS: The patient to keep wounds clean and
dry. The patient is allowed to shower but no bathing or
swimming until at least followup or until further notice. The
patient to take all medications as prescribed. The patient to
call for any fever, redness or drainage from the wound, chest
pain, shortness of breath or if there are any other questions
or concerns.
DISCHARGE FOLLOWUP: The patient to follow up with Dr.
[**Last Name (STitle) **] in 4 weeks and to call ([**Telephone/Fax (1) 1504**] to schedule an
appointment. The patient to follow up with primary care
doctor in 1 week to have laboratories drawn to check
electrolytes; specifically his potassium with his Lasix
restarted.
MEDICATIONS ON DISCHARGE: Colace 100 mg p.o. b.i.d.,
Protonix 20 mg p.o. daily, aspirin 81 mg p.o. daily, Percocet
5/325 1 to 2 tablets p.o. q.4-6h. as needed for pain,
atorvastatin 10 mg p.o. daily, terazosin 2 mg p.o. at
bedtime, amiodarone 400 mg p.o. b.i.d. x 7 days then 400 mg
daily x 7 days then 200 mg daily after that point, metoprolol
50 mg p.o. b.i.d., lisinopril 10 mg p.o. daily, furosemide 40
mg p.o. b.i.d. for 7 days, potassium chloride 20 mEq p.o.
daily for 7 days.
DISCHARGE DISPOSITION: The patient will be discharged to
home with visiting nurse assistance.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2118-7-10**] 12:29:46
T: [**2118-7-10**] 12:55:02
Job#: [**Job Number 28824**]
|
[
"4241",
"9971",
"42731",
"4019",
"41401",
"2724",
"25000"
] |
Admission Date: [**2152-9-21**] Discharge Date: [**2152-10-5**]
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
ischemic left leg
Major Surgical or Invasive Procedure:
angiogram with Tpa of PT artery [**2152-9-22**]
History of Present Illness:
Onset ofleft toe pain seven days prior to admission with known
pvd s/p bilaterl lower extremity bpg's ( left fem-PT with issvg)
with increasing leg and thigh pain 24hrs prior to admission.
Evaluated at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ER , no dopperable pulses left leg. IV
bolus heparin given and patient transfered to [**Hospital1 8482**] for further
evaluation.
Past Medical History:
history of dyslipdemia
histroy of CAD,3Vessel disease by cardiac cath with Aortic valve
stenosis
history of hyponatremia
histroy of ESRD [**1-22**] DM on hemodialysis (Tu,[**Last Name (un) **],Sat)
hisory of anemia of chronic disease
history of chronic systolic CHF,compensated
history of gout,asymptomatic
history of degenerative arthritis
histroy of lumbar disc disease s/p laminectomy
histroy of depression
histroy of DVT ? Lower extremity
history of polymyalgia rheumatica
histroy of nephrolithiasis
history of BPh
history of recurrent UTi
histroy of carotid disease [**Doctor First Name 3098**] <40%,[**Country **] nl
histroy of lucnar infract
histroy of left menisectomy
histroy of left inguinal herinaorrphy
Social History:
nursing home resident
former tobacco and ETOH abuser
Family History:
unknown
Physical Exam:
Gen: no acute distress, dementied
Lungs: CTA
Heart: RRR
ABD:bengin
EXT: Left cold from foot to knee with blue toes. poor capillary
refill. necrotic toe tips. Rt. Ext warm
pulse exam: palpable femorals bilateral.left DP monophasic graft
palpable at knee.rt. DP and Pt dopperable graft palpable.
Neuro: Ox1, nonfocal
Brief Hospital Course:
[**2152-9-22**] IV heparin. remained NPO for angio. Renal consulted for
hemodialysis needs.
angiogram with TPA of left Pt.IV heparin.
[**2152-9-23**] Found unresponsive on Am rounds.T max 100(ax) B/p 97/45
fasting glucose 66. IV dextros 50% administered 40% fase mask
applied with improvement in oxygenation. EKG no acute changes.
abg's obtained. Transfered to ICU.CVVHF began.CT head negative.
requiring Neo gtt.intubated for airway protection.
[**Date range (1) 75561**] remained in ICU.Neuro consulted for ? seizure
activity.Recommendations EEG r/o seizure disorde,MRI?MRA r/o
stroke, LP if febrile to r/o encephlitis( less likely given
clinical picture),continue ativan gtt. toxic-metabolic
encephlopathy secondary to lack of hemodialysis and azotrenam.
Inital and repeat EEG's did notdemonstrate any seizure activity
but did demonstrate severe encophalopathy.Ultrasounds of
carotids demonstrated bilateral < 40% internal carotid
stenosis.MRI of head and neck demonstrated no intracrainal mass
or hemorrhage. patent rt. carotid without disease but < 40% ICA
diseae on left.Dilantin gtt began.[**2152-9-27**] tunnel catheter
placed. Neo weaned. Remained on insulin gtt.Mental staus slowly
improving.[**9-29**] epo began at HD.Tube feed began.[**9-30**] labetolol
gtt for SBP HTN.[**10-1**] Family meeting made DNR.[**10-2**] labetolol
ggt weaned. Extubated .[**10-3**] Patient made CMO and transfered to
regular nursing floor for continued care.
[**2152-10-4**] Lost bed at nursing home awaiting new bed. CMO
continued. Rehab screen restarted
[**2152-10-5**] discharged for hospice care.
Medications on Admission:
imdur 30mgm daily
colace 100mgm [**Hospital1 **]
ducolax supp prn
minocycline 100mgm [**Hospital1 **]
gabapentin 100mgm [**Hospital1 **]
levothryoxine 50mcg daily
nepro caps daily
vitamin c
folic acid
lopressor 12.5mgm [**Hospital1 **]
pholso
asa 325mgm daily
lantus 6 units @ HS humalog sliding scale
simvistatin 80mg HS
clexa 10mgm HS
seroquel 12.5mgm q6h prn
regland prn
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Morphine 2 mg/mL Syringe Sig: [**12-22**] ml Injection Q2H (every 2
hours) as needed.
3. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: [**1-24**] ml Injection
Q8H (every 8 hours) as needed.
4. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Health of [**Hospital3 **] - [**Location (un) 32944**]
Discharge Diagnosis:
Ischemic left lower extremity pain
history of PVD s/p left fem-Pt bpg ISSVG
history of dementia
history of Dm2
histroyof hyperlipdemia
historyof coronary artery diseae 3 vessel by cardiac cath
history of aortic valve stenosis
history of hyponatremia
histroyof ESRD on hemodialysis
historyof chroinc anemia
histroyof chronic systolic congestive heart faillure,
compensated
history of gout
history of degenerative arthritis
history of DVT lower extermity
history of depression
history of polymyalgia rheumatica
historoy of nephrolithiasis
history of BPH,recurrent UTI's
history of lacunar infract with known carotid artery stenosis
history of disc disease,s/p lumbar laminectomy and discectomy
history of left menesectomy
history of right HD cath
history of inguinal hernia s/p repair left
histroy of perpheral vascualr disease s/p rt. sfa-dp bpg with
reversed GSV, complicated by wound infection s/p STSG, s/p left
fem-pt bpg ISSVG
Discharge Condition:
hemodynamically stable
Discharge Instructions:
followup as needed
Patient is DNR/DNI. Comfort measures only
Followup Instructions:
none
Completed by:[**2152-10-5**]
|
[
"40391",
"0389",
"4280",
"311",
"V4581",
"V1582",
"496",
"4241"
] |
Admission Date: [**2116-2-16**] Discharge Date: [**2116-5-27**]
Date of Birth: [**2116-2-16**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 65944**] was the 899 gram
product of a 25 and 6/7 weeks gestation born to a 34 year old
G2, P0, now 1 mother.
Prenatal screens - blood type O positive, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella immune, GBS negative.
PRENATAL HISTORY: Significant for rupture of membranes 10
days prior to delivery. Received full course of betamethasone
and antibiotics. Mother presented on day of delivery with
preterm labor and premature rupture of membranes with fetal
tachycardia. The infant was delivered by spontaneous vaginal
delivery, emerged vigorous with good cry, brought to warmer,
dried, suctioned and stimulated. Pink with good heart rate.
Apgars were 8 and 9 at 1 and 5 minutes respectively. The
infant was admitted to newborn intensive care unit.
PHYSICAL EXAMINATION: Anterior fontanel open and flat.
Palate and clavicles intact. Coarse breath sounds with fair
aeration. Mild retractions. Regular rate and rhythm. No
murmurs. Normal femoral pulses. Abdomen soft, nondistended.
No hepatosplenomegaly. No masses. Normal male genitalia.
Patent anus. Moves all extremities well. The infant was
symmetrically in the 50th percentile for his gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname **]
was admitted to the newborn intensive care unit and intubated
and received a total of 2 doses of surfactant, remained
intubated for a total of 2 weeks at which time he
transitioned to CPAP. He remained on CPAP until [**2116-4-1**]
at which time he transitioned to nasal cannula oxygen. He
remained on nasal cannula until [**2116-5-12**] when he
transitioned to room air (at 37 weeks corrected gestational age).
He continues to be stable in room
air. He was treated with caffeine citrate for management of
apnea bradycardia of prematurity. Caffeine citrate was
discontinued on [**2116-4-14**]. His last documented apneic
bradycardiac episode was on [**2116-4-24**].
CARDIOVASCULAR: [**Known lastname **] is status post indomethacin therapy
for patent ductus arteriosus. An echocardiogram was performed
on [**5-20**] demonstrating a normal study. No patent ductus
arteriosus with a small PFO. He presented with increasing
blood pressures on [**2116-5-19**]. Peak blood pressure was
136/86 with a mean of 99. He infant is currently on Captopril
of 2 mg PO t.i.d with good management of his blood pressures
(goal is systolics <105). A full cardiac evaluation revealed a
normal cardiac ECHO with pulmonary pressures less than half
systemic. A renal evaluation revealed likely renal etiology for
the hypertension and is discussed below.
FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was 899
grams, discharge weight is 3715g.
The infant was initially started on 100 cc per kg per day of
D10W. Enteral feedings were initiated on day of life 5 and
advanced to full enteral feedings over the next 10 days.
Maximum caloric intake was 150 cc per kg per day of breast
milk 30 calorie with ProMod. He is currently ad lib enteral
feeding breast milk concentrated to 26 calorie with NeoSure
powder. His intake PO is marginal and growth should be followed
closely.
He has had a history of osteopenia of prematurity, with elevated
alkaline phostphatase, no history of fractures. He was
suppplemented with Vit D for several weeks and that has been
discontinued. His most recent nutrition labs were on [**5-12**], Alk
phos 638, Ca 10.4, Phos 5.9. He should be continued on neosure
for increased Ca and Phos concentrations until 6-9 months of age,
although the concentration may be decreased for good growth or
increased intake. He should be evaluated closely if there is any
concern for fractures by clinical exam.
Due to the captopril and the risk for hyperkalemia, his
electrolytes have been followed closely recently. Most recent
set of electrolytes were drawn on [**5-25**],
and had sodium of 141, potassium of 4.9, chloride of 107, CO2
26, BUN 10, creatinine of 0.2. Thes should be followed weekly
initally.
GASTROINTESTINAL:Peak bilirubin 4.5/0.4; was
treated with phototherapy, resolved by day of life 12.
GENITOURINARY: The infant had onset of increased blood pressure
on [**2116-5-19**]. Renal team was consulted. Dr. [**Last Name (STitle) 6861**] from
[**Hospital3 1810**] renal team consulted on the infant. A renal
and adrenal US was normal, aldosterone was elevated at 75, and
renin level is still pending. A urine catecholamines were also
sent and are still pending (phone # for results 1-[**Telephone/Fax (1) 65945**],
[**Company 5620**]. A Ca/Cr ratio in the urine was slightly
elevated at 0.95. The infant had a DMSA scan which demonstrated a
left upper pole cortical defect, suggestive of microembolic
injury form his UAC at birth. It is recommended that a VCUG is
performed to rule out vesicoureteral reflux as a cause of the
renal injury noted on DMSA. Amoxicillin 75 mg PO prophylaxis was
started until reflux can be ruled out by VCUG. Dr. [**Last Name (STitle) 6861**] can be
reached at [**Telephone/Fax (1) 65946**]. He should be follow by a pediatric
nephrologist closely in [**State 9512**] (referral to UAB Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 65947**], phone #[**Telephone/Fax (1) 65948**].
HEMATOLOGY: Blood type is O positive, direct Coombs negative.
The infant received 1 packed red blood cell transfusion
during his hospital stay on [**2-27**]. His most recent
hematocrit on [**5-1**] was 32.8 with a reticulocyte count of
5.2%.
INFECTIOUS DISEASE: CBC and blood culture on admission
remained benign. Blood culture was negative at 48 hours at
which time ampicillin and gentamycin were discontinued. The
infant started receiving amoxicillin prophylaxis for possible VUR
on [**2116-5-23**]. He is receiving 75 mg PO daily.
NEUROLOGIC: The infant has had multiple head ultrasounds, the
most recent being on [**2116-5-15**]. The findings include a
small cyst in the right frontal region that appears to be in
the periventricular frontal lobe, just superior to the
caudate head. This is of uncertain etiology and significance.
There is also a tiny incidental choroid plexus cyst on the
left in the region of the foramen of [**Doctor Last Name 23609**] and there was also
a development of small mount of increased extra-axial fluid
along the vertex. This is also a nonspecific finding. The
infant has been appropriate for gestational age with no
neurological concerns.
SENSORY: Hearing screen was performed with automated auditory
brain stem responses and the infant passed.
OPHTHALMOLOGY: The infant was most recently seen on [**2116-5-18**] revealing stage 2, zone 3 in the right eye; stage 1,
zone 3 in the left eye (regressing). Recommended follow up in 2
weeks post discharge at UAB pediatric ophthalmology. The
ophthalmologist who was seeing the baby was [**First Name9 (NamePattern2) 65949**] [**Name (STitle) **]. She
is available at [**Telephone/Fax (1) 50314**].
PSYCHOSOCIAL: Social work has been involved with the family.
Parents have been involved in the infant's care.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: In the [**Doctor First Name **] Air Force base
pediatric clinic ([**Last Name (LF) **], [**First Name3 (LF) **]). Telephone No.: [**Telephone/Fax (1) 65950**].
[**Location (un) 25121**] Air Force Base [**Hospital **] Clinic
CARE RECOMMENDATIONS:
1. Feedings: Continue ad lib feeding breast milk
concentrated to 26 calorie with NeoSure supplementation.
2. Medications: Continue captopril 2 mg PO t.i.d. Continue
amoxicillin 75 mg PO daily.
3. Car seat position screening was performed and the infant
passed a 90 minute screen.
4. Immunizations received: The infant received Hepatitis B
vaccine on [**2116-3-17**], Pediarix on [**2116-4-19**],
HIB and pneumococcal 7-valent on [**2116-4-19**].
DISCHARGE DIAGNOSES:
1. Premature infant born at 25 and 6/7 weeks gestation.
2. Respiratory distress syndrome.
3. Rule out sepsis with antibiotics.
4. Patent ductus arteriosus.
5. Retinopathy of prematurity.
6. Hypertension.
7. Rule out vesico-ureteral reflux.
8. Anemia of prematurity.
9. Apnea bradycardia of prematurity, resolved.
10.Osteopenia of Prematurity
[**First Name11 (Name Pattern1) 3692**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 27992**], MD [**MD Number(2) 65951**]
Dictated By:[**Last Name (NamePattern1) 58682**]
MEDQUIST36
D: [**2116-5-27**] 00:37:27
T: [**2116-5-27**] 02:05:35
Job#: [**Job Number 65952**]
|
[
"7742",
"4019",
"V053",
"V290"
] |
Admission Date: [**2173-8-27**] Discharge Date: [**2173-9-1**]
Date of Birth: [**2116-3-26**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
woman with a history of type 1 diabetes, hypertension, and
coronary artery disease with a recent positive stress
thallium, who was in her usual state of health until
approximately 1 p.m. on the day of admission when she was at
work in a medical center where she is a medical assistant.
She stood up and suddenly felt unsteady with a "heavy
feeling," nausea without vomiting, diaphoresis followed by
chills, and then experienced sharp left-sided chest,
shoulder, pain lasting a few seconds. This was followed by a
heavy feeling in both arms for about two to three hours until
she reached the Emergency Room and was given three sublingual
nitroglycerin which relieved this arm heaviness.
At work where she was surrounded by nurses and doctors, when
her vital signs were taken she had a pulse of 80 and systolic
blood pressure of 120, and an electrocardiogram done there
revealed 1-mm ST depressions in I, aVL and V3 through V6. She
had no dyspnea, cough, fever, dysuria, or any recent skin
infections. Laboratories in the Emergency Room were
consistent with diabetic ketoacidosis including
hyperglycemia, increased anion gap acidosis and dehydration.
She was started on intravenous fluids, insulin drip,
nitroglycerin drip, heparin drip, aspirin, and Lopressor.
Her initial creatine kinase was elevated at 227; the next one
was 182 with a MB of 6, troponin less than 0.3
Additionally, in the Emergency Department she also had two
bouts of emesis. She reports she has never experienced chest
pain or been admitted diabetic ketoacidosis before.
PAST MEDICAL HISTORY:
1. Type 1 diabetes since childhood.
2. Hypercholesterolemia.
3. Hypertension.
4. Hypothyroidism.
5. Peripheral vascular disease, status post right lower
extremity bypass.
6. Echocardiogram in [**2173-6-20**] showed an ejection
fraction of 50% with focal hypokinesis of her basal inferior
wall and basal inferior septum, mild-to-moderate mitral
regurgitation, focal hypokinesis consistent with coronary
artery disease.
7. Stress thallium in [**2173-4-20**] without a nuclear report
showed inferolateral defect, partially reversible, 65 maximum
heart rate, 18,000 rate pressure product, 5.5-minute [**Doctor First Name **]
protocol, ejection fraction of 54%.
MEDICATIONS ON ADMISSION: Medications at home included
Diovan 80 mg p.o. q.d., Zestoretic 20 mg p.o. b.i.d.,
aspirin 81 mg p.o. q.d., Synthroid 125 mcg p.o. q.d., Humalog
insulin, insulin pump which the patient has been on for
approximately six years, atenolol 25 mg p.o. q.d.,
Lasix 40 mg p.o. q.d., and Prempro.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Father died of a cerebrovascular accident at
the age of 60. Mother died of congestive heart failure at
the age of 78. Brother died of cerebrovascular accident at
the age of 38.
SOCIAL HISTORY: The patient is married with two children.
She is a medical assistant. She quit smoking 26 years ago
and drinks occasional alcohol. She does not use drugs.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs were
temperature of 97.9, pulse of 80, blood pressure 170/80,
respiratory rate of 18, oxygen saturation of 98% on room air.
In general, an obese pleasant woman in no apparent distress.
HEENT revealed normocephalic and atraumatic. Pupils were
equal, round, and reactive to light. Extraocular muscles
were intact. The oropharynx was clear. Mucous membranes
were dry. Neck had no lymphadenopathy. Jugular venous
pressure 10 cm, trachea was midline. Cardiovascular revealed
normal S1 and S2. No S3. A 1/6 systolic murmur at the left
lower sternal border. Pulmonary was clear to auscultation
bilaterally, and No wheezes, rhonchi or crackles. Abdomen
was obese, soft, nondistended, decreased bowel sounds, and
nontender. No hepatosplenomegaly. Extremities were warm, no
edema. Pulses were intact bilaterally. Chronic venous
stasis changes bilaterally. Central nervous system revealed
alert and oriented times three. A nonfocal motor and sensory
examination. Rectal per Emergency Room report was
guaiac-negative.
PERTINENT LABORATORY DATA ON ADMISSION: Arterial blood gas
was 7.19/26/112 on 1.5 liters nasal cannula oxygen.
Laboratories at 6 p.m. revealed white blood cell count 13.3,
hematocrit 35.8, platelets 318; differential with neutrophils
of 85%, bands 0, lymphocytes 12.6%, monocytes 2.2%,
eosinophils 2.2%, basophils 0.5%. PT 12.3, PTT 22.4, INR 1.
Sodium 126, potassium 8.5, chloride 95, bicarbonate 10,
BUN 84, creatinine 2, glucose 779, anion gap 30. Creatine
kinase 227, 182. MB of 6. Troponin less than 0.3.
Urinalysis revealed specific gravity 1.018, no blood, nitrite
negative, no protein, greater than 1000 glucose, 15 ketones,
negative bilirubin, 0.2 urobilin, pH of 5, 0 red blood cells,
0 white blood cells, no bacteria, no yeast, less than
1 epithelial cell. Midnight laboratories were sodium 133,
potassium 6.1, chloride 101, bicarbonate 12, BUN 84,
creatinine 2, glucose 610, anion 26. Calcium 8.4,
phosphorous 4.5, magnesium 2.
RADIOLOGY/IMAGING: Electrocardiogram at work revealed sinus
rhythm at 80 with borderline first-degree AV block, normal
axis, 0.5-mm to 1-mm ST depressions in I, aVL, V3 to V6,
decreased voltage in limb and precordial leads, poor R wave
progression. No comparison to previous electrocardiogram.
Electrocardiogram in the Emergency Room revealed normal sinus
rhythm, 0.5-mm ST depressions as above.
Electrocardiogram post sublingual nitroglycerin revealed
normal sinus rhythm, ST depressions resolved, poor R wave
progression.
Chest x-ray on admission revealed no acute pleural or
parenchymal disease.
IMPRESSION: A 54-year-old woman with multiple cardiac risk
factors including hypertension, hypercholesterolemia,
diabetes, family history, and postmenopausal state, who
presented with anginal symptoms consistent with unstable
angina. Recent positive stress test with a reversible
inferior defect and electrocardiogram changes consistent with
anterolateral ischemia as well as diabetic ketoacidosis.
HOSPITAL COURSE:
1. CARDIOVASCULAR: (a) Coronaries: The patient was ruled
out for myocardial infarction with creatine kinases and
troponin being negative. She was placed on aspirin, heparin
drip, and nitroglycerin drip to be titrated to pain. Her
captopril was held on the first night but was started on the
second day of admission. A cholesterol panel was checked.
Lopressor 25 mg p.o. t.i.d. was started for blood pressure
control, and she was scheduled for cardiac catheterization on
[**Last Name (LF) 766**], [**8-30**]. Repeat electrocardiograms were stable.
On the second day of admission she was started on
captopril 12.5 mg p.o. t.i.d. Cholesterol panel revealed a
total cholesterol of 180, LDL 98, HDL 55, triglycerides 136
which were all within normal limits. She was not started on
a lipid-lowering drug.
The patient's cardiac catheterization on [**8-30**] showed
a right dominant heart with a patent left main coronary
artery, diffuse disease of 50% to 60% in the left anterior
descending artery, minimal-to-moderate disease, diffuse
disease in the left circumflex, and total occlusion of her
right coronary artery proximally with right-to-right and
left-to-right collaterals. They were unsuccessful at passing
a wire passed the stenosis and the procedure was terminated.
It was unclear of the age of the right coronary artery
stenosis, especially given the presence of collaterals. It
was recommended that she undergo an exercise thallium in the
near future to evaluate for reversible defects and to then be
evaluated for coronary artery bypass graft if she was at
increased risk; however, it was also felt that her exercise
thallium could be held off until she experienced angina
again.
On [**9-1**] the patient did have hyperkalemia at
approximately 5.7. There were electrocardiogram changes
consistent with hyperkalemia including no peaked T waves.
She was sent home on the following medications for coronary
artery disease, including aspirin 325 mg p.o. q.d. and
metoprolol 50 mg p.o. t.i.d.
(b) Myocardium: The patient had no evidence of congestive
heart failure on examination or on chest x-ray. Her oxygen
saturations remained stable as did her urine output, vital
signs, and weight. The patient was treated initially with
aggressive hydration for her diabetic ketoacidosis. She was
also aggressively hydrated prior to her cardiac
catheterization on [**8-30**]. She was started on
captopril on hospital day two. The patient was sent home on
Lasix 40 mg p.o. q.d. and Zestril 5 mg p.o. q.d.
(c) C-conduction: The patient had prolonged P-R on her
admission electrocardiogram. Her electrolytes were followed
closely and she was maintained on telemetry. She was
interview he unit for one night, and on hospital day two was
stable enough to be transferred to the floor. After her
cardiac catheterization on [**8-30**] she was found to have
a high potassium at 5.7; on repeat it was 5.5, and the
following day it remained elevated at 5.6. On the day of
discharge she was given 15 mg of Kayexalate and instructed to
have her potassium rechecked 48 hours after discharge. She
had no electrocardiogram changes with hyperkalemia including
no peaked T waves.
2. PULMONARY: The patient's pulmonary status remained
stable with stable oxygen saturations throughout her
hospitalization stay. Her chest x-ray on admission showed no
acute cardiopulmonary process, and despite her aggressive
hydration her pulmonary status did remain stable. She was
sent home on Lasix 40 mg p.o. q.d. as she was on at home
prior to admission.
3. ENDOCRINE: The patient was admitted with metabolic
status consistent with diabetic ketoacidosis. It was unclear
whether this precipitated her cardiac ischemia or whether the
cardiac ischemia precipitated the diabetic ketoacidosis.
Other causes for diabetic ketoacidosis were ruled out
including infection of various systems of her body with a
negative chest x-ray and negative urinalysis. The patient
remained afebrile throughout her hospitalization stay. On
admission she had severe hyperglycemia with an increased
anion gap and osmolar gap as well as hyperkalemia. As her
hospital stay progressed, her metabolic status stabilized
quickly. Her anion gap, potassium, and bicarbonate, and
glucose were all followed very closely including every hour
glucose checks for the first 48 hours. She was hydrated
aggressively with intravenous fluids and was on an insulin
drip for the first few hours of her hospital stay.
An Endocrine consultation was requested regarding input of
control of her diabetes with her background of using an
insulin pump for the last several years. The patient was
asked to bring in her own pump from home but while she was
waiting for this to arrive she was covered with a
sliding-scale Humalog for meals and NPH 15 units b.i.d., and
her insulin drip was weaned off on hospital day two. The
patient was asked for her input on insulin dosing as she had
a lot of experience with this. Her NPH dosing was increased
to 20 units b.i.d. On the morning of her cardiac
catheterization her NPH was halved as she was n.p.o.
On [**8-31**] the patient was instructed to resume her
insulin in the morning, and her NPH insulin was discontinued.
However, there was delay with installing her pump and she
became hyperglycemic with a glucose of greater than 400 for
several hours in the afternoon, requiring several units of
regular insulin sliding-scale. That evening she became
hypoglycemic with her glucose reaching to the 40s; however,
she remained asymptomatic and after receiving food and drink
by mouth her glucose normalized and her pump was functioning
appropriately as she was discharged home. The patient was
discharged on her regular dosing of insulin using the pump
and Humalog sliding-scale at meals.
The patient was continued on Synthroid and TSH was checked on
admission. She was also continued on her home dose of
Prempro. Her TSH was low at 0.18, and the patient was
advised to see her endocrinologist in the near future as an
outpatient to perhaps decreasing her Synthroid dose. She was
discharged on the same Synthroid dose that she was admitted
on of 125 mcg p.o. q.d.
4. RENAL: On admission, the patient's creatinine was 2.
Her baseline was unknown. This was thought to be secondary
to prerenal azotemia secondary to her dehydration from her
diabetic ketoacidosis. Her creatinine was followed closely
throughout her hospital stay. On admission her sodium was
falsely decreased secondary to her hyperglycemia but was
within normal limits after correction. Her urine output was
followed and remained stable. Her renal function continued
to improve with aggressive hydration. Upon discharge she was
advised to have her BUN and creatinine rechecked in 48 hours.
5. FLUIDS/ELECTROLYTES/NUTRITION: The patient was hydrated
aggressively on admission to treat her diabetic ketoacidosis.
Her electrolytes were followed closely. The patient was
initially n.p.o. and then her diet was advanced slowly on
hospital day two to a cardiac American Diabetes Association
diet which she tolerated well. Her renal function,
potassium, anion gap, and bicarbonate all continued to
improve. She was n.p.o. overnight in preparation for her
cardiac catheterization on [**8-30**] with her NPH halved
the morning of her catheterization. Her magnesium was
repleted as needed, and afterwards she resumed her regular
diabetic and cardiac diet without problems. She was hydrated
overnight prior to this procedure. After her catheterization
her intravenous fluids were discontinued. On [**8-31**]
she was found to be hyperkalemic, and on [**9-1**] she was
given 15 mg of Kayexalate to treat this. She was advised to
have the potassium rechecked as an outpatient in 48 hours.
6. PROPHYLAXIS: Zantac.
7. LINES: Peripheral IV.
8. CODE STATUS: Full code.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to home.
MEDICATIONS ON DISCHARGE:
1. Lasix 40 mg p.o. q.d.
2. Zestril 5 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Synthroid 125 mcg p.o. q.d.
5. Insulin pump per patient.
6. Humalog sliding-scale per patient.
7. Metoprolol 50 mg p.o. t.i.d.
DISCHARGE INSTRUCTIONS: The patient was to follow up with
her primary care physician and her cardiologist within one to
two weeks after discharge. She should have her potassium,
BUN, and creatinine rechecked on [**Last Name (LF) 2974**], [**9-3**]. She
was also advised to see her endocrinologist in the near
future to discuss her Synthroid dose.
DISCHARGE DIAGNOSES:
1. Unstable angina.
2. Diabetic ketoacidosis.
3. History of type 1 diabetes.
4. Hypercholesterolemia.
5. Hypertension.
6. Hypothyroidism.
7. Peripheral vascular disease.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2173-9-1**] 22:00
T: [**2173-9-5**] 14:38
JOB#: [**Job Number 21396**]
|
[
"41401",
"4019",
"2449",
"2724"
] |
Admission Date: [**2142-8-8**] Discharge Date: [**2142-8-31**]
Date of Birth: [**2081-4-1**] Sex: M
Service: SURGERY
Allergies:
Hayfever
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Chronic abdominal pain
Major Surgical or Invasive Procedure:
1. Pylorus-preserving Whipple's resection [**2142-8-23**].
2. Extended adhesiolysis [**2142-8-23**].
History of Present Illness:
This 61-year-old gentleman is well-known to me, as I have cared
for him for the last 6 months. He presented at that time with a
multiple month history of chronic abdominal pain and flare-up of
pancreatitis. These were biochemically proven flare-ups. He,
however, did not have good evidence of this on imaging, and
ultimately we went to an operative exploration to assess the
quality of the
pancreas to determine if he truly had pancreatitis. What we
found at that endeavor was a totally normal body and tail of the
pancreas and a firm, hard mass effect of the head and neck. We
placed a J-tube at that point, as this was a surprise finding,
and we were unprepared to do a Whipple procedure at that point
in time. He continued to get imaging which suggested a
stricturing effect in the genu of his pancreatic duct. He has
festered and lost weight for a
significant amount of time now, and has been basically
hospitalized for a few months with chronic pain from this. He
now requires a definitive operation for his abnormal pancreatic
head.
Past Medical History:
1. Acute on chronic pancreatitis with multiple admissions
2. Nephrolithiasis
3. Hypertension
4. CAD, bare metal stent to proximal LAD placement [**2142-4-12**] by
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25699**] at [**Hospital1 3278**] [**Telephone/Fax (1) 47432**]
5. s/p cholecystectomy
6. h/o RLE DVT in setting of cholecystectomy (completed 3 months
coumadin)
7. History of knee surgery
Social History:
The patient lives in [**Location 246**], he currently manages a
transportation company. The patient is married with 4 children
and 2 grandchildren. Tobacco: None; ETOH: none, Illicits: None.
Family History:
No family history of pancreatic pathology; Father: Died of Liver
cancer at age 62; Mother Died of heart disease in her 60's
Physical Exam:
On Admission:
VS: 98.1 65 133/70 18 99
GEN: In NAD
LUNGS: CTA(B)
COR: RRR
ABD: TTP in RLQ no overt peritoneal signs with some [**Last Name (un) **] in
left lower quadrant. Soft, ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.
.
AT Discharge:
VS: 99.1 PO, 73, 133/87, 18, 98% RA
GEN: Appears well in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **].
LUNGS: CTA(B).
COR: RRR
ABD: Subcostal chevron incision with steri-strips OTA c/d/i.
Appropriately TTP along incision, otherwise soft/NT/ND.
EXTREM: No c/c/e.
NEURO: Comfortable. A+Ox3. Non-focal/grossly intact.
SKIN: As above, otherwise intact.
Pertinent Results:
[**2142-8-8**] 07:05AM GLUCOSE-85 UREA N-15 CREAT-0.7 SODIUM-142
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-31 ANION GAP-9
[**2142-8-8**] 07:05AM ALT(SGPT)-39 AST(SGOT)-36 ALK PHOS-71
AMYLASE-40
[**2142-8-8**] 07:05AM LIPASE-50
[**2142-8-8**] 07:05AM CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-2.1
[**2142-8-8**] 07:05AM WBC-5.8 RBC-4.25* HGB-12.2* HCT-36.7* MCV-86
MCH-28.7 MCHC-33.3 RDW-13.8
[**2142-8-8**] 07:05AM PLT COUNT-248
[**2142-8-7**] 11:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2142-8-7**] 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2142-8-7**] 07:08PM GLUCOSE-110* UREA N-20 CREAT-0.8 SODIUM-140
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-14
[**2142-8-7**] 07:08PM ALT(SGPT)-32 AST(SGOT)-28 ALK PHOS-82 TOT
BILI-0.3
[**2142-8-7**] 07:08PM LIPASE-75*
.
[**2142-8-13**] CXR:
Chronic pancreatitis. The heart size is normal. The lungs
demonstrate bilateral lower lung linear opacities involving the
inferior aspect of the middle lobe and both lower lobes. No
pleural effusions are identified. Postoperative changes are
present in the cervical spine.
.
[**2142-8-22**] ECHO:
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level.
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. Borderline PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is elongated. 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 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
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2142-8-22**] ECG:
Sinus rhythm. Baseline artifact. Non-specific intraventricular
conduction
delay. Non-specific inferior T wave changes. Compared to the
previous tracing of [**2142-8-13**] inferior T wave changes and artifact
are new.
Bradycardia is absent.
Intervals Axes:
Rate PR QRS QT/QTc P QRS T
80 190 104 376/411 49 2 2
.
[**2142-8-23**] PATHOLOGY - SPECIMEN SUBMITTED: Jejunum, BLUE STITCH
PANCREATIC NECK MARGIN LONG GREEN STITCH AT SMA MARGIN LONG SILK
AT BILE DUCT:
DIAGNOSIS:
1. Segment of jejunum: no diagnostic abnormalities.
2. Whipple resection: duodenum and partial pancreas:
A. Focal acute and chronic pancreatitis with focal fat necrosis.
No evidence of malignancy.
B. Acute and chronic inflammation of common bile duct and
focally of pancreatic ducts.
C. Focal pancreatic intraepithelial neoplasia, low grade.
D. Six lymph nodes with no evidence of malignancy.
Clinical: Chronic pancreatitis.
Gross: The specimen is received fresh in two containers, both
labeled with the patient's name "[**Known firstname **] [**Known lastname **]" and the medical
record number.
Specimen 1: The specimen is additionally labeled "jejunum". It
consists of a segment of small bowel which is stapled at both
ends. It is 15.2 cm in length and 2.5 cm in average diameter.
The intestine is opened and reveals an unremarkable mucosa. The
serosal surfaces are grossly unremarkable. Representative
sections are submitted as follows: A=distal and proximal
margins, B=random sections.
Specimen 2: The specimen is received in a container additionally
labeled "blue stitch at pancreatic neck margin, long green
stitch at SMA margin, long silk at bile duct". It consists of a
pancreaticoduodenectomy specimen. The pancreatic portion is
composed of the head and neck of the pancreas and measures 2.8 x
4.5 x 2.5 cm. The duodenal segment measures 9.5 cm in length and
2.2 cm in average diameter. The posterior retroperitoneal margin
and pancreatic margin and uncinate margins are identified and
inked. The duodenum is opened along its length, opposite the
pancreas to reveal unremarkable tan mucosa. The ampulla is
identified and is probe patent. The common bile duct is
identified and is probe patent and opened along its length. The
pancreas is serially sliced to reveal tan cut surfaces. There is
a focal fibrotic area located in the distal neck of the pancreas
with an associated cystic area which abuts the peritoneal margin
and is 0.3 x 0.3 x 0.3 cm. This cystic area is filled with a
yellow soft substance. The remainder of the pancreatic
parenchyma is unremarkable. The peripancreatic adipose tissue is
removed and entirely submitted for potential lymph nodes.
Representative sections are submitted as follows: C=bile duct
margin, D=duodenal end, E=pancreatic neck margin, F=uncinate/SMA
margin, G=retroperitoneal margin, H=pancreas with duct,
I=ampulla, J-K=random pancreatic sections, L-W=peripancreatic
adipose tissue. W=contains the cystic area.
.
[**2142-8-29**] KUB/upright:
The visualized lung bases and heart appear normal. No free air
or ectopic gas is seen. No bowel distention is obvious without
any air-fluid levels present. Stool is seen within the ascending
colon and descending colon. Staples are seen that traverse
transversely across the abdomen. Clips in the right upper
quadrant suggest status post cholecystectomy. A peritoneal
drain is seen ending within the abdomen. No abnormal
calcification or ectopic gas is seen. The osseous structures
appear unremarkable.
.
[**2142-8-29**] CXR:
There is no evidence of free air below the diaphragms, within
the limitations of this study technique. The air-fluid level on
the left is most likely within the stomach. The abdominal drain
is partially imaged.
The upper lungs are clear. Bibasilar opacities in the lungs are
linear most likely consistent with atelectasis. There is no
appreciable pleural effusion. There is no pneumothorax. The left
PICC line tip is at the level of mid SVC.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the General Surgical Service on
[**2142-8-8**] for recurrent pancreatitis associated with chronic pain,
which was poorly controlled as an outpatient, and poor
nutrition. Upon initial admission, he was made NPO, started on
IV fluids, and given either IV Morphine or Dilaudid for pain
control. The patient was hemodynamically stable. During the
initial stage of this admission, pain management was a major
issue. The Chronic Pain Services was consulted early on, and
they followed the patient throughout his stay. Their
recommendations were greatly appreciated. Pre-operatively, the
patient's pain was ultimately well controlled on Dilaudid 8-12mg
PO Q3-4 Hours with episodic use of IV Morphine for breakthrough
pain. IV Dilaudid was substituted for PO Dilaudid when the
patient was NPO.
On [**2142-8-9**], an EGD/EUS was performed by Dr. [**Last Name (STitle) **] (GI), which
revealed an ill-defined hypoechoic area was noted surrounding
the PD stent in the head of the pancreas (this was mostly likely
secondary to stent related changes, however, neoplasm cannot be
ruled out) and a FNA was performed.
On [**2142-8-10**], the patient then underwent an [**Date Range **] with stent
removal. The previously described 8mm stricture in the genu was
still present. The patient recovered from the procedure without
complication. Post-procedural pancreatic enzymes remained
stable.
A PICC line was placed on [**2142-8-15**] for possible parenteral
nutrition, given poor nutritional intake prior to admission.
With improved pain control, the patient was able to advance his
diet pre-operatively to regular with fair to good intake. TPN
was ultimately not required. Pre-operative screening, labwork,
diagnotics, and consent were accomplished.
On [**2142-8-22**], the patient was brought to the OR for planned
pylorus-preserving Whipple's resection, which was aborted due to
asystolic arrest occurring at induction of anesthesia, likely
due to a transient vagal episode. He responded quickly to
rescusitation efforts, was transferred to the SICU, where he was
extubated shortly thereafter without residual complication.
Cardiology was consulted, and cleared the patient for surgery
the next day.
On [**2142-8-23**], the patient was again taken to the OR from the SICU
for planned pylorus-preserving Whipple's resection and included
extended adhesiolysis, which went well without complication
(reader referred to Operative Note for further details). After a
brief, uneventful stay in the PACU, the patient arrived on the
floor NPO with an NG tube, on IV fluids, with a foley catheter
and a JP drain in place, and a IV Ketamine for pain control with
good effect. Telemetry monitoring was continued
post-operatively without event. The patient was hemodynamically
stable.
On [**Date Range **]#1, the IV Ketamine infusion was adjusted, a Dilaudid PCA
was added, a Fentanyl patch was applied, and the patient was
started on IV Toradol for 2 days in consultation with the Pain
Service. His immediate post-operative pain was well controlled
on this regimen. The Ketamine infusion was discontinued by
[**Date Range **]#2.
He experienced severe, crampy abdominal pain on [**2142-8-29**], which
did not respond well to his pain regimen. Blood and urine
cultures ordered were unremarkable. The PICC was discontinued
with the tip sent for culture. Labwork stable. A KUB/upright did
not revealed an obstruction or free air, but stool was seen
within the ascending colon and descending colon. After initial
attempt at stimulating a bowel movement with oral agents and
both dulcolax PR and enemas, the patient finally experienced a
large bowel movement and complete relief of his abdominal pain
with digital disimpaction. A vigorous bowel regimen was
prescribed for constipation prophylaxis without further problem.
On [**Name2 (NI) **]#7, the Dilaudid PCA was discontinued, and the patient was
started on Dilaudid PO PRN in addition to the Fentanyl patch
with excellent pain control. It was this regimen with which he
was discharged.
After the NGT was discontinued, he was started on sips on [**Name2 (NI) **]#3.
His diet was progressively advanced to regular with good
tolerability. Foley catheter was discontinued on [**Name2 (NI) **]#3; he
voided without a problem. Telemetry was discontinued on [**Name2 (NI) **]#3;
he remained hemodynamically stable without further cardiac
complaint. The patient ambulated frequently, was adherent with
respiratory toilet. On [**Name2 (NI) **]#8, staples were removed, and
steri-strips placed.
At the time of discharge on [**2142-8-31**], 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 was discharged home without
services. He will follow-up with his own Pain Management
Specialist as an outpatient. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Multivitamin 1 tab PO daily, Omeprazole 20mg PO daily,
Hydromorphone 4mg 1-2 tabs PO Q3-4Hours PRN pain, Amlodipine 5mg
PO daily, Miralax 17gm in 8oz water daily PRN constipation,
Colace 100mg 1 cap PO BID, Metoprolol 25mg [**1-19**] tab PO BID,
Clopidorel 75mg PO daily, ASA 81mg PO daily.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**4-23**]
hours as needed for fever or pain.
2. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours) as needed for Acute on Chronic
Pain.
Disp:*10 Patch 72 hr(s)* Refills:*0*
5. Polyethylene Glycol 3350 17 gram (100 %) Powder in Packet
Sig: One (1) packet in 8oz water or juice PO once a day as
needed for constipation.
Disp:*30 packets* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3-4HOURS as
needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
11. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Chronic pancreatitis with chronic abdominal pain.
2. Dense adhesions of the bowel and liver and upper
abdomen.
Discharge Condition:
Stable.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain 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.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-27**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Surgery). Date/Time: [**2142-9-14**],
10:00am. Phone: ([**Telephone/Fax (1) 2828**]. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
Please contact your [**Name2 (NI) 1194**] Management Specialist to arrange a
follow-up appointment in the next 2-3 weeks.
Please call ([**Telephone/Fax (1) 60785**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) 60786**] (PCP) in 2 weeks.
Completed by:[**2142-8-31**]
|
[
"4019",
"41401",
"V4582"
] |
Admission Date: [**2181-7-23**] Discharge Date: [**2181-8-14**]
Date of Birth: [**2129-1-19**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: Patient is a 52-year-old woman
who was in her usual state of health until [**2181-7-22**] when
she was at a community fair and complained of a headache.
She was unable to express herself and collapsed. She was
taken to a local hospital where she was initially alert and
oriented. Became somnolent. She had a head CT which showed
subarachnoid hemorrhage. She became more somnolent and was
intubated en route for airway protection. She was
transferred to [**Hospital **] Medical Center ED. Her vital signs on
presentation: 166/76, heart rate 59, respiratory rate 16,
sats 100 percent. On exam, she was intubated, awake. Pupils
were 2 down to 1 mm bilaterally. She was following commands
and moving extremities times 4. She was agitated on the
ventilator and was therefore started on propofol drip. She
was given 100 grams of Mannitol. Blood pressure remained in
the 160s. She was started on a Nipride drip. She was loaded
with Dilantin and transported to [**Hospital1 190**] for further management.
PHYSICAL EXAMINATION: She was intubated, with no spontaneous
movement, unresponsive. HEENT: Anicteric. She had an
endotracheal tube in place. Neck was supple. Lungs: Clear
to auscultation anteriorly. Cardiovascular: Distant heart
sounds, regular rate and rhythm. Abdomen: Obese, soft,
nontender, nondistended. Extremities: No clubbing,
cyanosis, or edema. Neuro: Mental status - Unresponsive to
verbal stimuli, slight grimace to pain, does not follow
commands. Cranial nerve: No blink to threat. Pupils equal,
round, reactive to light; conjugate gaze; no doll's, no
corneal, no facial asymmetry, no gag. Motor: Slight
withdrawal of the left lower extremity greater than upper
extremity and no spontaneous movement. Sensory: Withdraws
to pain times 4.
LABORATORY DATA: CT shows subarachnoid hemorrhage with no
hydrocephalus and no ventricular blood. She had a
spontaneous subarachnoid hemorrhage, most likely aneurysmal
bleed. She was still unresponsive but recently treated with
Versed and vecuronium before transport. Sedation was
discontinued. She had a CTA of the head. She was started on
nimodipine, continued on Dilantin.
Off sedation, patient was examined today. Her exam was much
improved. She was awake, alert, following commands, pupils 2
mm and sluggish. She had positive corneas, positive blink to
threat, withdrew all 4 extremities briskly with stimulation
and moved extremities to command. She localized the pain.
CT again showed subarachnoid hemorrhage, left greater than
right, with no hydrocephalus. CTA: Question of fullness of
the A-comm. Patient had a ventricular drain placed and was
taken for angio.
Patient underwent a coiling embolization of a ruptured A-comm
aneurysm on [**2181-7-24**] without complication. The patient's
drain was opened at 10 cm above the tragus, and her blood
pressure was kept less than 130.
Post coiling, her exam: Pupils were 2 down to 1.5, she
opened her eyes to command, wiggles her toes easily to
command, weak grasp bilaterally with much encouragement,
blood pressure was kept less than 130.
On [**2181-7-25**] the patient was taken to the Operating Room for
clipping of a second non-ruptured aneurysm on the A-comm
artery. Patient tolerated the procedure well, without
complication. Postop, vital signs are stable. She was
awake, alert, following commands, moving all extremities,
able to show thumbs up, prior CP was 9 to 10, CBP 10 to 11.
She was monitored again in the ICU.
On [**2181-7-26**] the patient was extubated. She was awake,
alert, following commands, moving all extremities. Her blood
pressure was increased to the 150 to 160 range, and she was
seen by the Cardiology Department due to having episodes of
tachycardia and 1.4 second pauses and escaped beats.
On [**2181-7-26**] patient had a head CT that showed decreased
size of ventricles compared to [**2181-7-24**]. Patient has
remained stable, was out of bed with P.T., started on a
regular diet. Blood pressure continued to be in the 140 to
160 range, and goal CBP 10 to 12. Patient still having
episodes of SVT. Cardiology recommended just watching it.
Patient had adequate escape beat to get her out of the
rhythm. Patient was also treated with flecainide for the
runs of SVT and given intermittent doses of metoprolol and
labetalol for episodes of SVT.
Vascular Surgery was consulted on [**2181-7-30**] for placement of
an IVC filter. A temporary filter was placed and the patient
tolerated the procedure well, without complication on
[**2181-7-30**]. Patient continued to have episodes of SVT, and
flecainide was increased to t.i.d. The patient was ordered
for a TTE. Patient's echo showed a decreased EF thought
maybe secondary to neurocardiogenic effect of the hemorrhage.
Flecainide was stopped and the patient was treated with
amiodarone.
Patient's neurologic status continued to remain stable. She
was awake, alert, oriented times 3, with no drift. Strength
was [**3-21**] in all muscle groups on [**2181-8-1**]. Continued to
have frequent bursts of SVT. On [**2181-8-1**] the patient was
taken for angio for assessment of aneurysm clipping and she
was assessed for vasospasm. Patient did have diffuse
vasospasm, moderate, in the right MCA/ACA region and left
MCA/ACA region. Triple H therapy was continued, although
patient's EF was low. The patient was requiring large
amounts of Neo-Synephrine to keep her blood pressure in the
appropriate range. The patient was started on albumin but
went into respiratory distress and required intubation on
[**2181-8-2**].
Chest x-ray on [**2181-8-2**] showed bilateral consolidation.
Head CT on [**2181-7-31**] was stable. She was started on
dobutamine and continued on amiodarone and metoprolol for her
runs of SVT.
On [**2181-8-1**] the patient had Enterobacter in her urine. She
also had gram-positive cocci in her CSF. Infectious Diseases
was consulted on [**2181-8-4**] due to the gram-positive cocci in
the CSF. Patient is also currently on Zosyn for broad
coverage for pneumonia and on vancomycin for treatment of
shunt infection of the CSF. Patient was started in
intracecal vancomycin. The vent drain was removed and a
lumbar drain was placed. Despite problems with intubation
and pneumonia, the patient's neurologic status continued to
remain stable. Patient was moving all 4 extremities,
following commands, pupils were equal, round, and reactive to
light.
On [**2181-8-7**] patient had a head CT which showed evolution of
subarachnoid blood with no hydrocephalus. Lumbar drain was
draining 10 to 15 cc an hour and patient continued on
vancomycin and Zosyn for antibiotic coverage.
Patient was extubated on [**2181-8-8**]. Chest x-ray showed mild
CHF. Head CT was stable. Patient continued on Zosyn for
pneumonia, continued on vancomycin. Patient was transferred
down to the Step-Down Unit on [**2181-8-10**]. Neurologically,
she remained stable, continuing on the Zosyn. Vancomycin was
discontinued and ampicillin 2 grams q. 6. Started. Coag-
negative staph on the shunt tip is most likely with
contamination. Patient was awake, alert, and oriented times
3. Face is symmetric. She had no drift. Her strength was
[**3-21**] in all muscle groups. She was seen by physical therapy
once she arrived on the floor, was out of bed, ambulating.
On [**2181-8-12**] ID recommended discontinuing the Zosyn and
starting ampicillin. Nimodipine was discontinued on
[**2181-8-13**]. The patient had neurologically remained stable
and is ready for transfer to rehab.
DISCHARGE MEDICATIONS:
1. Ampicillin 2 grams IV q. 6h.
2. Lansoprazole 30 p.o. once daily
3. Percocet 1 to 2 tabs p.o. q. 4h. p.r.n.
4. Vancomycin 1250 IV q. 12 hours
5. Miconazole 2 percent powder topically p.r.n.
6. Sodium chloride 2 grams p.o. t.i.d.
7. Amiodarone 400 mg p.o. b.i.d. Apparently patient is
receiving amiodarone 200 mg p.o. t.i.d. for 2 weeks, then
on [**2181-8-19**] she should drop down to 200 mg p.o. once
daily.
8. Heparin 5000 units subcutaneously t.i.d.
9. Colace 100 mg p.o. b.i.d.
10. Insulin sliding scale
The lumbar drain was discontinued on [**2181-8-13**], and the
patient remains on ampicillin 2 grams IV q. 6h.
DISCHARGE CONDITION: Stable.
FOLLOW UP: Dr. [**Last Name (STitle) 1132**] with a repeat head CT in 2 weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 6583**]
MEDQUIST36
D: [**2181-8-13**] 11:30:03
T: [**2181-8-13**] 12:18:28
Job#: [**Job Number 57018**]
|
[
"486",
"5990",
"4280",
"42789",
"4019"
] |
Admission Date: [**2170-7-15**] Discharge Date: [**2170-7-17**]
Date of Birth: [**2103-1-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
67 year old haitian male with pmh of hypertension was admitted
from OSH after waking up this morning with acute shortness of
breath/chest pressure.
.
He had previously been well with no prior episodes of dyspnea or
chest pain. He woke up at 6:30 AM with dyspnea that
progressively worsened (after taking a shower), which prompted
him to call 911. He denied having any associated chest pain,
nausea, vomiting, or diaphoresis. He also denied any recent
fevers, cough, or respiratory infections.
He was taken by ambulance to [**Hospital3 4107**]. His symptoms
improved on O2 administration and SL ntg in the ambulance. His
troponin I was 0.07, and CK-MB = 6 (CK = 500), and his ECG
showed a LBBB pattern. A subsequent ECG showed RBBB with AV
dissociation. He ruled in for an NSTEMI, and started on an ACS
protocol with ASA, lopressor, NT paste, plavix, integrillin, and
heparin.
He was trasferred in the PM to [**Hospital1 18**] CCU for further evaluation.
On arrival, he was in no acute distress and denied any
sob/cp/n/v. His vital signs were: 126/89, P89. 98% on 4L n/c
Past Medical History:
Hypertension
Social History:
Social history is significant for the absence of tobacco use.
There is no history of alcohol abuse.
He speaks Creole
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T 97.9/97.8 , BP 133/73 (115-133)/(69-73), RR (18-22), O2Sat
= 97% on 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 with no elevated JVP.
CV: RRR, normal S1, S2. No S4, no S3. Mild systolic decrescendo
murmur heard at lower right sternal border.
Chest: No chest wall deformities, scoliosis or kyphosis. Poor
air movement. Bilateral crackles at the base, no wheezing.
Abd: Protuberant, soft, NTND, No HSM appreciated. Bowel sounds
heard in four quadrants. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; 1+ PT/DP
Left: Carotid 2+ without bruit; 1+ PT/DP
Pertinent Results:
[**2170-7-15**] 11:17PM CK(CPK)-977*
[**2170-7-15**] 11:17PM CK-MB-10 MB INDX-1.0 cTropnT-0.02*
[**2170-7-15**] 11:17PM PT-13.9* PTT-86.4* INR(PT)-1.2*
[**2170-7-15**] 02:35PM GLUCOSE-102 UREA N-15 CREAT-1.2 SODIUM-143
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-28 ANION GAP-13
[**2170-7-15**] 02:35PM estGFR-Using this
[**2170-7-15**] 02:35PM CK(CPK)-975*
[**2170-7-15**] 02:35PM cTropnT-0.03*
[**2170-7-15**] 02:35PM CK-MB-11* MB INDX-1.1
[**2170-7-15**] 02:35PM CALCIUM-9.2 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2170-7-15**] 02:35PM WBC-5.1 RBC-4.57* HGB-15.6 HCT-46.1 MCV-101*
MCH-34.1* MCHC-33.8 RDW-14.2
[**2170-7-15**] 02:35PM NEUTS-63.1 LYMPHS-28.7 MONOS-5.5 EOS-1.8
BASOS-0.8
[**2170-7-15**] 02:35PM PLT COUNT-229
[**2170-7-15**] 02:35PM PT-13.6* PTT-118.6* INR(PT)-1.2*
EKG demonstrated LBBB pattern with QS on V1/V2, with significant
change compared with prior EKG from several hours earlier in the
day which demonstrated RBBB plus left anterior fascicular block
with AV dissociation .
ECHO [**2170-7-16**]
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated with moderate to severe global left
ventricular hypokinesis (LVEF = 25 %). The lateral wall and
basal anterior wall contract best. No masses or thrombi are seen
in the left ventricle. Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
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 (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Mild left ventricular hypertrophy with cavity
enlargement and
moderate-severe global dysfunction c/w diffuse process
(multivessel CAD,
toxin, metabolic, etc.). Preserved right ventricular systolic
function. Mild mitral regurgitation.
CATH
Final report pending
Clean vessels
Brief Hospital Course:
The patient was admitted with acute shortness of breath
--Pump: The patient appeared euvolemic on exam, however an echo
revealed EF of 20%. The etiology of this cardiac failure is
unknown, however he is scheduled for follow up with a cardiac
MRI, coronary sinus protocol. HIV, TSH, B12 and folate, lyme
disease IgG and IgM, as well as [**Doctor First Name **] and hemochromatosis studies
were sent, results pending at the time of discharge.
--Ischemia: Due to NSTEMI. Cath revealed normal LMCA, LAD, LCX
and RCA with no disease, final complete report pending at time
of discharge . The patient was initially maintained on
atorvastatin, aspirin, heparin, ntg SL, and integrillin. Plavix
and the statin were subsequently discontinued. The patient was
started on metoptolol and lisinopril prior to discharge.
--Rhythm: Currently patient is in NSR with lbbb. Unclear if ECG
is different from baseline. Transient ECG change with RBBB with
lafb and AV dissocation may represent transient reperfusion
arrhythmia (AIVR).
.
Medications on Admission:
Motrin
"Medication for hypertension"
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
might repeat up to 3 times every 5 minutes.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive heart failure
Discharge Condition:
No chest pain or shortness of breath. Ambulatory
Discharge Instructions:
You were admitted because you had shortness of breath and you
were found to have congestive heart failure. Your heart was
found to work at about 30% of normal. Because of your heart
failure you will need to take 2 new medications: lisinopril and
metoprolol. You will also need to stay away from a salty diet.
If you have swelling in your extremities or or difficulty
breathing then you will need to talk to your doctor. You should
also weigh yourself each morning. If you gain over 3 lbs then
you should also call your doctor who may need to give you a
fluid pill.
If you have any chest pain, shortness of breath,
light-headedness, loss of consiousness, or any other concerning
symptoms then please seek immediate medical attention.
We have made an [**Doctor First Name 648**] for you with Dr. [**Last Name (STitle) **], a
cardiologist at [**Hospital1 18**]. You should also see Dr. [**Last Name (STitle) **] in
follow-up.
We are also setting up an [**Last Name (STitle) 648**] for an MRI of your heart
here at [**Hospital3 **]. Do not miss [**First Name (Titles) **] [**Last Name (Titles) 648**] on [**8-1**]
at 10 am.
Followup Instructions:
With Dr. [**Last Name (STitle) **] on [**8-14**] at 1:20pm ([**Telephone/Fax (1) 5862**].
With Dr. [**Last Name (STitle) **] on Monday [**7-30**] at 11:15am.
MRI at [**Hospital1 18**]. [**8-1**] AT 10 AM. Please go to the [**Location (un) **] of
the [**Hospital Ward Name 2104**] building, and come with someone who speaks English.
|
[
"41071",
"4280",
"4019"
] |
Admission Date: [**2148-7-29**] Discharge Date: [**2148-8-7**]
Date of Birth: [**2094-9-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
melena and coffee ground emesis
Major Surgical or Invasive Procedure:
upper endoscopy with injection of epinephrine
History of Present Illness:
53 year old male, Vietnamese speaking with chronic HBV and
recent diagnosis of HCC with invading IVC and right atrium and
recent hx of right multifocal lobal PE who was discharge on
[**7-26**] on lovenox. Pt presents today with complains of melena and
coffee ground emesis since last night. Pt states that he has
occ. black stools in the last 5 days ranging from yellow to
black stools 2-3 times per day. Last night he developed severe
epigastric and overall diffused abd pain. He than had small
loose black bowel movement total of 7 stools last night. He also
had small amount of coffee ground emesis overnight and this
morning had 2-3 episodes of large amounts (almost filling up
toilet bowel) coffee ground emesis. He came to ED for further
evaluation. He denies having any chills, fever, any prior nausea
or vomiting. He was having [**3-13**] loose BM per day for the past
"few" wks and most recently for the last 5 days, it has ranged
from yellow to black. His urine has been dark yellow, but he
denies any other GU symptoms. He denies having any SOB or DOE.
In the ED, his vitals were 97.1 F, BP 117/81, HR 118, RR 22,
Sats 99% on RA. He NG tube placed and he had 800ml of coffee
ground fluid. He had rectal exam and was guaiac positive. He was
given 80mg of protonix, 50 mcg of octreotide, 30mg protamine and
2 L of NS. He was typed and crossed. Hepatology was also
consulted since they were following pt during last admission for
HCC.
.
Of note pt was evaluated by Onc team chemotherapy was offered,
but pt decided that he did not wanted to received any treatment
for his malignancy with invasion to IVC and right atrium, as
well as multiple blood clots in the liver and lungs. He
understands that if he does not get treatment that his disease
is terminal. He has met with palliative care and was
transitioning to hospices, although he still full code for now.
.
On arrival to the floor, pt appears comfortable. He is alert and
conversing. VS: temp 99.4F, HR 121,118/79, 21, 97% on RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. No recent
change in bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
Chronic Hepatitis B, HepB serologies on [**2148-7-16**]
Social History:
Pt works as a machinist, used to smoke [**5-13**] cigarettes a day for
30+ years, quit 2 weeks ago. Endorses only occasional EtoH,
denies recreational drug use. Pt emigrated to the US from
[**Country 3992**] in the early 80s. Lives at home with wife and two
children, aged 8,11.
Family History:
Denies any family history of cancers.
Physical Exam:
Vitals - temp 99.4F, HR 121,118/79, 21, 97% on RA.
General: Thin man in NAD
HEENT: EOMI, PERRL slight scleral icterus, MMM, 7cm JVD
(non-elevated)
Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: Distended, mildly tender to deep palpation over the
RUQ, hepatomegaly noted 3-4 cm beneath subcostal margin + BS x 4
Extremities: No edema or asterixis noted
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. Cranial nerves II-XII intact, 7 deferred. [**6-12**]
strength noted diffusely. Sensation intact to light touch.
Pertinent Results:
Labs on admission:
[**2148-7-29**] 09:10AM BLOOD WBC-9.5 RBC-4.14* Hgb-10.7* Hct-33.0*
MCV-80* MCH-25.8* MCHC-32.4 RDW-18.1* Plt Ct-246
[**2148-7-29**] 09:10AM BLOOD Neuts-80.6* Lymphs-14.2* Monos-4.3
Eos-0.5 Baso-0.5
[**2148-7-29**] 09:10AM BLOOD PT-16.9* PTT-35.7* INR(PT)-1.5*
[**2148-7-29**] 09:10AM BLOOD Glucose-185* UreaN-28* Creat-0.7 Na-132*
K-6.0* Cl-95* HCO3-26 AnGap-17
[**2148-7-29**] 09:43PM BLOOD ALT-275* AST-434* LD(LDH)-904*
AlkPhos-615* Amylase-30 TotBili-9.1*
[**2148-7-29**] 09:43PM BLOOD Albumin-2.3* Calcium-7.3* Phos-2.9 Mg-1.9
[**2148-7-29**] 09:23AM BLOOD Hgb-11.7* calcHCT-35
Chest x ray [**2148-7-29**]:
Portable AP chest radiograph was compared to [**2148-7-16**].
The NG tube has been inserted with its tip being in the
proximal/mid stomach. Cardiomediastinal silhouette is stable.
The previously demonstrated small areas of atelectasis on the CT
torso have improved in the interim. There is no appreciable
pleural effusion or pneumothorax.
Endoscopy [**2148-7-29**]:
Findings: Esophagus: Normal esophagus.
Stomach: Other Fresh blood clots noted.
Duodenum: Excavated Lesions A samll single cratered non-bleeding
ulcer was found in the duodenal bulb, possible ulcers in the
duodenal bulb. Other Active bleeding noted. 5 cc.Epinephrine
1/[**Numeric Identifier 961**] hemostasis with success.
Impression: Fresh blood clots noted.
Active bleeding noted. (injection)
Ulcer in the duodenal bulb
Otherwise normal EGD to third part of the duodenum
Recommendations: C/w PPI and Octreotide gtt
f/u Hct and transfusion as needed.
Brief Hospital Course:
MICU COURSE:
53 year old male with Hep B, new diagnosis of HCC with invasion
to IVC and right atrium and right multifocal PE previously
Lovenox who is admitted to MICU with GI bleed.
# GI bleed: GI was consulted and EGD revealed bleeding duodenal
ulcer, s/p epinephrine injection. No eseophageal varices were
seen. H. Pylori positive on Ab test. Lovanox was held in setting
of GI bleed. He was given a total of 5 UPRBC, FFP and Vit K. He
continued to have episodes of melena but HCT stabalized at 26
suggesting no further bleeding. Based on a detailed discussion
of the risks and benefits and benefits of treating his H pylori
with hepatology a decision was made to start him antibiotic
therapy.
#HCC: The patient has a recent diagnosis of HCC. Disease is
extensive infiltrating IVC and right atrium. Pt was offered
chemo, but has refused at this time given extent of disease. He
was in the process of being transferred to hospice care. He was
scheduled to see Dr. [**Last Name (STitle) **], onc as outpatient on the day of
admission. He was seen by palliative care and although he wished
to treat his acute GI bleed, he decided not want to pursue
treatment for his HCC. His goals included getting home to be
with his family.
#Multifocal pulmonary emboli: Given malignancy infiltration
into IVC and right atrium, uncertain if the embolies are due to
cancer infiltration or thrombus. He was started on lovenox
recently, but now presented with GI bleed. His anticoagulation
was held in the setting of bleeding. It was not thought that an
IVC filter would be helpful in this case give that malignancy is
infiltrating into right atrium. He was kept on pneumoboots for
prophylaxis.
# DM: recent HgA1c of 8.6% on insulin at home (as per family 6
units at home) He was continued on insulin sliding scale.
# Pain: diffuse abd pain, tx with morphine prn with some effect,
it was changed to dilaudid with improved affect. Pt c/o pain in
the RUQ which is similar to chronic pain. He was encouraged to
ask for pain medications as needed so that his requirement could
be estimated. Abd pain improved during MICU stay. Palliative
care followed. Patient was changed to a po regimen SL morphine
in order to prepare him for potential hospice transfer.
# code status: DNR/DNI - 90 min family meeting held upon arrival
to the floor. [**Name (NI) **] HCP did not want agressive meausures c/w
with note of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1764**] on [**7-24**].
.
Disposition: hospice/[**Hospital1 1501**] in [**Location (un) 2251**] should patient become
stable.
=====================
SUMMARY SINCE ARRIVING TO GENERAL MEDICAL FLOOR:
53 year old male with metastatic HCCV and chronic hep B with PEs
presents with UGIB s/p 6 U PRBCS, EGD and cautery. Goals of
care to focus mainly on comfort/palliation. Had an IR guided
diagnostic paracentesis without evidence for SBP. A permanent
Pleurex catheter was placed for palliation. Given his
significant ascites and scrotal edema, he was started
onLasix/Aldactone [**2148-8-5**]. Palliative care and Hospice worked
together with the team and family to coordinate a discharge plan
that was in keeping with the patient's goals of care.
.
The triple antibiotic regimen was discontinued for the H. pylori
given the complexity of the regimen, the patient's overall
prognosis and his [**Doctor Last Name 688**] appetite/ability to tolerate po's.
.
Dr. [**Last Name (STitle) **] updated Dr. [**Last Name (STitle) **] via telephone re: the
discharge plan of care.
Medications on Admission:
Lovenox 60 mg/0.6 mL Syringe Subcutaneous every twelve (12)
hours
Vicodin PRN pain
Insulin U 100
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO
Q2H (every 2 hours) as needed for PAIN.
[**Last Name (STitle) **]:*qs mg* Refills:*0*
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO every
other day.
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO every other
day.
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0*
4. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
[**Last Name (STitle) **]:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for nausea, anxeity, breathing problems, sleep.
[**Name2 (NI) **]:*100 Tablet(s)* Refills:*0*
6. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Transdermal
every three days.
[**Name2 (NI) **]:*10 * Refills:*0*
7. Drain care
Please drain Pleurex catheter daily (up to 2 liters each day) if
this offers the patient comfort.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 269**] hospice care
Discharge Diagnosis:
Primary:
Metastatic hepatocellular carcinoma
Duodenal ulcer
Secondary:
pulmonary embolus- off anticoagulation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with a gastrointestinal bleed. You underwent
an endoscopy which demonstrated an ulcer. You were also found to
be H pylori positive. This was treated with some antibiotics and
a proton pump inhibitor. We stopped the three antibiotics at
discharge because it's not clear that they will be that helpful
to you in the long-term. You were also started on two
medications to decrease your swelling, Lasix and Spironolactone.
.
We also drained some fluid from your abdomen and put in a
Pleurex catheter to allow your caregivers to continue to drain
fluid from your abdomen for comfort.
Followup Instructions:
Dr. [**Last Name (STitle) **] is aware of your situation and that you have gone
home with Hospice.
|
[
"2851",
"2761",
"25000",
"V5861"
] |
Admission Date: [**2175-8-5**] Discharge Date: [**2175-8-16**]
Date of Birth: [**2094-6-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / Iodine / Dicloxacillin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
endoscopy
History of Present Illness:
Mr. [**Known lastname 25280**] is an 81 y/o M with extensive past cardiac history
including CAD (s/p CABG, prior PCIs with stenting), ischemic
cardiomyopathy with LVEF of 20% and NYHA class III CHF (s/p [**Known lastname 3941**]
placement), DM, HLD, HTN, A.fib (on Coumadin), PVD (chronic
lower extremity ulcers) who presented with chest pain.
The patient was at [**Hospital 100**] Rehab and at 02:10 AM was noted to
have acute onset substernal chest pressure without radiation,
[**8-18**] in intensity, BP 106 mmHg systolic at that time. EMS called
and received report that patient had an episodic HR of 160 bpm
without symptoms (unverified). Received nitro SL with
improvement in pain. Also got ASA. On arrival, CP was [**2-17**] and
substernal without dyspnea. No nausea, palpitations or
diaphoresis. Denied shortness of breath or leg swelling.
Of note, the patient was recently admitted here [**Date range (1) 25296**] with
hypotension. No clear etiology identified during that admission
but suspected to be cardiac. An echo showed a reduction in LVEF
to 20% from ~30%. There were intermittent NSVT episodes. Also
had slowly downtrending crit related to possible GIB. Mildly
anemic and received 1 unit PRBCs. No scope performed but scope
in [**2-19**] showed moderate gastritis, duodenal ulcer. He has known
diverticuli.
Mr. [**Known lastname 25280**] saw his cardiologist, Dr. [**Last Name (STitle) **], on the day PTA
where he was noted to be doing well. An [**Last Name (STitle) 3941**] interrogation did
reveal on VF episode requiring shock.
In the ED, initial VS were 98.3 110 106/62 16 94% 2L Nasal
Cannula. Labs revealed hct of 27.0, lactate of 5.7, Cr 2.0
(baseline 1.3), BNP 11,422 (baseline ~5,000), trop 0.04 (c/w
prior). ECG showed a.fib @ 114, LAD, occassional PVCs and IVCD,
non-specific ST-changes with peaked T-waves (similar to
previous). CXR without acute process. Guiac (+) with maroon
stool in vault. The patient received vanc/levo/flagyl in the ED
due to concern for sepsis.
On arrival to the [**Last Name (STitle) **] initial VS were 97/55 109 100%2L. Patient
is mentating well and [**Last Name (STitle) **] any CP/palp/SOB. Reports feeling
cold. No signs of active infection and broad spectrum abx not
continued in [**Last Name (STitle) **]. Can re-start if becoming febrile.
Past Medical History:
# Diabetes
# Hyperlipidemia
# Hypertension
# Peripheral [**Last Name (STitle) 1106**] disease with chronic LE ulcers
# s/p resection of R 1st MT joint [**2-/2166**]
# s/p R BK [**Doctor Last Name **] -DP w/nrsvg [**4-11**]
# s/p plasty of bpg [**4-13**]
# s/p agram [**3-14**]
# arteriogram [**12-18**]
# [**2174-2-10**] R 3rd toe debrid by podiatry
# [**2174-2-8**] right BK [**Doctor Last Name **] to PT bypass w/ NRSVG
# [**Last Name (LF) 19874**], [**First Name3 (LF) **] 20% (echo [**7-9**])
# CAD s/p CABG x 4 in [**2-/2166**]
# VT s/p dual-chamber [**Year (4 digits) 3941**] placement
# Atrial fibrillation on warfarin
Social History:
Married, has 6 children. [**Year (4 digits) 4273**] tobacco. Quit EtOH 25 years
ago. [**Year (4 digits) 4273**] illicits. Lives alone at [**Doctor Last Name 406**] Estates [**Location (un) 8608**] retirement community. Has occasional nursing help.
Manages his own finances. Per daughter, he usually has fair
understanding of his medical conditions, but has had a few
episodes of confusion; he was found confused and wandering on
previous admission
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission:
Vitals: 97/55 109 100%2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular, normal S1 + S2, II/VI systolic murmur
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Condom cath
Ext: Poor pulses b/l with eschar over ulcer on right
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
On discharge:
98 36.7 71 104/67 20 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: A-paced on monitor (regular), normal S1 + S2, II/VI systolic
murmur
Lungs: bilateral crackles lower lung field
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: Poor pulses b/l with eschar over ulcer on right
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities
Pertinent Results:
Labs:
[**2175-8-5**] 03:22AM BLOOD WBC-9.4 RBC-3.35* Hgb-8.4* Hct-27.0*
MCV-81* MCH-24.9* MCHC-31.0 RDW-23.8* Plt Ct-252
[**2175-8-5**] 03:22AM BLOOD Neuts-66 Bands-0 Lymphs-29 Monos-4 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-0
[**2175-8-5**] 03:22AM BLOOD PT-40.4* PTT-33.7 INR(PT)-4.0*
[**2175-8-5**] 03:22AM BLOOD Glucose-145* UreaN-56* Creat-2.0* Na-137
K-5.7* Cl-94* HCO3-25 AnGap-24*
[**2175-8-5**] 03:22AM BLOOD CK-MB-2 proBNP-[**Numeric Identifier **]*
[**2175-8-5**] 03:22AM BLOOD cTropnT-0.04*[**2175-8-5**] 11:20AM BLOOD
CK-MB-3 cTropnT-0.15*
[**2175-8-5**] 06:25PM BLOOD cTropnT-0.15*
[**2175-8-6**] 01:28AM BLOOD CK-MB-2 cTropnT-0.13*
[**2175-8-5**] 03:22AM BLOOD Calcium-9.3 Phos-2.6* Mg-1.7
[**2175-8-5**] 03:42AM BLOOD Lactate-5.7* K-4.3
[**2175-8-5**] 11:44AM BLOOD Lactate-1.7
[**2175-8-6**] 01:43AM BLOOD Lactate-2.4*
[**2175-8-6**] 09:32AM BLOOD Lactate-1.4
Radiology:
CXR [**2175-8-5**]
No acute cardiopulmonary process.
CXR [**2175-8-7**]
IMPRESSION: AP chest compared to [**6-25**] through [**2175-8-5**]:
Lungs grossly clear. There could be a new small left pleural
effusion. Heart size is top normal. No pulmonary edema.
Transvenous right ventricular pacer
defibrillator lead follows the expected course. The right
atrial lead is more medially oriented than generally seen, but
unchanged since at least [**2174-2-8**].
IMPRESSION:
XRAY Right Foot [**2175-8-7**]
1. Ulcer at the distal aspect of the 3rd toe without
radiographic signs of acute osteomyelitis.
Micro:
URINE CULTURE (Final [**2175-8-14**]):
GRAM NEGATIVE ROD(S). ~[**2163**]/ML.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification.
Discharge Labs:
[**2175-8-16**] 04:30AM BLOOD WBC-8.4 RBC-4.02* Hgb-10.6* Hct-33.4*
MCV-83 MCH-26.5* MCHC-31.9 RDW-22.3* Plt Ct-200
[**2175-8-16**] 04:30AM BLOOD PT-19.8* PTT-33.4 INR(PT)-1.9*
[**2175-8-16**] 04:30AM BLOOD Glucose-103* UreaN-12 Creat-1.4* Na-133
K-3.4 Cl-103 HCO3-27 AnGap-6*
[**2175-8-16**] 04:30AM BLOOD Calcium-7.8* Phos-2.0* Mg-1.8
Brief Hospital Course:
Mr. [**Known lastname 25280**] is an 81 y/o M with extensive [**Known lastname 1106**] history who
presented with chest pain and anemia. Transferred to MICU due to
concern of demand ischemia in setting of LGIB.
#Chest Pain - The patient has an extensive coronary history. His
present episode of chest pain ocurred in the setting of
tachycardia to the 160s (reported by EMS) and a hematocrit below
his baseline. Given pt's EKG and clinical picture, the elevated
troponin was most likely demand ischemia. He was given packed
RBCs to increase oxygen supply for increased demand. A CHF
exacerbation despite an elevated BNP, but unclear likely given
clear lungs and no fluid overload on CXR. Other etiologies
including PE was considered but his INR was supratherepeutic and
pt was not hypoxic. Cardiology was [**Known lastname 4221**] and did not believe
that this was ACS and did not recommend coronary angiography.
# Anemia - The patient has a long history of anemia and has
known history of gastric erosions, but no ulcers, and
diverticuli. CT Abdomen this month has no evidence of
malignancy. Pt is presently on iron supplementation. Guaiac (+)
stool in ED and on the floor. Pt was transfused several units of
RBCs (followed by lasix) to maintain a goal of hct>30 for demand
ischemia.
# A. Fib - CHADS2 score of 4. The patient presented in afib with
a rate in the 110s, and hemodynamically stable. Pt may have had
an episode of NSVT with EMS before arriving to ED since he had
SVT during last admission. No SVT episodes during [**Known lastname **] course. Pt
was continued on metoprolol with rates maintained below 100,
until the patient developed the GI bleed. Metoprolol was held
given blood pressures in 90/50 and his heart rate was well
controlled without it. Given his GI bleed, his coumadin and
metoprolol were held at the time of discharge.
#. C.diff colitis- The patient was found to have C. diff colitis
and started on metronidazole on [**2175-8-9**]. He will need to
complete 14 days of metronidazole.
# PVD - Patient with PVD leading to ulcerations. Patient with
stent placed recently and it was of high priority that he
continued anti-platelet and AC with plavix and warfarin at
present. With pt's GI bleed, [**Date Range 1106**] team was amenable to
discontinuing Plavix. Wound care team followed pt throughout
course.
# Acute on Chronic Kidney Disease - Cr elevated to 2.0 on
admission. Also with BUN elevation to suggest pre-renal state.
[**Month (only) 116**] also be due to renal vein congestion in the setting of CHF.
After receiving blood products, his Cr improved and was 1.4 at
the time of discharge.
# [**Month (only) 19874**]/CAD - Worsening EF thought to be due to progressive CAD.
It was imperative to give blood/fluid slowly and diurese as
needed. CXR and lungs presently clear with absent JVD on my
exam. Pt's home torsemide was held. The statin and ACE
inhibitor were restarted by the time of discharge. The patient
should follow up with his cardiology within 2-3 weeks after
discharge to assess the need to restart his torsemide.
# Delirium - Had difficulty with sundowning on prior admission.
Seen by [**Female First Name (un) **] consult and was started on zyprexa PRN agitation at
night.
# DMII: Pt's home metformin was hekd and BG were monitored four
times a day. He was discharge on an Insulin sliding scale.
Transitional issues:
- Reassesment regarding restarting Coumadin, metoprolol and
torsemide
- F/u with his PCP [**Name Initial (PRE) 176**] 1 week of discharge from rehab
- F/u with his cardiology within 2-3 weeks of discharge from the
hospital
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Bisacodyl 10 mg PO DAILY:PRN Constipation
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. Torsemide 20 mg PO BID
7. Warfarin 5 mg PO DAILY16
8. Atorvastatin 80 mg PO DAILY
9. Lisinopril 2.5 mg PO DAILY
10. MetFORMIN (Glucophage) 850 mg PO BID
11. Nitroglycerin SL 0.3 mg SL PRN Chest Pain
12. OLANZapine 2-5 mg PO HS:PRN Delerium
13. Pantoprazole 40 mg PO Q12H
14. Metoprolol Tartrate 12.5 mg PO TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN Constipation
4. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding
Scale using HUM Insulin
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 14 Days
Started on [**2175-8-9**]; Please continue to take this medication
until [**2175-8-23**]
7. Lisinopril 2.5 mg PO DAILY
8. Bisacodyl 10 mg PO DAILY:PRN Constipation
9. Ferrous Sulfate 325 mg PO BID
10. OLANZapine *NF* 2.5 mg Oral qhs
11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
12. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name **] centre
Discharge Diagnosis:
gastrointestional bleed
coronary artery disease
chronic congestive heart failure
clostridium difficile infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 25280**],
You were admitted to [**Hospital1 69**] for
chest pain. We don't believe you had a heart attack, but the
chest pain was likely related to lower oxygen to your heart.
You are now chest pain free after receiving blood.
We also found that you had a bleed within your gastrointestional
system. You underwent endoscopy, in otherword we looked with a
camera at your gastrointestion system, which did not find the
source of your bleeding. We have stopped your plavix and
currently stopping your coumadin after discharge. We have also
stopped your torsemide and metoprolol given lower blood
pressure. You should follow up with your cardiology and
determine if you should restart the torsemide, metoprolol, and
coumadin.
We also found that you had an infection of your colon caused by
a bacteria, clostridium difficle. You will need to take
antibiotics to treat this infection.
Finally, it is important that you rebuild your strength after
discharge at the rehab extended care facility.
We are stopping your torsemide and metoprolol given your recent
GI bleed. Please talk with your cardiology about restarting
metoprolol, torsemide and coumadin within 2-3 weeks of
discharge. Also, please see your primary care doctor within 1
week of discharge from rehab.
Followup Instructions:
Please see your cardiology after discharge within 2-3 weeks of
discharge.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"2851",
"5849",
"4280",
"40390",
"5859",
"25000",
"2724",
"42731",
"V5861",
"V4581"
] |
Admission Date: [**2120-4-25**] Discharge Date: [**2120-4-26**]
Date of Birth: [**2049-6-24**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 4212**]
Chief Complaint:
hyperglycemia
Major Surgical or Invasive Procedure:
Left 5th digit amputation
Left 3rd digit debridement
History of Present Illness:
70M with DM, ESRD on HD, AFib s/p ampuation L 5th digital
amputation and dorsal 3rd digit debridement on [**2120-4-25**] with
hyperglycemia, transferred to [**Hospital Unit Name 153**] for insulin gtt.
Night prior to arrival patient took his usu 18 units of lantus.
AM of surgery FSG was 66 at home so he took no Humalog (usu on
sliding scale). In OR pt received 750cc D5NS. Post-op FSG was
500, persisted to undetectable level despite 12 units regular
insulin given at 15:00, 16:00, and 18:00 (for a total of 36
units regular insulin). On arrival to [**Hospital Unit Name 153**] at 19:30 pt's FSG
still undetectable. He received half a liter of 1/2NS.
Pt states he feels well and has no complaints. Denies f/c, LH,
HA, blurry vision. He states he has had a dry cough. He denies
abd pain, d/c, n/v. He denies rash or tender cellulitis
Past Medical History:
1. Atrial fibrillation, anticoagulation with Coumadin
2. Diabetes since age 40 with neuropathy, nephropathy,
gastoparesis last HgbA1C was 10.7 [**10-25**]
3. End stage renal disease on HD M,W,F since [**10-22**]
4. Peripheral vascular disease
5. Hypertension
6. Hyperlipidemia
PSH:
1. Left AV fistula [**2115**]
2. Left popliteal to dorsalis pedis saphenous vein graft in
[**2116-11-21**] by Dr. [**Last Name (STitle) **]
3. Right popliteal to dorsalis pedis saphenous vein graft
[**2116-12-22**] by Dr. [**Last Name (STitle) **]
4. Right sesamoidectomy and right first MPJ resection in
[**2116-12-22**] following bypass graft by podiatry service
5. Right transmetatarsal amputation on [**2117-6-7**] by Dr.
[**Last Name (STitle) **]
Social History:
The patient quit smoking cigarettes 35 years ago. He does not
drink alcohol. He has a prosthetic limb for his right leg.
He recieves dialysis in [**Hospital1 392**]
Family History:
non-contributory
Physical Exam:
Vitals: 98.4 86 130/92 93%RA
gen- Well appearing NAD
heent- oropharynx clear, mmm, neck supple
pulm- faint R basilar crackles
cv- irreg irreg II/VI syst murmur
abd- s, nt, nd, +bs
ext- R BKA, L no edema, R upper arm fistula with bruit, no
induration or erythema, L hand 5th digit distal amputation, 3rd
digit covered in gauze
neuro- A&O x3 moves all 4, no gross deficits
Pertinent Results:
Admission Labs:
*
CHEM: GLUCOSE-539* UREA N-47* CREAT-5.8* SODIUM-135
POTASSIUM-5.2* CHLORIDE-92* TOTAL CO2-27 ANION GAP-21 Calcium
8.8, Mag 2.0, Phos 5.2
*
CBC: WBC-4.3 RBC-4.17* HGB-13.1* HCT-39.9* MCV-96 PLT 101
DIFF: NEUTS-79.0* LYMPHS-15.8* MONOS-2.4 EOS-2.4 BASOS-0.3
*
COAGS: PT-13.8* PTT-25.7 INR(PT)-1.3
*
Serum Osm: 315, Serum Ketones (acetone): Negative
*
TISSUE Left 5th finger-
*
GRAM STAIN (Final [**2120-4-25**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
CULTURE: Pending at time of discharge
*
5/5 Blood Cx: No growth to date
*
CXR [**4-25**]: Negative for infiltrate or edema. Stable cardiomegaly.
Brief Hospital Course:
This is a 70 y/o Male with h/o DMI, HTN, PVD, who presented for
hyperglycemia s/p amputation of left 5th digit and debridement
of left 3rd digit. On admission to the ICU, his serum blood
glucose was 539 and his anion gap was 16 (with a serum bicarb of
33). His serum ketones were negative and his serum Osm was 315.
Urinalysis was not able to be performed due to the patients ESRD
w/ anuric state. He was asymptomatic at the time of presentation
and his hyperglycemia was felt to be secondary to recieving D5
during his surgical procedure. Stress from the procedure,
although a minor procedure, also may have contributed. Of note
CXR was negative for infiltrate and blood culture was
preliminary negative. EKG was negative for ischemic changes. He
was started on an insulin drip at 5 units per hour for glycemic
control and he was quickly weaned off after 4 hours. Blood
sugars were subsequently well-controlled at <110. He had one
episode of low blood sugar to 38, but he was asymptomatic at the
time and responded to PO sugar intake. His anion gap was reduced
to 12 and his serum Osm decreased to 306. He was re-started on
his outpatient regimen of glarine 17 units qhs with good
glycemic control. After overnight monitoring he was discharged
to home on [**4-26**]. He will resume dialysis on [**4-27**] as discussed with
the renal service.
In regards to his left finger amputation, his wound was dressed
per plastic surgery recommendations. He was started empirically
on Vancomycin given his history of MRSA to complete a 2 week
course (given at hemodialysis). Further antibiotics were held
until final wound culture results returned. These were pending
at the time of discharge. He will follow-up with his PCP for
review of this data.
Medications on Admission:
atenolol 50 mg po daily
coumadin 6 mg daily (last dose 4/4)
lipitor 40 mg daily
nephrocaps two with each meal
renagel two with each meal
phoslo two with each meal
lantus 18 units daily
humalog sliding scale
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: Two (2) Cap
PO DAILY (Daily).
6. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous
DOSE W/HEMODIALYSIS () for 2 weeks.
7. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
8. Warfarin Sodium 6 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Humalog 100 unit/mL Solution Sig: see sliding scale.
Subcutaneous 4 x each day: follow sliding scale as attached .
Discharge Disposition:
Home
Discharge Diagnosis:
1. Left 5th Digit Necrosis
2. Diabetes I
3. Anion Gap Metabolic Acidosis
4. End Stage Renal Disease
5. Hypertension
Discharge Condition:
Good. Afebrile. Hemodynamically stable. Blood sugars well
controlled.
Discharge Instructions:
Please report fever, chills, abdominal pain or blood sugars not
controlled by your current medical regimen to your primary
physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9006**]. Follow-up with [**Last Name (un) **] as scheduled below.
Please take all prescribed medication. PLease follow your
fingersticks carefully.
Followup Instructions:
1. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2120-5-2**] 12:10
2. Follow-up at [**Last Name (un) **] with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2489**] NP[**5-9**] at
9:30 am. You will aslo see Dr. [**First Name (STitle) **] in Eye Clinic that same
day.
3. Follow-up with Dr. [**Last Name (STitle) **] on [**2120-7-25**] at 10:30 am.
|
[
"40391",
"42731",
"2762",
"2724",
"V5861"
] |
Admission Date: [**2147-11-17**] Discharge Date: [**2147-12-5**]
Date of Birth: [**2092-11-28**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
headache and neck stiffness
Major Surgical or Invasive Procedure:
central line placed, arterial line placed
History of Present Illness:
54 year old female with recent diagnosis of ulcerative colitis
on 6-mercaptopurine, prednisone 40-60 mg daily, who presents
with a new onset of headache and neck stiffness. The patient is
in distress, rigoring and has aphasia and only limited history
is obtained. She reports that she was awaken 1AM the morning of
[**2147-11-16**] with a headache which she describes as bandlike. She
states that headaches are unusual for her. She denies photo- or
phonophobia. She did have neck stiffness. On arrival to the ED
at 5:33PM, she was afebrile with a temp of 96.5, however she
later spiked with temp to 104.4 (rectal), HR 91, BP 112/54, RR
24, O2 sat 100 %. Head CT was done and relealved attenuation
within the subcortical white matter of the right medial frontal
lobe. LP was performed showing opening pressure 24 cm H2O WBC of
316, Protein 152, glucose 16. She was given Vancomycin 1 gm IV,
Ceftriaxone 2 gm IV, Acyclovir 800 mg IV, Ambesone 183 IV,
Ampicillin 2 gm IV q 4, Morphine 2-4 mg Q 4-6, Tylenol 1 gm ,
Decadron 10 mg IV. The patient was evaluated by Neuro in the
ED.
.
Of note, the patient was recently diagnosed with UC and was
started on 6MP and a prednisone taper along with steroid enemas
for UC treatment. She was on Bactrim in past but stopped taking
it for unclear reasons and unclear how long ago.
.
Past Medical History:
chronic back pain, MRI negative
osteopenia - fosamax d/c by PcP
leg pain/parasthesias
h/o hiatal hernia
Social History:
No tob, Etoh. Patient lives alone in a 2 family home w/ a
friend. She is an administrative assistant
Family History:
brother w/ ulcerative proctitis, mother w/ severe arthritis,
father w/ h/o colon polyps and GERD
Physical Exam:
VS: 101.4 ; 101/55; 87; 20; 100% at 2L NC
Gen: Middle aged, ill-appearing woman, restless in bed,
rigoring, in moderate distress
HEENT: NC/AT, PEERL, MM dry, no lesions, OP clear, sclera
non-icteric
Neck: stiff; palpable small LN in right supraclavicular area
CV: regular, Nl S1, S2, 3/6 systolic murmur at left lower
sternal border
Pulm: crackles at base of right lung
Abd: + BS, soft, mildly tender in periumbilical area, ND, no
rebound, no guarding
Ext: 2+ bilateral pitting edema in lower extremities
bilaterally, warm skin
Skin: no exanthems
Neuro: A&O x3, expressive aphasia, CN 2-12 intact, patient has
2+ patellar reflexes bilaterally, no gross motor or sensory
deficits.
Pertinent Results:
[**2147-11-16**] 05:55PM BLOOD WBC-6.5 RBC-2.64* Hgb-8.2* Hct-24.6*
MCV-93 MCH-31.0 MCHC-33.3 RDW-20.1* Plt Ct-577*
[**2147-11-16**] 05:55PM BLOOD Neuts-92.2* Bands-0 Lymphs-5.3*
Monos-1.4* Eos-0.9 Baso-0.2
[**2147-11-16**] 05:55PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
[**2147-11-16**] 05:55PM BLOOD PT-12.9 PTT-24.2 INR(PT)-1.1
[**2147-11-18**] 04:52AM BLOOD Fibrino-782*
[**2147-11-16**] 05:55PM BLOOD Glucose-111* UreaN-19 Creat-0.9 Na-140
K-3.7 Cl-99 HCO3-29 AnGap-16
[**2147-11-16**] 05:55PM BLOOD LD(LDH)-288*
[**2147-11-17**] 05:14AM BLOOD ALT-28 AST-42* LD(LDH)-424* AlkPhos-33*
Amylase-63 TotBili-0.6
[**2147-11-18**] 04:52AM BLOOD ALT-25 AST-25 LD(LDH)-315* AlkPhos-34*
TotBili-0.3
[**2147-11-17**] 05:14AM BLOOD Lipase-25
[**2147-11-17**] 05:14AM BLOOD Albumin-2.2* Calcium-7.5* Phos-3.6
Mg-1.5* Iron-8*
[**2147-11-21**] 06:43PM BLOOD Albumin-1.8* Calcium-7.7* Phos-3.6 Mg-1.7
[**2147-11-17**] 05:14AM BLOOD calTIBC-152* Ferritn-298* TRF-117*
[**2147-11-17**] 08:01PM BLOOD Type-ART Temp-38.9 Rates-/24 FiO2-100
pO2-58* pCO2-33* pH-7.47* calHCO3-25 Base XS-0 AADO2-645 REQ
O2-100 Intubat-NOT INTUBA
[**2147-11-18**] 12:44AM BLOOD Type-ART Temp-39.1 Rates-/24 FiO2-100
pO2-69* pCO2-35 pH-7.48* calHCO3-27 Base XS-2 AADO2-632 REQ
O2-99 Intubat-NOT INTUBA Comment-NON-REBREA
[**2147-11-18**] 04:18PM BLOOD Type-ART FiO2-100 pO2-222* pCO2-31*
pH-7.47* calHCO3-23 Base XS-0 AADO2-478 REQ O2-79 Intubat-NOT
INTUBA
[**2147-11-18**] 04:38PM BLOOD Type-ART pO2-61* pCO2-33* pH-7.45
calHCO3-24 Base XS-0 Intubat-NOT INTUBA
[**2147-11-19**] 12:11AM BLOOD Type-ART Temp-37.6 Rates-/20 Tidal V-350
FiO2-100 pO2-137* pCO2-35 pH-7.47* calHCO3-26 Base XS-2
AADO2-559 REQ O2-90 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2147-11-19**] 10:29AM BLOOD Type-ART PEEP-8 pO2-89 pCO2-33* pH-7.51*
calHCO3-27 Base XS-3 Intubat-NOT INTUBA
[**2147-11-21**] 05:25AM BLOOD Type-ART Temp-38.4 Rates-/24 FiO2-100
pO2-58* pCO2-36 pH-7.52* calHCO3-30 Base XS-5 AADO2-638 REQ
O2-100 Intubat-NOT INTUBA
[**2147-11-22**] 04:52AM BLOOD Type-ART Temp-37.3 Rates-0/24 O2 Flow-5
pO2-64* pCO2-29* pH-7.50* calHCO3-23 Base XS-0
[**2147-11-16**] 06:01PM BLOOD Lactate-2.1* K-3.4*
[**2147-11-21**] 08:04PM BLOOD Lactate-0.8
[**2147-11-18**] 08:41AM BLOOD freeCa-1.01*
[**2147-11-22**] 04:16AM BLOOD WBC-9.4# RBC-3.77* Hgb-11.5* Hct-33.4*
MCV-89 MCH-30.5 MCHC-34.5 RDW-20.0* Plt Ct-597*
[**2147-11-17**] 05:14AM BLOOD WBC-7.6 RBC-2.16* Hgb-6.8* Hct-20.0*
MCV-92 MCH-31.6 MCHC-34.2 RDW-20.0* Plt Ct-415
[**2147-11-17**] 03:57PM BLOOD Hct-23.2*
[**2147-11-18**] 04:11PM BLOOD WBC-5.1 RBC-2.60* Hgb-7.8* Hct-22.7*
MCV-87 MCH-30.1 MCHC-34.4 RDW-21.0* Plt Ct-395
[**2147-11-19**] 05:52AM BLOOD WBC-4.8 RBC-3.08* Hgb-9.0* Hct-26.5*
MCV-86 MCH-29.2 MCHC-33.9 RDW-20.7* Plt Ct-409
[**2147-11-21**] 06:43PM BLOOD Neuts-91.0* Bands-0 Lymphs-7.3*
Monos-1.4* Eos-0.2 Baso-0
[**2147-11-22**] 04:16AM BLOOD Plt Ct-597*
[**2147-11-21**] 04:39AM BLOOD PT-12.2 PTT-22.6 INR(PT)-1.0
[**2147-11-21**] 04:39AM BLOOD Plt Ct-498*
[**2147-11-18**] 04:11PM BLOOD Plt Ct-395
[**2147-11-22**] 04:16AM BLOOD Glucose-104 UreaN-19 Creat-1.1 Na-136
K-4.1 Cl-104 HCO3-21* AnGap-15
[**2147-11-21**] 06:43PM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-133
K-4.3 Cl-100 HCO3-24 AnGap-13
[**2147-11-20**] 04:41PM BLOOD Glucose-161* UreaN-15 Creat-1.0 Na-138
K-4.3 Cl-99 HCO3-28 AnGap-15
[**2147-11-19**] 05:52AM BLOOD Glucose-81 UreaN-16 Creat-0.8 Na-138
K-5.0 Cl-106 HCO3-23 AnGap-14
[**2147-11-18**] 04:52AM BLOOD Glucose-140* UreaN-13 Creat-0.9 Na-136
K-4.3 Cl-103 HCO3-23 AnGap-14
[**2147-11-17**] 05:14AM BLOOD Glucose-223* UreaN-21* Creat-1.0 Na-135
K-4.3 Cl-99 HCO3-27 AnGap-13
.
.
.
Radiology:
CXR [**11-16**]: Diffusely increased opacities at the lung fields
bilaterally. In an immunocompromised patient, this is concerning
for PCP [**Name Initial (PRE) 2**]. Radiographically, the differential includes
pulmonary edema. Additionally, there is a faint opacity at the
right lung base, which may represent atelectasis or focal
pneumonic process.
.
CT-Head [**11-16**]: Focus of low attenuation within the subcortical
white matter of the right medial frontal lobe. This may
represent a subacute infarction; however, an underlying mass
lesion cannot be completely excluded. An MRI examination with
gadolinium and diffusion-weighted imaging is recommended for
further evaluation. No intracranial hemorrhage noted.
.
MR-head-w&w/o gadolinium [**11-18**]:
Signal abnormality in the medial right frontal lobe involving
the corpus callosum does not demonstrate enhancement. This
finding most likely represent a small infarct. However, in
absence of ADC map, age of the infarct could not be determined.
No abnormal enhancement is seen. Follow up is suggested, if
clinically indicated.
.
Echo [**11-18**]:
1.The left atrium is mildly dilated.
2. 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%).
3. Right ventricular chamber size and free wall motion are
normal.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis. Trace aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. While difficult to
assess given the limited views suspect Mild (1+) mitral
regurgitation is seen.
6.The estimated pulmonary artery systolic pressure is normal.
7.There is no pericardial effusion.
.
If clinically indicated, would recommend a TEE.
.
CXR [**11-21**]:
Resolution of congestive failure with persistent small bilateral
pleural effusions and bibasilar atelectasis
.
Studies:
EEG [**11-17**]: This is a mildly abnormal EEG due to the presence of
a slow
and disorganized background with bursts of generalized slowing -
all
consistent with a mild encephalopathy of toxic, metabolic, or
anoxic
etiology. No evidence for ongoing seizures is seen.
Brief Hospital Course:
A/P: 54 woman on immunosuppressive therapy for UC (prednisone,
6MP) who presents with new onset HA, fever with bacterial
meningitis and gram positive rod bacteremia.
.
#. Listeriosis - meningitis and bacteremia. Patient presented
with headache, nuchal rigidity, expressive aphasia, afebrile on
admission but temp to 104.4 in the ED, where she also started to
have rigors. LP showed >300 WBC, poly predominant with 5%
monocytes, protein 152 glucose 16. CSF gram stain showed gram
positive rods, blood culture grew gram positive rods, speciation
eventually grew listeria. Empiric treatment based on gram stain
was started: ampicillin and bactrim (to cover both nocardia and
question of PCP, [**Name10 (NameIs) 3**] below), vanc and ceftriaxone as well pending
confirmation of gram stain and culture results. Once
speciations was confirmed, a five day course of gentamicin was
started for synergy, and vancomycin and ceftriaxone d/c'd.
Bactrim was maintained on treatment dose for concern for PCP
[**Name Initial (PRE) 4**] [**11-21**], when it was changed to prophylaxis dose. Early on
admission, she developed hypotension that required levophed, but
was weaned off of pressors within the first couple of days of
admission with PRBCs (total of 4 units) and volume
resussitation. Given bacteremia, TTE was done, no vegetations
or lesions noted. Head CT on admission showed right medial
frontal lobe likely infarct versus mass lesion, no hemorrhage.
Subsequent MRI confirmed infarct, unclear date, and EEG
consistent with meningitis. Neurology was consulted, and the
patient was placed on dilantin for seizure prophylaxis given
meningoencephalitis. She spiked fevers to 101-102 over the first
several days of admission. By [**11-19**], her neurological exam was
markedly improved, and by [**11-21**] her headache was gone, no
meningeal signs noted, although her baseline essential tremor
was slightly more severe. Surveillance blood cultures reamined
negative from [**11-17**] on. Notably, she was transferred from ICU
to floor on [**11-21**], but noninvasive BP was read as 60/d, patient
mentating well, sent back to ICU. In the ICU, an arterial line
was placed, and consistently read 20-30 mmHg higher than
sphyngomanometer. This discrepancy was of unclear etiology, but
persistent. Patient maintained normal mentation, good urine
output, no tachycardia, and it was judged that, for some unclear
reason, the cuff pressures underestimated by 20-30 points. On
[**11-23**], she was sent to the floor for further care and management.
.
#. Bilateral lung opacities/hypoxia. Initial chest film read as
increased opacities bilaterally concerning for PCP (given
steroids and no PCP [**Name Initial (PRE) 5**]) vs. bacterial pneumonia vs. pulmonary
edema. She had signifcant oxygen requirement, and her
respiratory distress led to her being placed on CPAP+PS. The
origin of her significant hypoxia was originally thought to be
secondary to likely vascular leak from sepsis/CHF versus PCP. [**Name10 (NameIs) 6**]
induced sputum was attempted, but was unsuccessful, and was not
repeated initally given her unstable respiratory status, and
susbsequent evaluation that likelihood of PCP was small. She
responded well to lasix diuresis, with reduced O2 requirements.
.
#. UC: She continued to receive her outpatient dose of
prednisone, which was changed on [**11-22**] to dexamethasone IV; her
outpatient 6-MP was held. After several days with no diarrhea,
it recurred on [**11-22**] soon after her diet had advanced. C.diff was
negative. She was made NPO, and fed via TPN for bowel rest. On
[**11-24**], it was noted that she began passing BRBRP, her hematocrit
was noted to drop two points and pt was typed and crossed and
consent for blood transfusion.
.
#. Anemia. On admission, she was found to be anemic. She
received PRBCs for anemia on admission and again [**11-19**] for mixed
venous sat <70%. She was found to have iron binding studies c/w
anemia of chronic disease. Her HCT was followed closely, and
remained stable for the remainder of her admission.
.
#. FEN: Her diet was advanced as tolerated, but she was made NPO
with TPN on [**11-22**] after she developed diarrhea, thought secondary
to continued UC activity.
.
#. Prophylaxis: PPI. Hold SQ Hep, pneumoboots. Initially on
droplet precautions.
.
#. Code status: FULL
.
#. Communication: patient, her sister, brother, and mother
.
#. Lines: peripheral IV x 2. left subclavian CC. A-line. Eval
for PICC; once in place, can d/c central line, a-line.
Surgery Discharge part:
Pt underwent total abdominal colectomy with ileoostomy on
[**2147-11-26**]. She was on Clinda/Gent peri-procedure and Amplicillin
for 21 days at first. She was seen by PT/OT and was NPO until
the ostomy started to function. SHe had c/o nausea as diet was
tolerated and it was slowed down. MRI was suspicious for an
abcess and amplicillin was started for at least a total of 6
weeks as per ID. She was given a PICC. On [**12-5**] she was
cleared by PT and was in good condition for d/c to rehab on
[**2147-12-5**].
Medications on Admission:
AMBIEN 10 mg--1 tablet(s) by mouth at bedtime
CLONAZEPAM 1 MG--One twice a day
FLUOXETINE 20 MG--2 every day
FOSAMAX 70MG--One qweek as directed
FUROSEMIDE 20 mg--1 tablet(s) by mouth once a day
MERCAPTOPURINE 50 mg--1 tablet(s) by mouth twice a day
PREDNISONE 20 mg--2 tablet(s) by mouth once a day as per
gastroenterologist
PROTONIX 40 mg--1 tablet(s) by mouth once a day
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2-4HPRN ().
4. Zolpidem 5 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. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QTHUR (every
Thursday).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
13. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln
Injection Q4H (every 4 hours): Please take until at least
[**12-28**]. You will be further instructed by the infectious
disease doctors.
14. PREDNISONE TAPER
(see included sheet)
10 mg in morning and 10 mg in evening for 3 days
Next take 10 mg in the morning and 7.5 mg in evening for 3 days
Next take 7.5 mg in the morning and 7.5 mg in the eveing for 3
days
Then take 7.5 mg in the morning and 5 mg in the evening
Next take 5 mg in the morning and 5 mg in the evening for 3 days
Then take 5 mg in the morning and 2.5 mg in the evening for 3
days
Next take 2.5 mg in the morning and 2.5 mg in the evening for 3
days
Finally take 2.5 mg in the morning and none in the evening for 3
days.
Then take no more prednisone
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Listeria meningitis
Ulcerative colitis
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor if you have a fever >101.4, inability to
pass gas or stool into the ostomy, severe pain, persistent
nausea, vomiting, or any other concerns. Please take all
medications as prescribed and complete the course of
antibiotics.
Followup Instructions:
Please make an appointment to see Dr. [**Last Name (STitle) **] in 2 weeks,
telephone [**Telephone/Fax (1) 9**]. Please follow up with your primary care
MD in [**1-22**] weeks.
You have an appointment with Infectious disease on [**12-25**] ([**Telephone/Fax (1) 10**].
You have an MRI scheduled on [**2147-12-22**] [**Telephone/Fax (1) 11**].
|
[
"4280"
] |
Admission Date: [**2117-12-14**] Discharge Date: [**2117-12-20**]
Date of Birth: [**2058-5-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
shortness of breath/PE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 yo man w/ hx DM Type II, HTN, obesity who presented to the ED
with acutely worsening SOB, lightheadedness, diaphoresis
following BM. Pt describes 3 days of DOE of 10 feet that he
first noticed ambulating while at work without noticable
precipitants. Pt noted no other symptoms until the day of
admission, when he felt diaphoretic, lightheaded and nauseated
while moving his bowels. He required assisstance to leave the
bathroom and subsequently contact[**Name (NI) **] EMS. He noted severe SOB
and a sensation of vomiting during this episode. On admission to
the ED, he reported no CP, V/D, F/C/M, orthop, PND, dysuria,
incontinence, recent travel or sick contacts.
Vitals on presentation were 958-99-128/82-16-100% on NRB (100%).
A CXR was unremarkable and a CT was obtained in the setting of
continued SOB. CT chest demonstrated large PEs in the left main
and right main with invasion into the segmental/sub-segmental
branches. Pt was started on heaprin gtt with improvement to
hemodynamic status. He was admitted to the [**Hospital Unit Name 153**] for 24 hour
observation (following that, spent 1 day awaiting transfer to
medicine). Since admission to the unit, pt notes no SOB, F/C/M,
N/V/D, CP. He has been hemodynamically stable is transferred for
further evaluation and observation.
Past Medical History:
1. hypertension
2. NIDDM
3. Gout
Social History:
married with 4 children
denies tobacco/alcohol/IVDA
Family History:
father died of MI at 58
no history of clots/cancers
Physical Exam:
T97.7 R24 SpO2 90% on NC BP122/78 P98
Gen-NAD, pleasant
HEENT-anicteric, oral mucosa moist, neck supple
CV-rrr, no r/m/g, faint heart sounds
resp-CTAB, faint breath sounds due to body habitus, no wheezes,
no accessory muscle use, speak in full sentences
[**Last Name (un) 103**]-soft, active BS, nontender, obese abdomen
neuro-A+O x3, PERL, EOMI, CNII-XII intact, moves all 4 limbs
symmetrically
extremities-DP 2+ bilaterally, no pitting edema, no swelling, no
calf tenderness, no palpable cords
Pertinent Results:
EKG [**12-14**]:
sinus with LAD, Q in II, III, aVF(old), no ST changes
CTA [**12-14**] :There is a large pulmonary embolus within the
left main pulmonary artery and multiple left segmental and
subsegmental branches.There is also a large pulmonary embolus
in the right
main pulmonary artery and multiple segmental and subsegmental
branches.
In the right middle lobe,there is a more nodular density
measuring approximately 7 mm, but this is adjacent to a
vessel, and not clearly separate from it. In both lower
lobes,there are peripheral opacities which are more linear as
opposed to wedge-shaped, more likely atelectasis, although
infarcts cannot be excluded in this setting.
Echo ([**12-15**]): Probably normal LV systolic function (due to poor
imager quality, a regional wall motion abnormality cannot be
excluded). Mild to moderate tricuspid regurgitation with
moderate pulmonary hypertension.
EKG ([**12-15**]): Sinus rhythm with slowing of the rate as compared to
the previous tracing of [**2117-12-14**]. Ventricular ectopy is no
longer recorded. There is prior inferior myocardial infarction
and probable anterior myocardial infarction as well. Diffuse
non-specific ST-T wave abnormalities. There is slight Q-T
interval prolongation. Compared to the previous tracing of
[**2117-12-14**] ventricular ectopy has abated and the rate has slowed.
Otherwise, no diagnostic interim change.
[**2117-12-14**] 07:30PM PT-13.6 PTT-23.3 INR(PT)-1.2
[**2117-12-14**] 07:30PM PLT COUNT-166
[**2117-12-14**] 07:30PM WBC-6.3 RBC-5.26 HGB-15.5 HCT-46.0 MCV-87
MCH-29.5 MCHC-33.7 RDW-13.5
[**2117-12-14**] 07:30PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-1.7
[**2117-12-14**] 07:30PM CK-MB-8 cTropnT-<0.01
[**2117-12-14**] 07:30PM LIPASE-34
[**2117-12-14**] 07:30PM ALT(SGPT)-60* AST(SGOT)-62* LD(LDH)-583*
CK(CPK)-1008* ALK PHOS-61 AMYLASE-41 TOT BILI-0.4
[**2117-12-14**] 07:30PM GLUCOSE-268* UREA N-11 CREAT-1.0 SODIUM-137
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-16
[**2117-12-15**] 02:00PM BLOOD CK-MB-8 cTropnT-<0.01
[**2117-12-15**] 08:23AM BLOOD CK-MB-8 cTropnT-<0.01
[**2117-12-14**] 07:30PM BLOOD CK-MB-8 cTropnT-<0.01
[**2117-12-20**] 07:10AM BLOOD WBC-5.7 RBC-4.95 Hgb-14.5 Hct-42.4 MCV-86
MCH-29.2 MCHC-34.1 RDW-13.8 Plt Ct-269
[**2117-12-20**] 07:10AM BLOOD Plt Ct-269
[**2117-12-20**] 07:10AM BLOOD PT-18.4* PTT-76.8* INR(PT)-2.1
Brief Hospital Course:
59 yo man w/ hx of HTN, DM II who presents with large bilateral
pulmonary emboli of unknown source treated successfully with
anticoagulation. He has been hemodynamically stable since
admission and notes no new complaints on transfer.
B/L PULM EMBOLI ?????? Large bilateral PE unaccounted for by hx ?????? no
hx long travel, coagulopathy. It is interesting, however, that
pt notes brother and sister (for a total of 3 out of 9 siblings)
that have presented to their respective physicians with clots. A
full set of studies (Factor V, homocysteine, lupus,
anti-cardiolipin ab, anti-thrombin, Protein C, S, etc) should be
considered ?????? will discuss w/ PCP as this may be best followed as
an outpt. He received coumadin 10mg yesterday w/ no change in
INR (1.4) and 15mg this AM prior to transfer. His warfarin dose
was titrated up secondary to body mass and non-response on 10mg
and heparin gtt continued until INR was between 2 and 3. On the
day of discharge, his INR was therapeutic at 2.1 on 12.5mg
coumadin; however, given that he was therapeutic for less than
2days and he was adamant about leaving, lovenox 120mg SC Q12 x2
days was prescribed. He will need close follow-up as an outpt
for furter titration of warfarin. He will likely require
lifelong anticoagulation.
HTN: Anti-hypertensives were withheld as pt was normotensive in
the setting of massive bilateral PEs. Pt will follow-up with his
PCP to restart antihypertensives as an outpatient.
DMII: Pt's serum glucose was high on admission, but reasonably
well controlled on his home meds, pioglitazone 30' and glyburide
10" with RISS coverage. He was on a dibetic diet.
ELEVATED TRANSAMINASES : On admission, pt's transaminases were
noted to be elevated. This was thought secondary to increased
load in the right heart s/p PE. LFTs trended down during his
stay.
PRESYNCOPE: Likely a vasovagal response secondary to valsalva
during BM in combination with developing PEs. Remained
asymptomatic during this admission. Pt also has hx of elevated
creatinine (nl MB fraction) and ruled out for MI; no evidence of
another acute muscular condition.
PROPHY: receiving heparin, ambulating as tolerated
FEN: Diabetic diet
CONTACT: wife: [**Telephone/Fax (1) 15752**], [**Name2 (NI) **]r: [**Telephone/Fax (1) 15753**]
DISPO ?????? Upon successful transition to warfarin and development
of appropriate outpatient therapeutic strategy, pt was
discharged home. He will follow-up with Dr.[**First Name (STitle) 1313**] on Thursday
[**12-23**] and have an INR check Wed [**12-22**].
Medications on Admission:
norvasc
glyburide
actos
diovan 160/12.5
ASA
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
3. Pioglitazone HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED).
7. Enoxaparin Sodium 120 mg/0.8 mL Syringe Sig: One (1)
injection Subcutaneous Q12H (every 12 hours) for 2 days.
Disp:*4 injection* Refills:*0*
8. Coumadin 2.5 mg Tablet Sig: Five (5) Tablet PO at bedtime.
Disp:*150 Tablet(s)* Refills:*2*
9. Outpatient [**Name (NI) **] Work
PT/INR
Please fax results to ([**Telephone/Fax (1) 15754**].
ATTN: Dr.[**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 1313**]
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral pulmonary emboli
HTN
Diabetes
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor and return to the hosiptal for any
increasing shortness of breath, chest pain, or any other
concerning symptoms you may have.
Please continue lovenox injections for 2 days amd follow-up with
Dr.[**First Name (STitle) 1313**] later this week for check of INR.
Followup Instructions:
Please follow-up with Dr.[**First Name (STitle) 1313**] in 1 week after discharge.
Please call for appointment: [**Telephone/Fax (1) 7318**].
Please have your bloodwork checked on Thursday, [**2117-12-23**] and faxed
to Dr.[**First Name (STitle) 1313**] for possible titration of your coumadin dose.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"25000",
"4019"
] |
Admission Date: [**2148-5-25**] Discharge Date: [**2148-5-26**]
Date of Birth: [**2148-5-23**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 73130**] is the former
3.525 kg product of a term gestation pregnancy, [**Known lastname **] to a 40-
year-old, G2, P1 woman. Prenatal screen: Blood type B
negative, antibody negative, RPR nonreactive, rubella immune,
hepatitis B surface antigen negative, Group beta strep status
negative. The pregnancy was uncomplicated. Rupture of
membranes occurred 23 hours prior to delivery. There was no
maternal fever or other sepsis risks factors. The baby was
[**Name2 (NI) **] by spontaneous vaginal delivery and had Apgars of 8 at 1
minute and 9 at 5 minutes. He was admitted to the newborn
nursery where he had an unremarkable newborn nursery course
except for several episodes noted by the mother of [**Name2 (NI) 1440**]
holding with circumoral and central cyanosis. The baby was
admitted to the neonatal intensive care for observation.
PHYSICAL EXAMINATION AT DISCHARGE: Weight 3.27 kg, length 20
inches, head circumference 35.25 cm. General: A pink, active,
nondysmorphic male in no acute distress. [**Name2 (NI) **] sounds clear
and equal. Cardiovascular: Regular rate and rhythm, no
murmur. Femoral pulses +2. Abdomen: Soft, nontender,
nondistended, no masses. Cord on and drying. GU: Normal male.
Circumcision healing, no evidence of drainage. Anus patent.
Musculoskeletal: Spine intact. Hips normal. Neuro: Nonfocal
and age appropriate exam.
HOSPITAL COURSE BY SYSTEMS/PERTINENT LABORATORY DATA:
1. Respiratory: This baby was monitored for 24 hours. Some
of these [**Name2 (NI) 1440**] holding episodes were observed. The baby
did have concurrent circumoral cyanosis but maintained
oxygen saturations greater than 98% in room air and did
not demonstrate any heart rate changes.
2. Cardiovascular: No murmurs were noted. This baby
maintained normal heart rates and blood pressures.
3. Fluids/Electrolytes/Nutrition: The baby has been ad lib
breast feeding, waking every 1-2.5 hours and feeding well
for 10-20 minutes each side.
4. Infectious Disease: There were no issues.
5. Gastrointestinal: Serum bilirubin on day of life #2 had a
total of 6.1 mg/dl.
6. Hematology: Infant's blood type is B+ (coombs negative).
7. Neurology: This baby has maintained a normal neurological
exam and there are no neurological concerns.
8. Sensory Audiology: Hearing screening was performed with
automated auditory brainstem responses. This baby passed
in both ears on [**2148-5-25**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with the parents. Primary
pediatric care will be provided through [**Hospital 620**] Pediatrics,
[**Last Name (NamePattern1) 40688**], [**Location (un) 620**], [**Numeric Identifier 3002**], ([**Telephone/Fax (1) 63539**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Ad lib breast feeding.
2. No medications.
3. Iron and vitamin D supplementation: Iron supplementation
is recommended for preterm and low birth weight infants
until 12 months corrected age. All infants fed
predominantly breast milk should receive vitamin D
supplementation at 200 international units (may be
provided as a multivitamin preparation) daily until 12
months corrected age.
4. Car seat position screening not indicated.
5. State newborn screen sent on [**2148-5-25**], no
notification of abnormal results to date.
6. Immunizations: Hepatitis B vaccine was administered on
[**2148-5-24**].
7. Immunizations recommended:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of
the following 4 criteria:
a. [**Month (only) **] at less than 32 weeks.
b. [**Month (only) **] between 32 and 35 weeks with 2 of the
following:
Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway
abnormalities, or school-age siblings, chronic
obstructive pulmonary disease, hemodynamically
significant congenital heart 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.
8. 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 6 weeks but fewer than 12 weeks of age.
FOLLOW-UP APPOINTMENTS: Appointment at [**Hospital 620**] Pediatrics
within 3 days of discharge.
DISCHARGE DIAGNOSES:
1. Term newborn.
2. [**Hospital **] holding episodes.
3. Status post circumcision.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Name8 (MD) 73131**]
MEDQUIST36
D: [**2148-5-26**] 06:23:08
T: [**2148-5-26**] 12:22:23
Job#: [**Job Number 73132**]
|
[
"V053"
] |
Unit No: [**Numeric Identifier 69276**]
Admission Date: [**2145-7-8**]
Discharge Date: [**2145-7-28**]
Date of Birth: [**2145-7-8**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 12967**] is a former 29
and [**12-29**] week gestational age infant, now 20 days old with
corrected gestational age at 32 and 1/7 weeks. She is 1.150
gram product of 29 and [**12-29**] week gestation, born to an 18 year-
old, Gravida I Para 0 to I who presented to [**Hospital1 18**] on [**2145-7-6**]
after hospitalization in [**Hospital3 1280**] Hospital with premature
rupture of membranes. She was treated with betamethasone,
antibiotics and mag sulfate. She was beta complete at the
moment of delivery. She progressed and had vaginal delivery
on [**2145-7-8**]. Her prenatal screens were remarkable for
blood group A positive, antibody negative, RPR nonreactive,
Rubella immune, HBS antigen negative. GBS unknown. No
additional infectious risk factors. At delivery, the infant
emerged vigorous. Blood by oxygen and stimulation were given.
Apgars were 8 and 9. He was transferred to neonatal ICU on
room air and admitted for prematurity.
PHYSICAL EXAMINATION: Birth weight 1150 grams which is 25th
percentile. Length is 39.5 cm which is 50 to 75th percentile.
Head circumference is 25 cm which is less than 10th
percentile. Infant pink, active,Baby Girl [**Known lastname 12967**] is a former
29 and [**12-29**] week gestational age infant, now 20 days old with
corrected gestational age at 32 and 1/7 weeks. She is 1.150
gram product of 29 and [**12-29**] week gestation, born to an 18 year-
old, Gravida I Para 0 to I who presented to [**Hospital1 18**] on [**2145-7-6**]
after hospitalization in [**Hospital3 1280**] Hospital with premature
rupture of membranes. She was treated with betamethasone,
antibiotics and mag sulfate. She was beta complete at the
moment of delivery. She progressed and had vaginal delivery
on [**2145-7-8**]. Her prenatal screens were remarkable for
blood group A positive, antibody negative, RPR nonreactive,
Rubella immune, HBS antigen negative. GBS unknown. No
additional infectious risk factors. At delivery, the infant
emerged vigorous. Blood by oxygen and stimulation were given.
Apgars were 8 and 9. He was transferred to neonatal ICU on
room air and admitted for prematurity. Infant pink, active,
non dysmorphic, well perfused and saturated in room air,
breathing comfortably. Anterior fontanel open and flat.
Mucous membranes moist. Nares patent. Palate is intact.
Regular rate and rhythm. Normal S1 and S2. No murmur
appreciated. Lungs are clear. Abdomen is benign. Genitalia
preemie female. Hips normal. Non focal neurologic exam. Tone
is appropriate for age. Spine intact. Anus patent.
HOSPITAL COURSE BY SYSTEM: Respiratory: Initial chest x-ray
without significant changes. She remained on room air for the
first 24 hours and then intermittently required low flow
nasal cannula. She was put on nasal cannula on day of life 10
and remained with low flow nasal cannula at 25 to 50 cc 100%
oxygen since then. She was started on caffeine on day of life
3 for apnea and bradycardia and she remained on caffeine
since then with good control of apnea of prematurity.
Cardiovascular: She remained stable through her hospital
course. Her exam was reassuring. No murmurs were appreciated.
Fluids, electrolytes and nutrition/gastrointestinal: On
admission, she was started on IV fluids. Feeds were
introduced on day of life 1. She received TPN with
intralipids through the umbilical venous catheter until day
of life 9. She slowly progressed on her feeds until full
feeds by day of life 10 and since [**7-18**], she is at full
pg feeds, at the moment of transfer. She is at 150 cc/kg of
breast milk 28 with Beneprotein, all nasogastric feeds. She
was treated for hyperbilirubinemia through her hospital
course. Her bilirubin peaked on day of life 3 at 6.7 over .3.
Phototherapy was discontinued on day of life 5. Her last
bilirubin was on [**7-15**], day of life 7 and was 3.7.
Hematology: Her initial CBC was reassuring with a hematocrit
of 43.5. Her last hematocrit was done on [**7-16**], day of
life 8 and was 41.9.
Infectious disease: On admission, CBC and blood culture were
sent. CBC with 4.9 white blood cell count, 63 polys, 3 bands,
20 lymphs, 2 myelocytes, and hematocrit of 43.5 and platelets
486. Blood cultures were sent and were negative at 48 hours.
She was treated with Ampicillin and Gentamycin due to
concerning CBC. She was treated for a total of 4 days. Repeat
blood cultures were drawn on [**7-15**] and grew gram positive
cocci in pairs and clusters. Repeat blood cultures prior to
antibiotics the same day were negative. She was treated for
48 hours with Vancomycin and Gentamycin. These positive blood
cultures were thought to be contamination. Her surface
cultures came back positive for MRSA on [**2145-7-27**],
day of life 19 and she is on contact precautions since then.
Neurology reassuring exam through the hospital stay. Head
ultrasound was done on [**2145-7-15**] and was within normal
limits.
Audiology: No hearing screen done yet.
Ophthalmology: Not examined. The patient is due to first exam
in 2 weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Transfer to level II special care
nursery in [**Hospital3 1280**] Hospital.
NAME OF PRIMARY PEDIATRICIAN: To be determined.
CARE AND RECOMMENDATIONS: Feeds at discharge: Full p.g.
feeds at 150 cc/kg, breast milk 28 with Beneprotein.
MEDICATIONS:
1. Vitamin E 5 units p.g. once a day.
2. Caffeine 7 mg p.g. once a day.
3. Ferrous sulfate as Fer-in-[**Male First Name (un) **] .15 cc once a day.
Car seat test is not performed here but should be done prior to
discharge home.
State newborn screen was sent on [**7-11**] and [**7-22**].
IMMUNIZATIONS RECEIVED: No hepatitis B vaccine given yet.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: (1) Born at less than
32 weeks; (2) Born between 32 weeks and 35 weeks with two of
the following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; (3) 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 29 and 2/7 weeks.
2. Rule out sepsis.
3. Hyperbilirubinemia.
4. Respiratory distress.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Doctor Last Name 69108**]
MEDQUIST36
D: [**2145-7-28**] 16:20:42
T: [**2145-7-28**] 17:18:49
Job#: [**Job Number 69277**]
|
[
"7742",
"V290"
] |
Admission Date: [**2123-1-20**] Discharge Date: [**2123-1-31**]
Date of Birth: [**2061-1-6**] Sex: F
Service:
ADMISSION DIAGNOSIS:
Chest pain.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post coronary artery bypass graft times three.
HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old
female with a past medical history for type 2 diabetes,
obesity, hypertension, and known coronary artery disease.
The patient had coronary artery stenting in [**2122-11-29**]
and was in her usual state of health until she awoke with
coughing, wheezing, chest heaviness and dull pain to the
shoulder blades. The patient took two nitroglycerin tablets
without relief and was transported by EMS system to the
Emergency Department. Cardiac workup was begun in the
Emergency Department and the patient was given 40 mg of
intravenous Lasix, supplemental oxygen and nitroglycerin
drip. The patient was also beta blocked with Metoprolol 10
mg intravenous times one and begun on Integrilin as well as
heparin.
PAST MEDICAL HISTORY:
1. Type 2 diabetes.
2. Hypertension.
3. Coronary artery disease.
MEDICATIONS: Aspirin 325 mg po q day, atenolol 50 mg po q
day, Lipitor 10 mg po q day, Isosorbide mononitrate 30 mg q
day, Plavix 75 mg po q day, Lasix 20 mg q.d., Rosiglitazone
50 mg q.d., Glyburide 5 mg po q day, Metformin 1000 mg
b.i.d., Lisinopril 40 mg q day, Vitamin B-12 100 micrograms q
day, iron sulfate 325 mg t.i.d.
ALLERGIES: Penicillin.
PHYSICAL EXAMINATION: The patient is an elderly woman in
some distress. Her vital signs are heart rate 94. Blood
pressure 113/54. Respirations 12. Oxygen saturation 99% on
3 liters nasal cannula. HEENT throat is clear. Neck is
supple, midline. No carotid bruit. Chest is significant for
slight crackles at the bases. Cardiovascular is regular rate
and rhythm without murmurs, rubs or gallops. Abdomen is
soft, nontender, nondistended and obese. No masses or
organomegaly. Extremities are warm, noncyanotic,
nonedematous times four. Neurological is grossly intact.
LABORATORIES ON ADMISSION: CBC 9, 34.1, 194, urinalysis is
negative. Chem 7 is 140, 5.1, 103, 24, 44, 1.1, 211. CKs
241 with MB of 6 and troponin I of 4.0.
HOSPITAL COURSE: The patient was admitted to the Emergency
Department and taken on an emergent basis to the cardiac
catheterization laboratory. The patient had 100% occlusion
of the right coronary artery, 70% of left anterior descending
coronary artery and 70% of the circumflex. Recommendations
made for urgent revascularization procedure. Plavix was held
for the procedure and the patient was continued on aspirin,
beta blocker, statin and ace inhibitor. The patient ruled
out for myocardial infarction post catheterization. On
[**2123-1-21**] the patient received 1 unit of packed red blood cells
for a hematocrit of 26. The patient tolerated this well
without problems. The patient did well on the floor while
waiting her bypass procedure. She was heparinized and did
receive a 2 unit of red blood cells on [**2123-1-24**] for a
hematocrit of 29.3.
The patient was appropriately preoped and taken to the
Operating Room on [**2123-1-25**]. At that time she had a coronary
artery bypass graft times three using the left internal
mammary coronary artery and saphenous vein graft. The
patient tolerated this without complications.
Postoperatively, the patient was taken to the Intensive Care
Unit for close monitoring. She was maintained on Propofol
and a Protonin drips, as well as an insulin drip for elevated
blood sugars. Nitroglycerin drip was used intermittently for
her hypertension. This was titrated to keep mean arterial
pressure between 60 and 90. The patient was extubated on
postoperative day number two and subsequently transferred to
the floor. She was transfused an additional 2 units of
packed red blood cells. On the floor, the patient did well
without any acute issues. She was seen by physical therapy
for conditioning and gait training. Chest tubes and pacer
wires were discontinued on postoperative day number three.
Cardiac medications were titrated to effect for heart rate
and blood pressure. The patient had an otherwise uneventful
course except for on the early morning of [**2123-1-30**] when the
patient had a short run of seven beat ventricular
tachycardia. The patient was kept for 24 hours after this
for monitoring. Since there was no significant repeat or
other arrhythmia at this time, the patient was discharged to
home on postoperative day number six tolerating a regular
diet and taking adequate pain control on po pain medications
and having no more anginal equivalents or arrhythmias on
telemetry.
PHYSICAL EXAMINATION ON DISCHARGE: Vital signs are stable,
afebrile. Temperature 98.3, heart rate 84, blood pressure
143/70, respirations 20, oxygen saturation 94% on room air.
Chest was clear to auscultation bilaterally. Sternal
incision was clean and dry with no drainage. Cardiovascular
is regular rate and rhythm without murmurs, rubs or gallops.
Abdomen is soft, nontender, nondistended. Extremities warm
and well perfuse without cyanosis or edema. Neurologically
intact.
LABORATORY ON DISCHARGE: CBC 7.8, 32.6, 208. Chemistries
137, 4.7, 101, 27, 26, 7.8, 129, magnesium 1.8.
MEDICATIONS ON DISCHARGE: Lasix 20 mg po b.i.d. times seven
days, potassium chloride 20 milliequivalents b.i.d. times
seven days. Colace 100 mg po b.i.d., aspirin 325 mg q day,
percocet 5/325 one to two tablets q 4 hours prn. Glyburide 5
mg q.d., iron complex 150 mg q.d., Lipitor 10 mg po q day,
cyanocobalamin 50 micrograms q day, Metformin 1000 mg b.i.d.,
Rosiglitazone 2 mg q.d., Lopressor 25 mg b.i.d.
DISCHARGE CONDITION: Good.
DISPOSITION: To home.
DIET: Cardiac, diabetic.
DISCHARGE INSTRUCTIONS: The patient is to follow up with her
cardiologist in one to two weeks. Diuresis and adjustment of
cardiac medications should be addressed at that time. The
patient should follow up with Dr. [**Last Name (STitle) 70**] in four weeks
time.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 14041**]
MEDQUIST36
D: [**2123-1-31**] 04:14
T: [**2123-2-2**] 05:54
JOB#: [**Job Number 14042**]
|
[
"41401",
"5070",
"4280",
"4019"
] |
Admission Date: [**2114-7-24**] Discharge Date: [**2114-9-25**]
Service: VASCULAR
CHIEF COMPLAINT: Worsening toe gangrene
HISTORY OF PRESENT ILLNESS: The patient was seen in the
Emergency Room on [**2114-7-24**] for increasing right foot pain and
gangrenous changes of his right foot. He is an 84-year-old
disease with stenting to LAD and diagonal prior to
consideration of vascular surgery for bilateral blue toe
syndrome. Surgery was delayed because the patient had
undergone cardiac catheterization and was placed on Plavix
secondary to his angioplasty and stent. He returns now with
progressive foot and leg ischemic changes.
1. Hypertension
2. Coronary artery disease
3. Chronic renal insufficiency failure on dialysis since
[**Month (only) **] of this year secondary to cholesterol embolization from
cardiac catheterization
4. History of congestive failure with an ejection fraction
of 25%
5. History of aortic stenosis with a valve area of 0.8 cm
square
6. History of left renal artery stenosis
7. Hypercholesterolemia
8. Gastroesophageal reflux disease on dialysis Monday,
Wednesday and Friday, status post angioplasty to the LAD and
diagonal with stents in [**Month (only) **] of this year
MEDICATIONS:
1. Zestril 2.5 mg qd
2. Lipitor 20 mg qd
3. Tums with meals
4. Plavix 75 mg qd, last dose was [**7-27**].
5. Epogen 4000 units at dialysis
6. Dilaudid 0.5 prn
7. Prevacid 30 mg [**Hospital1 **]
8. Lopressor 100 mg [**Hospital1 **]
9. Nephrocaps qd
10. Neurontin 200 mg qd
11. Enteric coated aspirin 325 mg qd
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: He presently is a resident at [**Hospital1 **] Rehabilitation. Denies drinking or smoking.
PHYSICAL EXAM:
VITAL SIGNS: 98.6??????, 125, 139/114, 20, O2 saturation 97%.
GENERAL APPEARANCE: Frail elderly male, older than stated
age.
HEAD, EARS, EYES, NOSE AND THROAT: Unremarkable.
CHEST: Clear to auscultation bilaterally.
HEART: Irregularly irregular rhythm.
ABDOMEN: Unremarkable.
MUSCULOSKELETAL: Left foot with middle gangrenous toe, dark
discoloration of the distal foot which is cool with a 1+
pedal pulse. The right foot second, third and fourth toes
are gangrenous changes with moderate skin on the dorsal
surface of the foot. There are no palpable pulses. There is
no edema. He has a stage II sacral ulcer.
STUDIES: Electrocardiogram obtained in the Emergency Room
showed a regular sinus rhythm. This was compared with the
previous electrocardiogram. He was admitted to the vascular
service for further evaluation and treatment.
LAB WORK: CBC with a white count of 19.8, hematocrit 28.7
and platelets 270. INR was 1.7. PTT was 28.6. BUN was 47,
creatinine 5.7. Potassium was 4.3.
Cardiology was notified of the admission and felt that there
was nothing from a cardiac standpoint that they had to offer.
The rest was medical management. The patient underwent
dialysis on the day of admission. The patient was preopped
for femoral AT. His chest x-ray showed mild pleural
effusions. Electrocardiogram was a regular rhythm.
LABS: CBC: White count 19.7, hematocrit 36.1, platelets
307. INR was 1.5. PTT was 47.7. BUN 49, creatinine 6.0,
potassium 4.2, ALT 147, AST 54, alkaline phosphatase 16,
total bilirubin 0.7. Albumin 2.9, calcium 8.2, phos 3.9,
magnesium 2.1.
The patient underwent on [**7-25**], a right BK [**Doctor Last Name **] to AT bypass
with reverse saphenous vein with intraoperative arteriogram.
He tolerated the procedure well and was transferred to the
PACU in stable condition. Postoperatively, he was
hemodynamically stable. His incisions were clean, dry and
intact. He had a palpable graft pulse. His postoperative
hematocrit was 35. His potassium was 4.4. Chest x-ray was
without pneumothorax and electrocardiogram as without
changes. The patient continued to do well and was
transferred to the VICU for continued monitoring and care
Postoperative day 1, there were no overnight events. He
remained hemodynamically stable. His hematocrit remained
stable. His extremities showed cool, cyanotic, necrotic tips
of the right toes. He had a palpable graft pulse and a
dopplerable DP. His lungs were clear to auscultation. His
diet was advanced as tolerated. He was continued on
perioperative antibiotics. His heparin was adjusted to meet
a therapeutic PTT of 60 to 80. He remained in the VICU.
Cardiology was reconsulted. His serial CK was 439. MB was
10. His troponin was 1.4. Cardiology was consulted
regarding elevated troponin in relevance to the patient.
They felt that he did not have acute coronary syndrome, was
most likely the troponin was secondary to congestive heart
failure. They recommended to continue cycling his CKs for a
total of three, continue aggressive medical management of his
coronary artery disease, perioperative beta blocking and
hemodialysis as indicated. Renal followed the patient during
his hospitalization and managed his hemodialysis needs. On
[**2114-7-27**], he underwent arterial Duplex. It was a limited
study. The graft was demonstrated to be patent.
Postoperative day 2, he was D-lined. He was transferred to
the regular nursing floor for continued management and care.
The patient continued to remain stable from a cardiac
standpoint and a renal standpoint. On [**2114-8-1**], the patient
underwent a right transmetatarsal amputation and a left third
toe amputation. He tolerated the procedure well and was
transferred to the PACU in stable condition. He continued to
do well and was transferred to the regular nursing floor.
His hematocrit remained stable at 31.4, BUN 24, creatinine
3.7, potassium 4.2. He was noted on postoperative day 1 to
have some ectopy. He was placed back in the VICU for rule
out. Serial CKS were obtained which were 46 and 44. His
vancomycin was monitored and dosed according to random level.
Physical therapy was requested to see the patient for non
weight bearing ambulation on the transmetatarsal amputation
site. This would be needed to be done for a total of four
weeks. The initial dressing was removed on postoperative day
#2. The wounds were clean, dry and intact.
Coumadin conversion was started on postoperative day 10 and
3. The amputation site looked good, but there were cyanotic
changes of toes 2 and 4 on the left. The left toes continued
to demarcate and on [**8-6**], the transmetatarsal amputation site
showed erythema. Three sutures were removed. The wound was
explored. There was old hematoma. Cultures were obtained.
The wound was packed. He was continued to be monitored.
Coumadinization was continued. His antibiotics were
discontinued on [**2114-8-7**]. The left toes continued to
demarcate, wound eventually require amputation. The graft
was palpable and the eschar on the wounds remained stable.
Physical therapy was requested to see the patient and begin
non weight bearing ambulation. Case management began
screening for rehabilitation potential versus discharge to
home. Cultures obtained on the transmetatarsal amputation
site on [**8-6**], gram stain with 2+ polys. There were no
organisms. The finalization of the culture was pending at
the time of dictation. Blood cultures obtained on [**8-5**] x2
were no growth but not finalized. Wound cultures from [**8-2**]
tissue grew Staphylococcus coagulase negative, rare yeast,
presumptively not C. albicans, isolated from broth media
only. Enterococcus isolated from broth media only.
Enterococcus was sensitive to vancomycin, resistant to
levofloxacin, sensitive to penicillin and ampicillin. There
were no anaerobes. Stool culture for Clostridium difficile
on [**7-29**] was negative. Chest x-ray was unremarkable. White
count on [**8-7**] was 15.8, hematocrit 32.2, platelets 483, PT
15.4, INR 1.7, PTT 55.6. The patient's electrolytes: Sodium
137, potassium 4.8, chloride 99, CO2 25, BUN 37, creatinine
5.2, glucose 82.
Ultimately his C.diff was positive. He was treated with flagyl
po, however, did not seem to improve as rapidly as expected.
Therefore, he was changed to po vanco and IV flagyl. He improved
with respect to his abdominal pain as well as his mental status.
His blood cultures came back positive for gram negative bacteria,
likely secondary to translocation. As a result, we were
concerned about mesenteric ischemia. A colonoscopy was completed
which demonstrated resolving ischemic colitis. As it was
resolving, we opted for conservative management at this time. Mr.
[**Known lastname **] [**Last Name (Titles) 27836**] extremely well.
At hemodialysis, he developed acute onset of shortness of
breath with hypotension. Hemodialysis was stopped and the
patient transferred back to the floor. His ABg at that time was
extremely acidotic and would ultimately require intubation. In
conjunction with the medical team, we discussed the option of
intubation with the family. They opted for conservative care
only. He expired shortly thereafter.
DISCHARGE DIAGNOSES:
1. Bilateral toe syndrome with gangrene, status post right
popliteal pedal bypass graft
2. Toe amputations, left second toe and right
transmetatarsal amputation
3. Hypertension controlled
4. End stage renal disease on hemodialysis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 7252**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2114-8-7**] 12:18
T: [**2114-8-7**] 13:49
JOB#: [**Job Number 42093**]
|
[
"41401",
"V4582",
"2720",
"53081"
] |
Admission Date: [**2104-6-26**] Discharge Date: [**2104-7-2**]
Date of Birth: [**2044-5-25**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 60-year-old white
female patient with no previous history of coronary artery
disease who presented after approximately 12 hours of
intermittent stuttering chest pain radiating to bilateral
arms. She did also have shortness of breath and nausea. She
presented to an outside hospital emergency department with
chest pain. Her electrocardiogram showed ST elevations in
the lateral leads with associated ST depression inferiorly.
She was treated with nitroglycerin as well as a heparin drip
and IV beta-blockers and was transferred to the [**Hospital1 346**] on [**2104-6-26**], for cardiac
catheterization. This revealed right dominant system with a
tight osteal left main lesion of 80 to 90 percent as well as
90 percent occlusion at the mid LAD. She had an intra-aortic
balloon pump placed at that time due to her anatomy and the
cardiothoracic surgical consult was obtained. She was
admitted to the Coronary Care Unit over night and
preoperatively prior to coronary artery bypass graft.
PAST MEDICAL HISTORY: Glaucoma.
MEDICATIONS PRIOR TO ADMISSION: Timolol.
ALLERGIES: Keflex and Percodan.
SOCIAL HISTORY: The patient denies alcohol or tobacco intake
and exercises regularly.
Physical examination preoperatively was unremarkable as were
preoperative laboratory values.
She was taken to the Operating Room on [**2104-6-26**], where
she underwent coronary artery bypass graft times 3 with the
LIMA to the LAD, saphenous vein to the OM and saphenous vein
to the diagonal. Postoperatively, she was transported from
the Operating Room to the Cardiac Surgery Recovery Unit in
good condition. The patient was transported from the
Operating Room on Neo-Synephrine with an intra-aortic balloon
pump intact. She was successfully weaned from mechanical
ventilation and extubated later the day of surgery. Her Neo-
Synephrine was weaned off the following day. Her intra-
aortic balloon pump was discontinued. She was started on
beta-blocker and transferred out of the Intensive Care Unit
to the Telemetry Floor on postoperative day 1. On
postoperative day 2, the patient remained hemodynamically
stable in sinus rhythm with a rate in the 80s. Her chest
tubes were discontinued. She was begun with diuretics. On
postoperative day 3, the patient continued to progress from a
physical therapy standpoint. She began ambulation. Her
epicardial pacemaker wires were discontinued on postoperative
day 3. She had not had arrhythmias and was tolerating her
beta-blocker and diuretic regimen.
On postoperative day 4, she continued to progress and
completed physical therapy level 5. She also had her beta-
blocker increased. However, the following day on
postoperative day 5, the patient had a syncopal event upon
getting out of the hot shower. She said that she felt
lightheaded and was helped down to the ground. She denies
any loss of consciousness and no hitting her head at all.
She was alert and oriented upon examination. At that time,
she denied any chest pain and was able to stand and ambulate
to bed without any difficulty. For that reason, her
Lopressor was discontinued and her diuretics were
discontinued as well. Although her blood pressure was 102/42
at the time of the event and her heart rate was 83 and normal
sinus rhythm, it was felt prudent to decrease her beta-
blocker as well as discontinue her Lasix and keep her in the
hospital for another 24 hours. She remained monitored for
the following 24 hours with no further events and no further
syncope and no further lightheadedness and is stable and is
being discharged home today.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Ranitidine 150 mg p.o. b.i.d.
3. Methazolamide 50 mg p.o. b.i.d.
4. Timolol eye drops 0.5 percent b.i.d.
5. Dilaudid 2 mg p.o. one-half to one tablet p.o. q. 4 to 6
hours p.r.n. pain.
6. Plavix 75 mg p.o. q.d.
7. Aspirin 81 mg p.o. q.d.
8. Lopressor 12.5 mg p.o. b.i.d.
9. Vitamin C 500 mg p.o. b.i.d.
10. Folic acid 1 mg p.o. q.d.
11. Niferex 150 mg p.o. q.d.
The patient is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in
approximately 5 weeks. She is to follow up with Dr. [**Last Name (STitle) **] in
one to two weeks as well as with her primary care physician.
DISCHARGE DIAGNOSIS: Coronary artery disease, status post
coronary artery bypass graft
DISCHARGE CONDITION: Good.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 5664**]
MEDQUIST36
D: [**2104-7-2**] 14:52:46
T: [**2104-7-2**] 15:43:56
Job#: [**Job Number **]
|
[
"41401"
] |
Admission Date: [**2111-4-21**] Discharge Date: [**2111-4-28**]
Date of Birth: [**2035-5-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Fevers, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 75 year old male with a history of recent
subdural hematoma s/p drainage, now being rehabilitated at
[**Hospital1 **], who has developed fevers and increasing abdominal
pain times 2 days. The patient was discharged from the
neurosurgical service on [**2111-4-14**] aster subdural drain and GJ
tube placement. He was started on ceftriaxone and vancomycin on
the day of presentation after becoming more obtunded prior to
transfer to [**Hospital1 18**].
Past Medical History:
Subdural hematoma
Hypertension
Hypercholesterolemia
Essential thrombocytopenia
s/p placement of GJ tube
infected GJ tube insertion site
h/o C diff infection
Social History:
portugese speaking, married with son and [**Name2 (NI) 6637**].
Family History:
noncontributary
Physical Exam:
T 102.0 HR 77 BP 142/64 RR 18 SpO2 99%
Obtunded, no response to pain
PERRLA, eyes closed
RRR
CTA b/l
Abd soft, distended. (+) LUQ GJ tube w/ surrounding edema and
redness. Able to express purulent drainage.
Guiac (+) stool
Moves all extremeties, 2(+) pulses
Pertinent Results:
[**2111-4-21**] 12:45PM BLOOD WBC-22.2*# RBC-3.58* Hgb-11.3* Hct-33.2*
MCV-93 MCH-31.4 MCHC-33.9 RDW-17.0* Plt Ct-709*
[**2111-4-21**] 12:45PM BLOOD Neuts-78.1* Lymphs-12.3* Monos-9.4
Eos-0.1 Baso-0.2
[**2111-4-21**] 12:45PM BLOOD Anisocy-1+ Macrocy-1+
[**2111-4-21**] 12:45PM BLOOD Plt Ct-709*
[**2111-4-21**] 02:30PM BLOOD PT-14.1* PTT-37.5* INR(PT)-1.3
[**2111-4-21**] 12:45PM BLOOD Glucose-108* UreaN-26* Creat-1.1 Na-134
K-5.1 Cl-98 HCO3-28 AnGap-13
[**2111-4-21**] 12:45PM BLOOD ALT-57* AST-58* AlkPhos-187* Amylase-52
[**2111-4-21**] 12:45PM BLOOD Lipase-18
[**2111-4-21**] 12:45PM BLOOD Albumin-3.1* Calcium-9.0 Phos-4.0 Mg-1.6
[**2111-4-21**] 12:55PM BLOOD Lactate-1.6
[**2111-4-21**] 11:16PM BLOOD freeCa-1.23
[**2111-4-23**] 10:37 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2111-4-23**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2111-4-23**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
[**2111-4-24**] 9:31 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2111-4-25**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2111-4-25**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
Reference Range: Negative.
Brief Hospital Course:
The patient presented to the hospital and was admitted to the
general surgical [**Last Name (un) 12003**]. Initially, he was placed on PO
vancomycin, IV Zosyn and IV Flagyl. He was transferred to the
ICU on the first hospital day. A CT was obtained, which showed
only focal inflammation of the cecum and terminal ileum with
some fat stranding but no free air or pneumotosis of the bowel.
He was transferred to the floor on hospital day #3. The
remainder of the hospital course was unremarkable. Of note, the
patient's WBC count decreased from 22 on admission to 6 at the
time of discharge. C diff toxin assays were negative x2. The
patient's abdominal tenderness resolved, and the GJ tube
insertion site was noted to be clean and intact without evidence
of cellulitis. He was discharged back to [**Hospital1 12004**] on hospital day #8 in stable condition,
tolerating tube feeds at goal and on PO flagyl and vancomycin.
Medications on Admission:
Colace
RISS
keppra
lopressor 125'
heparin sc
hctz
zocor
paxil
clonidine
flagyl
Discharge Medications:
1. Vancomycin HCl 10 g Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 2 days.
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
ml Injection TID (3 times a day).
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 days.
6. Ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO BID (2
times a day).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 2 days.
9. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Subdural hematoma
Hypertension
Hypercholesterolemia
Essential thrombocytopenia
s/p placement of GJ tube
infected GJ tube insertion site
h/o C diff infection
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital if you experience chills or fevers
greater than 101.5 degrees F. Please return if you notice
excessive redness, swelling, or tenderness of your GJ tube
insertion site, or if it begins to drain pus. Please return to
the hospital if you experience prolonged diarrhea. Complete all
antibiotics as prescribed.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 519**] in 2 weeks, unlss otherwise
instructed. Please call [**Telephone/Fax (1) 6554**] for an appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"4019",
"2720"
] |
Admission Date: [**2174-9-20**] Discharge Date: [**2174-9-22**]
Date of Birth: [**2120-10-27**] Sex: M
Service: [**Hospital1 139**]
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 53-year-old
male with a history of chronic obstructive pulmonary disease
(not requiring home oxygen), coronary artery disease, and
diabetes admitted directly to the Medical Intensive Care Unit
on [**9-20**] for hypoxemic and hypercapnic respiratory
failure.
Mr. [**Known lastname **] was in his usual state of health until the
morning of [**9-20**] when he developed progressive shortness
of breath not relieved by his usual inhalers. Prior to the
onset of this dyspnea, he relates experiencing a runny nose
and a sore throat for several days. However, he denies
experiencing chest pain, palpitations, nausea, vomiting,
fevers, chills, or a productive cough.
After several hours of worsening shortness of breath,
tachypnea and diaphoresis, the patient called Emergency
Medical Service and was taken to [**Hospital1 190**] for evaluation and treatment.
In the Emergency Department, the patient was noted to be in
severe respiratory distress; only able to speak 1-word
sentences. His vital signs were as follows; temperature was
97.9, blood pressure was 239/159, heart rate was 124,
respiratory rate was 36, and oxygen saturation of 83% on 100%
nonrebreather. The patient was then intubated, placed on a
nitroglycerin drip for blood pressure, started on steroids,
antibiotics, and nebulizers and admitted to the Medical
Intensive Care Unit.
In the Medical Intensive Care Unit, the patient was placed on
ventilator assist-control mode. He was intubated for less
than 24 hours. On the morning following his admission to the
Medical Intensive Care Unit, the patient was weaned off the
ventilator. His nitroglycerin drip was stopped. His oxygen
saturations were found to be greater than 95% on 5 liters
nasal cannula, and his blood pressure was well controlled
with a systolic blood pressure of 160.
The patient was then called out to the floor for further
observation. During the Intensive Care Unit stay, the
patient was ruled out for a myocardial infarction with cycled
enzymes and electrocardiogram.
PAST MEDICAL HISTORY:
1. Coronary artery disease; 3-vessel disease, status post
coronary artery bypass graft in [**2168**].
2. Hypertension.
3. Diabetes mellitus; complicated by nephropathy.
4. Chronic obstructive pulmonary disease; not requiring home
oxygen, unknown pulmonary function tests. Multiple
admissions for chronic obstructive pulmonary disease
exacerbations including one in [**2172**] which required
intubation.
MEDICATIONS ON ADMISSION: Home medications were albuterol,
aspirin, Flovent, NPH insulin, Atrovent, levofloxacin,
Ativan, Protonix.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is a long-time smoker with
greater than a 40-pack-year history; smoking half a pack per
day. He admits to occasional alcohol use; four beers on the
weekends, but denies any intravenous drug use. He lives
alone in [**Location 8391**] and has a girlfriend.
REVIEW OF SYSTEMS: Review of systems as above.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on the
floor were as follows; temperature was 98.1, blood pressure
was 150/80, heart rate was 86, respiratory rate was 22,
saturating 98% on 5 liters nasal cannula. The patient's
physical examination in general revealed the patient was a
well-developed and well-nourished male, in bed, appeared
comfortable, in no acute distress. Head, eyes, ears, nose,
and throat revealed pupils were equal, round, and reactive to
light. Sclerae were anicteric. His oropharynx was clear with
poor dentition and dry mucous membranes. Neck revealed the
patient had no jugular venous distention, no lymphadenopathy,
and his neck was supple. Cardiovascular revealed the
patient's heart was regular in rate and rhythm. A soft 2/6
systolic murmur at the left lower sternal border. No rubs or
gallops. Lungs revealed the patient had decreased breath
sounds at the bases, diffuse rhonchi most prominently
anteriorly in the right lung, and expiratory wheezes in the
right lung. His abdomen was obese, soft, nontender, and
nondistended, with good bowel sounds. Extremities revealed
the patient's extremities were notable for clubbing, tar
stains, and cyanosis; but no edema.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
revealed complete blood count was as follows; white blood
cell count was 11.1, hematocrit was 40.4, and platelet count
was 234. His Chemistry-7 revealed sodium was 140, potassium
was 4.1, chloride was 104, bicarbonate was 25, blood urea
nitrogen was 20, creatinine was 0.8, blood glucose was 190.
Calcium was 8.9, magnesium was 1.5, and phosphorous was 4.4.
His last arterial blood gas in the Unit prior to transfer to
the floor was on 4 liters of oxygen by nasal cannula with a
pH of 7.4, PCO2 was 48, and an O2 of 84.
RADIOLOGY/IMAGING: A chest x-ray from [**9-20**] (on the date
of admission) showed cardiomegaly, but no overt congestive
heart failure. No consolidations or effusions.
HOSPITAL COURSE:
1. PULMONARY: As previously mentioned, the patient was
intubated in the Emergency Department, started on Solu-Medrol
and levofloxacin, and rapidly weaned off the ventilator to
room air on which he was saturating 95% to 98% on discharge.
The patient was also treated with albuterol, Atrovent, and
Flovent during his stay in the Intensive Care Unit. Sputum
culture were sent but were pending at the time of discharge.
2. CARDIOVASCULAR: The patient was markedly hypertensive on
presentation to the Emergency Department. He was started on
a nitroglycerin drip with resolution of the hypertension.
The patient was then switched to his regular doses of
captopril and Lopressor with eventual blood pressures of 160
to 150/80 on discharge.
3. ENDOCRINE: The patient was kept on a regular insulin
sliding-scale during his stay, and blood sugars were
generally between 150 and 300.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease.
2. Coronary artery disease.
3. Diabetes mellitus.
4. Hypertension.
MEDICATIONS ON DISCHARGE:
1. Albuterol meter-dosed inhaler 2 puffs q.6h. as needed for
shortness of breath.
2. Prednisone 60 mg p.o. q.d. times two days; then 40 mg
p.o. q.d. times two days; then 20 mg p.o. q.d. times two
days.
3. Levofloxacin 250 mg p.o. q.d. (times seven days).
4. Flovent 110 mcg meter-dosed inhaler 4 puffs q.a.m.
5. Atrovent meter-dosed inhaler 4 puffs q.i.d.
6. Zestril 10 mg p.o. q.d.
7. Atenolol 10 mg p.o. q.d.
8. NPH insulin 25 units q.a.m. and 8 units q.p.m.
9. Regular insulin 10 units q.a.m.
DISCHARGE FOLLOWUP: The patient was arranged for a [**Hospital 702**]
clinic appointment at his usual clinic (which is the [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 9464**] Health Center in [**Location (un) 538**]) for Tuesday,
[**9-27**], at 2:15 p.m. with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] where he was to
receive education regarding his asthma and his asthma
medications; particularly his meter-dosed inhalers.
[**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 15074**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2174-9-22**] 17:00
T: [**2174-9-28**] 13:16
JOB#: [**Job Number 15075**]
|
[
"51881",
"4019",
"25000",
"41401",
"V4581"
] |
Admission Date: [**2106-6-24**] Discharge Date: [**2106-7-7**]
Date of Birth: [**2031-3-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Zenker's diverticulum
Major Surgical or Invasive Procedure:
* Transcervical diverticulectomy with cricopharyngeal myotomy
* Exploration of neck and wide drainage, EGD and possible
thoracic exploration [**2106-6-26**]
History of Present Illness:
75 yo M with large Zenker's diverticulum causing dysphagia and
emesis who was admitted for transcervical resection.
Past Medical History:
obstructive sleep apnea, type II diabetes mellitus,
hyperlipidemia, nephrolithiasis, s/p cholecystectomy, s/p
tonsillectomy, s/p suspension micro carbon dioxide laser
cricopharyngeal myotomy of Zenker diverticulum [**2090-11-8**],
Endoscopic CO2 laser Zenker diverticulotomy [**2092-1-31**]
Social History:
Works in design. Lives with wife. [**Name (NI) 1139**]: Quit 40 years ago.
EtOH: 1-2 drinks 2 times per month. Drugs: none
Family History:
Mother with hypertension
Physical Exam:
On admission to Medical ICU:
Vitals: T: 97.1 BP: 155/51 P:75 R:23 O2: 98% RA
General: Alert, oriented, no acute distress, conversant, and
cooperative with exam
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, II/VI systolic ejection murmur,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
On day of discharge:
VS: T: 98.6 HR: 53 SB BP: 134/68 RR 16 Sats: 98% RA
General: alert oriented no distress
HEENT; normocephalic, mucus membranes moist
Neck: supple
Card: RRR
Resp: clear breath sounds
GI: benign
Extr: warm no edema
Incision: neck incision clean dry intact, no erythema, JP site
clean
Pertinent Results:
[**2106-6-24**] CK(CPK)-182 CK-MB-4 cTropnT-<0.01
[**2106-6-24**] GLUCOSE-220* UREA N-23* CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-29 ANION GAP-12
[**2106-6-24**] CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-1.5*
[**2106-6-24**] WBC-8.6# RBC-4.20* HGB-12.9* HCT-36.8* MCV-88 MCH-30.7
MCHC-35.0 RDW-12.4 PLT COUNT-165
[**2106-7-7**] WBC-8.0 RBC-3.60* Hgb-10.8* Hct-31.7* MCV-88 MCH-29.9
MCHC-33.9 RDW-13.4 Plt Ct-416
[**2106-7-7**] Glucose-75 UreaN-20 Creat-1.1 Na-137 K-4.1 Cl-102
HCO3-29
.
[**2106-6-24**] CXR
Nasogastric tube ends well seated in the upper stomach. Skin
staples and
surgical drains project over the left supraclavicular region of
the neck. No pneumothorax or mediastinal widening. Heart size
normal. Lungs clear.
.
[**2106-6-25**] CXR
No evidence of pneumomediastinum or abnormal mediastinal
widening.
However, if there is concern for esophageal leak, CT would be
more sensitive in its detection. Findings were discussed with
the house officer by phone at 10 a.m. on [**2106-6-25**].
.
[**2106-6-26**] CXR
There is some minimal increased opacity of the upper mediastinum
bilaterally. This could be post-operative change or
inflammation; however, if there is concern for an esophageal
leak CT would be more sensitive. There continues to be
subsegmental atelectasis at the left lower lung with partial
obscuration of the left hemidiaphragm and a small left pleural
effusion. Otherwise the lungs are clear.
.
[**2106-6-26**] CT chest with contrast
1. Upper mediastinal extraluminal air and fluid collection with
extensive
adjacent edema, greater than expected postoperatively. This
collection at
points appears contiguous with the esophageal lumen, concerning
for breakdown of the esophageal closure.
2. Small bilateral pleural effusions, with associated
atelectasis. No
evidence of pneumonia.
3. Secretions within the right main stem bronchus, with possible
evidence of minimal aspiration in the right upper lobe.
Esophagus
[**2106-7-6**]: There is no evidence of leak from the cervical
esophagus or residual posterior esophageal pouch. Contrast
passes freely through the esophagus.
[**2106-7-3**]: Contrast pools in the residual pouch in the proximal
esophagus. A tiny linear streak of contrast extends from the
residual posterior esophageal pouch without significant pooling,
which may represent a tiny leak. Contrast passes freely through
the esophagus into the stomach.
IMPRESSION: Possible tiny esophageal leak.
[**2106-7-7**] WBC-8.0 RBC-3.60* Hgb-10.8* Hct-31.7* MCV-88 MCH-29.9
MCHC-33.9 RDW-13.4 Plt Ct-416
[**2106-7-7**] Glucose-75 UreaN-20 Creat-1.1 Na-137 K-4.1 Cl-102
HCO3-29
Micros
[**2106-6-30**] pleural 4+ PMN, no orgs
[**2106-6-26**] fluid 4+ PMN, 3+ GPC, 2+GPR, 1+GNR; prevotella and C.
albicans
[**2106-6-26**] Tissue cx 2+ PMN, 1+ GPC, 1+GNR: prevotella and C.
albicans alloderm
[**2106-6-26**] Blood cx P
[**2106-6-26**] Tissue cx Prevotella also found, susc pending
Brief Hospital Course:
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a transcervical diverticulectomy with
cricopharyngeal myotomy on [**2106-6-24**]. Briefly, the surgery was
complicated by extremely friable mucosa which necessitated
suture closure of the defect with placement of an alloderm patch
for increased support. Please see the operative report for
further details. He was transported to the PACU in good
condition with a left neck JP drain and NGT in place.
Post-operatively he became hypertensive with systolics in the
190's to 200's that were unresponsive to hydralazine,
nitroglycerine, and nitro paste. He was transferred to the the
ICU for increased blood pressure monitoring and Medicine was
consulted. His blood pressure normalized with a labetalol drip
that was weaned off several hours later. A cardiac work-up
failed to show any evidence of myocardial infarction. A CXR on
POD #1 showed a mildly widened mediastinum without clear signs
of mediastinitis. On POD #2 the patient spiked a fever 101.4 and
was pan-cultured (including fluid from JP drain). His
antibiotics coverage was broadened from clindamycin to
Vancomycin/Ciprofloxacin/Flagyl. Given the concerning widening
of the mediastinum on repeat CXR, CT chest was ordered which
showed extraluminal air and edema. In conjunction with purulent
JP drainage, Thoracic Surgery was consulted for open exploration
of neck and possibly chest. The patient was taken to the OR
overnight on [**2106-6-26**] for neck washout. The tissue and fluid
cultures from this surgery showed mixed bacteria and [**Female First Name (un) **]
albicans. As a result fluticasone was added to the antibiotic
regimen. Immediately post-operatively his blood sugars were high
(200s) and since he was given a goal rate of 65ml/hr through NG
tube. He was started on an insulin drip and then Lantus and
Regular Q6 [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations on [**2106-6-29**]. He also
reached goal NGT feeds on [**2106-6-29**] and his sugars became well
controlled. He continued to have a left sided pleural effusion
and interventional pulmonology did a therapuetic and diagnostic
thoracentesis, getting 600cc out. The fluid analysis showed a
transudative effusion with 4+POLYMORPHONUCLEAR LEUKOCYTES but no
microorganisms. He was kept nothing by mouth and tube feeds were
slowly advanced to a goal of 75cc/hr through his nasogastric
tube. On [**2106-7-3**] he had a barium swallow to evaluate for
esophageal leak. The study could not rule out a leak and so he
was not allowed to eat, and tube feeds were continued, until
[**2106-7-6**] when he had a repeat barium swallow that showed no leak.
He will complete a 21 day course of clindamycin, cipro,
fluticasone. On [**2106-7-7**] he was discharged home on insulin
(lantus). He will follow-up with Dr. [**First Name (STitle) **], [**Last Name (un) **] and his PCP
and Infectious Disease.
Medications on Admission:
Lipitor QHS
glipizide [**Hospital1 **]
metformin TID
Januvia daily
omeprazole daily
Omnaris nasal spray daily
aspirin 325 mg daily
Tylenol PRN
Motrin PRN
Tylenol
Discharge Medications:
1. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 20 days.
Disp:*40 Tablet(s)* Refills:*0*
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 20 days.
Disp:*40 Tablet(s)* Refills:*0*
3. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
six (6) hours for 20 days.
Disp:*80 Capsule(s)* Refills:*0*
4. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*400 ML(s)* Refills:*0*
5. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
6. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous once a day: take as directed.
Disp:*1 bottle* Refills:*2*
7. One Touch Ultra Test Strip Sig: One (1) strip
Miscellaneous four times a day.
Disp:*120 strips* Refills:*2*
8. One Touch UltraSoft Lancets Misc Sig: One (1) lancet
Miscellaneous four times a day.
Disp:*120 lancets* Refills:*2*
9. Insulin Syringe Ultrafine [**1-3**] mL 29 x [**1-3**] Syringe Sig: One
(1) syringe Miscellaneous once a day.
Disp:*90 syringes* Refills:*2*
10. One Touch Ultra System Kit Kit Sig: One (1) meter
Miscellaneous as directed.
Disp:*1 meter* Refills:*2*
11. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. metformin 500 mg Tablet Sig: Three (3) Tablet PO QPM.
13. metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM.
14. glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
16. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for fever or pain.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Diabetes mellitus
hyperlipidemia
Nephrolithiasis
Obstructive sleep apnea
zenkers diverticulitis
mediastinitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-Incision develops drainage
Neck JP: empty daily and keep a log of output. Should drain fall
cover site with a clean dressinag and call the office
[**Telephone/Fax (1) 2348**]
Pain
-Acetaminophen 650 mg every 6-8 hours as needed for pain
-Ibuprofen 400-600 mg every 8 hours as needed for pain take with
food and water
-Oxycodone 5 mg as needed for pain
Acitivity
-Shower daily. Wash incision with mild soap & water, rinse pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-No driving while taking narcotics
-Take stool softner with narcotics
Medications
-Continue to monitor fingerstick blood sugars. Keep alog. Lantus
insulin daily
-Antibitics: Clindamycin, Cipro and Fluconazole through [**2106-7-26**]
-Metoprolol 50 mg daily. Your blood pressure was elevated
during your hospital course 130-160. Please follow-up with your
PCP for further management.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**0-0-**] Date/Time:[**2106-7-20**] 11:30
on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-7-20**] 8:45
[**Location (un) 861**] Radiology NOTHING TO EAT OR DRINK AFTER MIDNIGHT
Esophagus Study [**Location (un) 861**] Radiology XDI UPPER GI (TCC) RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-7-20**] 10:30
Nothing to Eat or DRINK after Midnight [**2106-7-20**]
Provider: [**Name10 (NameIs) 14621**] [**Last Name (NamePattern4) 14622**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2106-7-26**] 9:00 infectious disease in the [**Last Name (un) 2577**]
Building [**Last Name (NamePattern1) **] Basement level.
Follow-up with [**Hospital **] Clinic Dr. [**First Name8 (NamePattern2) 7208**] [**Last Name (NamePattern1) 978**] [**Telephone/Fax (1) 9979**] [**7-21**] 1:30 pm. Please call sooner if your blood sugars are not
well controlled.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3845**] [**Telephone/Fax (1) 16335**]
Completed by:[**2106-7-7**]
|
[
"51881",
"5119",
"32723",
"25000",
"2724"
] |
Admission Date: [**2200-3-13**] Discharge Date: [**2200-3-16**]
Date of Birth: [**2152-1-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
admit via ED for PNA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
48 year old man with MMP including Downs syndrome was referred
today from his rehab facility with increasing resp distress. By
report via the ED, he had an event this AM where he desatureated
to 80%.
.
He was recently admitted to [**Hospital1 18**] on [**3-4**] - [**3-11**] for PNA as well.
He had a similar presentation, with an O2 sat in the 80's. He
was treated for a LLL PNA with Zosyn for 7 days with improvement
in his O2 sats. He was noted to have difficulty managing his
secretions. Dr. [**Last Name (STitle) 5762**] called in to the ED saying that the
patient cannot swallow and tha the guardian would want a [**Name (NI) 9945**]
placed if needed. He was newly made NPO a [**3-13**] 3PM at NH for
unknown reasons.
.
In the ED, his vitals were 102.8, HR 130, BP 146/77, RR 28, 100%
O2 sat on NRB. He recieved 4L NS (Lactate only down 1.5). He
recieved haldol 10, levofloxacin, vancomycin, flagyl, and
tylenol in the ED.
.
On exam in the [**Hospital Unit Name 153**], he is a middle aged gentleman yelling. He
is non verbal. He is not able to answer questions.
Past Medical History:
- Downs syndrome
- Alzheimer's dementia
- Hepatitis B
- Urinary retention
- UTI with citrobacter (sensitive to fluoroquinolones) in
[**Month (only) 956**]
- Tonsilar hypertrophy, requires nectar liquids and pureed solid
diet
- T9-T12 compression fractures and bilateral hip fractures dx'd
in [**Month (only) 956**] and subacute appearing on xrays at that time
Social History:
Had previously lived in group home because of Down's syndrome;
has been Rosecommon ([**Hospital1 1501**]) resident since [**Month (only) 956**] because of
need for PT/OT following diagnosis of subacute hip fractures
Family History:
Noncontributory
Physical Exam:
99.5 125/62 118 33 98% 50% FM
Gen: nonverbal, moans when touched. moderate resp distress with
loud upper airway secretion sounds.
HEENT: OP clear, mm dry
CV: heart sounds obscurred by breath sounds
Pulm: transmitted upper airway sounds, pt unwilling to cooperate
with exam
Abd: scaphoid, soft, NABS
Ext: LE contractures, decreased bulk, min edema. sitting with
legs crossed.
Skin: no rashes
Pertinent Results:
[**2200-3-13**] 09:40PM PLT SMR-VERY HIGH PLT COUNT-651*
[**2200-3-13**] 09:40PM NEUTS-94.3* BANDS-0 LYMPHS-4.2* MONOS-1.3*
EOS-0.1 BASOS-0.1
[**2200-3-13**] 09:40PM WBC-15.9*# RBC-3.67* HGB-11.0* HCT-33.8*
MCV-92 MCH-30.0 MCHC-32.6 RDW-15.0
[**2200-3-13**] 09:40PM CALCIUM-8.6 PHOSPHATE-4.3 MAGNESIUM-2.1
[**2200-3-13**] 09:40PM estGFR-Using this
[**2200-3-13**] 09:40PM GLUCOSE-157* UREA N-15 CREAT-1.1 SODIUM-147*
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-20* ANION GAP-20
[**2200-3-13**] 09:55PM LACTATE-5.5* K+-3.5
[**2200-3-13**] 09:55PM TYPE-[**Last Name (un) **] COMMENTS-NOT SPECIF
[**2200-3-13**] 11:37PM LACTATE-4.0*
[**2200-3-13**] 11:37PM COMMENTS-GREEN TOP
Brief Hospital Course:
Mr. [**Known lastname 72441**] was initially kept strictly NPO due to his
suspected aspiration pneumonia. He was treated with vancomycin
and Zosyn for empiric coverage. He was given supplemental
oxygen via a face tent with standing nebulizer treatments. In
spite of his NPO status, he was having frequent episodes of
intermittent hypoxia requiring suctioning of thick, tenacious
secretions. This, in addition to serial CXRs revealed that he
was clearly aspirating his secretions on a continuous basis in
spite of his NPO status. Due to this as well as his baseline
dementia, it was thought that putting in a PEG tube for
nutrition would not solve the problem of aspiration since he was
clearly unable to manage his own secretions. Furthermore, it
was clear that he would need constant restraints to avoid
traumatic removal of a PEG, which was thought to be an
unacceptable impairment in his quality of life. In the setting
of all of these issues and his severe, acute, worsening
aspiration pneumonia, he was made comfort-measures-only by his
family and legal guardian; he was put on a morphine drip to help
with his obvious discomfort, and he expired shortly thereafter.
Medications on Admission:
Famotidine 20 mg PO BID
Hexavitamin Tablet PO DAILY (Daily).
Calcium Carbonate 500 mg Tablet,(2) Tablet, Chewable PO DAILY
Cholecalciferol (Vitamin D3) 400 unit Tablet Daily).
Haldol 1 [**Hospital1 **]
Acetaminophen 325 mg (2) Tablet PO every six (6) hours as needed
for pain.
celexa 10
Discharge Disposition:
Expired
Discharge Diagnosis:
Aspiration pneumonia
Down's syndrome
Alzheimer's dementia
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"5070",
"0389",
"2762",
"2859",
"2449"
] |
Admission Date: [**2162-3-10**] Discharge Date: [**2162-3-31**]
Date of Birth: [**2107-12-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
Hemodialysis line placement (temporary/tunnelled)
Hemodialysis
Esophagogastroduodenoscopy
Colonoscopy
History of Present Illness:
Mr. [**Known lastname 80802**] is a 54M with history of alcohol abuse, psoriatic
arthritis on [**Hospital 80803**] transferred from OSH to the [**Hospital1 18**] MICU due
to concern for fulminant liver failure.
.
Patients symptoms began on [**2162-2-20**] when he noted development of
jaundice. He presented for medical care on [**2-25**] and found to
have bili at that time was 11.2. He does endorse drinking
excessively, and reports alcohol daily for the last 2-3 years,
at least 6 drinks. He was diagnosed with alcoholic hepatitis and
returned home to RI.
.
On presentation to his PCP he was found to have new, worsening
renal failure and liver function tests. His INR was 2.8, PT
29.6, Na 133, K 3.5 BUN 88, Cr 5.2, Cl 95, CO2 23, AST 210, ALT
67, ALP 158, Tbili 29.5, Alb 1.5, WBC 17.8, Hct 29.6 at that
time. He was also complaining of mild abdominal bloating. On
presentation to the hospital he was found to have an INR greater
than assay. He was transferred to [**Hospital1 18**] for concern for
fulminant hepatic failure and transplant evaluation.
.
On arrival to the [**Hospital1 18**] MICU he was oriented x3 and in no
distress. He was monitored overnight and did well so was
transferred to the medical floor the following day, then later
to the liver service.
Past Medical History:
Psoriatic arthritis
Alcoholic hepatitis
S/p appendectomy
Depression
Social History:
Former electrical engineer. Divorced 5 years ago, has a teenager
daughter. Also states he feels mildly depressed.
Smoking: none
Drinking: 6 beers/day, additional brandy on weekends
IVDU: denies
Family History:
No history of liver disease.
Physical Exam:
PHYSICAL EXAM ON TRANSFER ([**3-31**]):
VS: 98, 81-97/42-59, 64-73, 18, 98% on RA
GEN: pleasant, ill-appearing man lying in bed supine in NAD
SKIN: jaundiced, no spider erythemas, no palmar flushing
HEENT: NC/AT, icteric sclera, PERRL, EOMI, dry MM, OP clear
NECK: supple, no LAD, normal JVP
CV: RRR, normal S1S2, no M/R/G
CHEST: CTAB, no W/R/R
ABD: soft, distended, min tenderness diffusely, liver edge
palpable 2cm below costal margin, NABS
EXTR: WWP, 3+ edema b/l in LE, 2+ DP/rad pulses b/l, min
asterixis
NEURO: AOx3, CNII-XII intact, [**4-20**] Motor strength in UE/LE b/l,
2+ DTR in [**Name2 (NI) **]/LE
Pertinent Results:
LABS ON ADMISSION:
.
[**2162-3-10**] 09:23PM BLOOD WBC-16.7* RBC-3.25* Hgb-10.0* Hct-29.5*
MCV-91 MCH-30.9 MCHC-34.1 RDW-18.9* Plt Ct-236
[**2162-3-10**] 09:23PM BLOOD Neuts-91.8* Lymphs-4.2* Monos-2.8 Eos-1.1
Baso-0.1
[**2162-3-10**] 09:23PM BLOOD PT-29.6* PTT-68.8* INR(PT)-3.0*
[**2162-3-10**] 09:23PM BLOOD Glucose-105 UreaN-101* Creat-5.2* Na-132*
K-3.2* Cl-95* HCO3-19* AnGap-21*
[**2162-3-10**] 09:23PM BLOOD ALT-64* AST-210* CK(CPK)-38 AlkPhos-188*
TotBili-30.5*
[**2162-3-10**] 09:23PM BLOOD Albumin-2.2* Calcium-8.3* Phos-5.8*
Mg-2.9*
.
LABS ON TRANSFER:
.
[**2162-3-31**] 06:20AM BLOOD WBC-10.2 RBC-2.43* Hgb-8.3* Hct-23.2*
MCV-95 MCH-34.1* MCHC-35.8* RDW-22.1* Plt Ct-116*
[**2162-3-31**] 06:20AM BLOOD PT-26.3* PTT-54.3* INR(PT)-2.6*
[**2162-3-31**] 06:20AM BLOOD Glucose-119* UreaN-76* Creat-4.8*#
Na-146* K-3.9 Cl-99 HCO3-23 AnGap-28*
[**2162-3-31**] 06:20AM BLOOD ALT-49* AST-70* AlkPhos-137*
TotBili-54.0*
[**2162-3-31**] 06:20AM BLOOD Calcium-10.1 Phos-4.8* Mg-2.8*
.
OTHER PERTINENT LABS:
.
ANEMIA WORKUP:
[**2162-3-23**] 03:30PM BLOOD Hgb A-100 Hgb S-0 Hgb C-0
[**2162-3-23**] 05:00AM BLOOD Ret Man-6.8*
[**2162-3-11**] 03:43AM BLOOD calTIBC-126* Ferritn-133 TRF-97*
[**2162-3-22**] 03:10PM BLOOD VitB12-1654* Folate-16.2 Ferritn-120
LDH - 100-200
.
LIVER WORKUP:
[**2162-3-12**] 05:00AM BLOOD HBsAg-NEGATIVE HBcAb-NEGATIVE
[**2162-3-11**] 03:43AM BLOOD HBsAb-BORDERLINE HAV Ab-NEGATIVE
[**2162-3-11**] 03:43AM BLOOD HCV Ab-NEGATIVE
[**2162-3-11**] 03:43AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2162-3-11**] 03:43AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2162-3-11**] 03:43AM BLOOD IgG-1600 IgM-115
[**2162-3-20**] 06:55AM BLOOD CERULOPLASMIN-Test
.
OTHER:
[**2162-3-11**] 03:43AM BLOOD Lipase-443*
[**2162-3-24**] 05:15AM BLOOD Lipase-138*
[**2162-3-17**] 05:10AM BLOOD TSH-0.34
[**2162-3-11**] 09:18AM BLOOD PTH-102*
[**2162-3-17**] 12:08PM BLOOD PTH-58
[**2162-3-11**] 03:43AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
URINE:
UA: Negative
Utox: Negative for bnzodzp barbitr opiates cocaine amphetm
mthdone
.
MICROBIOLOGY/INFECTIOUS WORKUP:
[**2162-3-17**] 12:21PM BLOOD B-GLUCAN-Test
[**2162-3-17**] 12:21PM BLOOD COCCIDIOIDES ANTIBODY,
IMMUNODIFFUSION-Test
[**2162-3-17**] 12:21PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-
TEST
[**2162-3-23**] 05:00AM BLOOD QUANTIFERON-TB GOLD-Test Name
.
BLOOD CULTURES:
[**Date range (1) 80804**] - NEGATIVE
[**3-29**], [**3-25**] (mycolytic) -pending (no growth to date)
.
URINE CULTURES: - NEGATIVE, LEGIONELLA AG-1 NEGATIVE
SPUTUM: OROPHARYNGEAL
MRSA SCREEN - NEGATIVE
.
.
RADIOLOGY:
.
CT CHEST/ABDOMEN/PELVIS ([**3-23**]):
1. Compared to prior chest CT from [**2154-3-16**], multifocal
ground-glass
opacities are improved.
2. 13-mm indeterminate hypodensity in the anterior right lobe of
the liver is unchanged from [**2162-3-16**]. Further evaluation
with ultrasound is
recommended.
3. Mild gallbladder wall thickening which likely relates to
liver
dysfunction.
4. Peripancreatic inflammatory change, which may be seen with
pancreatitis. Recommend clinical correlation.
5. Splenomegaly.
6. Ascites, predominantly within the pelvis. No evidence of
hemorrhage.
.
CT CHEST ([**3-16**]):
IMPRESSION:
1. Multifocal opacities which are predominately in the upper
lobes but also in the left lower lobe, raising the concern for
infection. The appearance is atypical for aspiration unless the
patient was in a prone position. Hemorrhage is also in the
differential in light of the elevated INR. Pulmonary edema is
less likely.
2. Splenomegaly.
3. Coronary artery disease.
4. Enlarged main pulmonary artery, which may represent pulmonary
artery
hypertension.
.
HD TUNNELLED LINE: ([**3-30**]):
Successful conversion of temporary catheter to a tunneled
hemodialysis
catheter. The tip of the catheter is in the right atrium and the
catheter is ready for use.
.
ABD ULTRASOUND: ([**3-11**]):
IMPRESSION:
1. Heterogeneous echotexture or increased echogenicity suggests
liver
disease/cirrhosis.
2. Trace ascites.
3. Patent main portal vein.
4. Gallbladder "sludge" but without son[**Name (NI) 493**] signs for acute
cholecystitis.
5. No intra- or extra-hepatic bile duct dilatation.
.
.
CARDIOLOGY:
.
EKG ([**2162-3-10**]):
Sinus rhythm
Low QRS voltage
Diffuse ST-T wave abnormalities
Rate PR QRS QT/QTc P QRS T
92 168 104 336/392 56 26 -23
.
TTE ([**2162-3-12**]):
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
80%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic arch is mildly dilated. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
The absence of a pericardial effusion does not exclude
pericarditis.
.
GI:
.
EGD biopsy: ([**3-25**])
Squamous epithelium with fungal forms consistent with [**Female First Name (un) 564**]
species.
.
EGD ([**3-25**]):
Impression:
1. Erythema with white exudate in the upper third of the
esophagus.Cold forceps biopsies were performed for histology.
2. Grade 1 Varices at the lower third of the esophagus without
any stigmata of bleeding
3. Mosaic pattern in the whole stomach compatible with portal
hypertensive gastropathy
4. Otherwise normal EGD to third part of the duodenum
.
COLONOSCOPY ([**3-25**]):
Impression:
1. Large nonbleeding external hemorrhoids
2. Small size Internal hemorrhoids
3. There were prominent venous collaterals at rectum and
rectosigmoid area consistent with nonbleeding moderate size
varices.
4. Otherwise normal colonoscopy to cecum
Brief Hospital Course:
In short, Mr [**Known lastname 80802**] is a 54yo M w recently diagnosed alcoholic
hepatitis, who originally p/w jaundice and abd bloating in the
beginning of [**2162-2-14**], was found to have fulminant hepatic
failure and acute renal failure, was transferred to [**Hospital1 18**] for
further management and evaluation.
.
# ALCOHOLIC HEPATITIS / FULMINANT LIVER FAILURE:
.
Unclear precipitant for acute decompensation. Most likely [**1-18**]
continued alcohol use, though usually patients have a history of
much heavier alcohol use. AST:ALT > 2:1. Patient had a negative
workup for possible infectious, autoimmune, toxic or metabolic
causes of liver failure. Abdominal U/S and CT Torso consistent
with cirrhosis. [**Last Name (un) 26460**] discriminant function of 116 and MELD of
46 on admission, very high risk of mortality.
.
Liver failure complicated by:
*** severe coagulopathy with rising INR (>3.0 on transfer),
which did not respond to PO/SC vitamin K administration and
required the transfusion of [**4-25**] units of FFP for procedures;
*** acute renal failure, thought to be acute tubular necrosis,
with no/minimal hepatorenal component (see below);
*** grade I/II esophageal/rectal varices, for which he was
started on nadolol;
*** minimal ascites, which did not require any paracenteses;
*** encephalopathy, for which he received rifaximin and
lactulose prophylaxis, - of note, patient's mental status has
been impressively good - AOx3, able to carry a good
conversation, joke.
*** no evidence for SBP or portal vein thrombosis.
.
Pt was not started on steroids/pentoxyphylline on admission due
to concern for infection (see below). However, since the
likelihood of infection was low, pt was tried eventually tried
on a prednisone 40mg regimen ([**Date range (1) 44643**]). Total bilirubin
decreased minimally from a 51 to ~41, however, started going up
again, so steroids were discontinued. Bilirubin continued to
rise to 57. Pt was tried on ursodiol with no effect, so
discontinued. Also given nutritional supplementation by tube
feeds for 2 weeks and vitamins. Given the minimal response to
steroids and continued rise of serum bilirubin, the prognosis
remains very poor. This has been discussed extensively with
patient and family.
.
.
# ANURIC ACUTE RENAL FAILURE:
Evaluated by the renal team, thought to be likely [**1-18**] acute
tubular necrosis from low flow state, given renal tubular casts
on microscopy. Concern for hepatorenal syndrome, since no
response to IVF, however, not likely given minimal ascites.
Albumin, octreotide, midodrine tried for 2 weeks with no
response. On [**3-12**], pt developed developed pleuritic chest pain
of unclear etiology. No evidence for pneumonia, low suspicion
for PE, ? bleed in the setting of coagulopathy. Pt was noted to
have a pericardial rub on exam and given BUN > 100, uremic
pericarditis was diagnosed and hemodialysis was initiated. Pt
remained on hemodialysis Mo/We/Fri from that point on, with no
improvement in kidney function. HD temporary line was changed to
a tunnelled catheter on [**3-30**]. Pt remains anuric on transfer on
hemodialysis.
.
.
# ? INFECTIONS:
Pt had leukocytosis ~15 w intermittent low O2 requirements.
Given the pleuritic chest pain on [**3-12**] and episode of emesis the
next day, with new radiological findings of multifocal pulmonary
opacities (see CT report), pt was thought to have an aspiration
pneumonia. The anatomical distribution of the opacities was not
consistent. Pt remained afebrile with no sxs of cough, SOB, etc.
Pt was started on levofloxacin ([**Date range (1) 80805**]) for a 10-day course,
but continued while pt was on steroids. On discontinuation, the
bilirubin continued to rise (but no fevers or other clinical
signs of infection), so patient was suspected to have another
possible infection. Started on ceftriaxone ([**3-28**]). EGD biopsy
from [**3-25**] showed [**Female First Name (un) 564**] on [**3-30**], so pt was started on
fluconazole ([**3-30**]).
.
.
# ANEMIA: Likely anemia of chronic disease and acute drops from
intermittent bleeding from esophageal irritation noted on EGD.
# DEPRESSION: Patient reports continued depression. Extensive
emotional support was provided, social work and family involved.
Citalopram was held given acute condition.
.
.
# FEN: renal diet, electrolyte replacement PRN
# Access: PIV, right subclavian HD tunnelled line
# PPx: no heparin SC because of coagulopathy, lactulose, nadolol
# Code: FULL (discussed w pt and family)
.
# GOALS OF CARE:
Have been discussed extensively with patient and family. Power
of attorney filled out by patient, but has to be notarized and
copies need to be sent to sister [**Doctor First Name **], who is the
healthcare proxy. Family is very supportive and has been present
for a good duration of his hospitalization. He is requesting
transfer back to [**State 792**]to be close to his home and his
brother.
.
# CONTACT:
Sister [**Name2 (NI) **] is HCP - cell: [**Telephone/Fax (1) 80806**] home: [**Telephone/Fax (1) 80807**]
.
****** PLEASE NOTE: *******
Ex-wife [**Name (NI) **] and daughter are OK to visit, but pt requests that
details of his illness not be discussed with them.
Medications on Admission:
Humira (last [**2-5**])
Citalopram 20 mg daily
Discharge Medications:
1. CeftriaXONE 1 g IV Q24H
day 1: [**2162-3-28**]
2. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Day 1: [**2162-3-30**].
3. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO QHD (each
hemodialysis).
4. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID (4
times a day).
6. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
12. Ondansetron 4 mg IV Q8H:PRN nausea
13. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal
TID (3 times a day) as needed.
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
alcoholic hepatitis
fulminant liver failure complicated by varices, coagulopathy,
encephalopathy
acute renal failure likely from acute tubular necrosis
presumed aspiration pneumonia
[**Female First Name (un) 564**] esophagitis
Discharge Condition:
hemodynamically stable, but very sick
Discharge Instructions:
You were transferred to our hospital in acute liver failure,
likely from alcohol. You developed acute kidney failure with
complications (uremia) for which we initiated hemodialysis. We
treated you for presumed infections with antimicrobials. Your
prognosis is very poor. Unfortunately, you do not meet the
criteria for liver transplant given your recent alcohol use.
You were transferred to our hospital in acute liver failure,
likely from alcohol. You developed acute kidney failure with
complications (uremia) for which we initiated hemodialysis. We
treated you for presumed infections with antimicrobials. Your
prognosis is very poor. Unfortunately, you do not meet the
criteria for liver transplant given your recent alcohol use.
Followup Instructions:
Transfer to [**State 792**]for further care
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
Completed by:[**2162-4-1**]
|
[
"5845",
"5070",
"2762",
"2761"
] |
Admission Date: [**2147-6-22**] Discharge Date: [**2147-6-28**]
Date of Birth: [**2074-1-11**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Serax
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
fever and chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72-year-old woman with DM2, ESRD on HD, sarcoidosis, COPD,
CHF (EF greater than 55 percent), now transferred to Medicine
service after stabilization and goal directed therapy for
presumed sepsis in MICU.
.
The pt was in her USOH until 48 hours PTA, when she developed
malaise, fever, and chills. The following day, she was noted to
have fever to 102F at hemodiaylsis. She was treated w/ a dose
of IV Vanc during HD, and then sent home. Yesterday, she
developed worsening fevers/chills despite dose of abx, and was
referred to ED by her PCP. [**Name10 (NameIs) 3754**] are no diarrhea, cough,
dysuria, sick contacts. She has tunneled line for access (R
Hickman) that was inserted 8 mo ago and was infected 6 mo ago
per pt report. At that time, her line was left in place and she
was treated through the infection w/ abx.
.
In ED her temp was 102F, she was normotensive w/ normal heart
rate, but was tachypneic w/ leukocytosis and initial Lactate
4.3. Code sepsis was initiated, L IJ placed, CTA performed to
r/o PE. She was then transferred to the MICU for goal directed
therapy.
.
In the MICU, the pt was treated w/ vancomycin and gentamicin for
presumed line infection. She received IVFs and was observed to
be hemodynamically stable overnight, resulting in decreased
lactate. Given the pt's stability and lack of septic
physiology, she is now transferred to the Medicine service for
ongoing care.
Past Medical History:
1. COPD: previously on home O2 [**3-8**] sarcoidosis, now not on home
O2
2. CHF: ECHO [**2146-2-18**] w/ left atrium markedly dilated, LVEF
>55%.
Normal Persantine MIBI in [**10-6**].
3. Type 2 diabetes.
4. Sarcoidosis: no active disease since [**2145**]
5. ESRD: Secondary to bilateral renal artery stenosis. HD on
Mon/Wed/Fri
6. Bilateral renal artery stenosis: Status post bilateral renal
artery stents in [**2-7**].
7. Breast cancer, status post left mastectomy in [**2126**].
8. Peripheral [**Year (4 digits) 1106**] disease, status post left femoral
popliteal in [**2140**] and a right femoral popliteal in [**2143**]. Most
recently s/p angioplasty and stent of fem-[**Doctor Last Name **] bypass on [**6-8**].
9. Mesenteric ischemia status post bypass [**2144**].
10. Hypertension
11. Hyperlipidemia
12. Hypothyroidism
13. S/P open CCY [**4-8**]
14. Anemia of ESRD: baseline HCT high 20s
Social History:
She lives with her husband. Independent in her ADLs. Quit
tobacco in [**2084**], no ethanol use.
Family History:
Non-contributory
Physical Exam:
General: elderly woman in NAD
HEENT: anicteric, EOMI, PERRL, OP clear w/ MMM, no LAD, no JVD,
left IJ cath in place, site without erythema or edema, neck
supple
Chest: R Hickman site c/d/i, no erythema or edema
CV: reg s1/s2, no s3/s4/r, +2/6 systolic murmur at apex
Pulm: moderate air movement, crackles at bases B
Abdomen: +BS, soft, NT, ND
Extremities: warm, dry ulcers on heels B and on L great toe w/
no erythema or edema
Neuro: A and O x 3, CN 2-12 intact, strength 4/5 throughout
UE/LE B, sensation to fine touch intact
Pertinent Results:
[**2147-6-23**] 02:05AM BLOOD WBC-16.3* RBC-2.42* Hgb-7.5* Hct-23.7*
MCV-98 MCH-31.0 MCHC-31.7 RDW-17.1* Plt Ct-302
[**2147-6-23**] 02:05AM BLOOD Plt Ct-302
[**2147-6-22**] 03:00PM BLOOD Neuts-83.1* Lymphs-12.4* Monos-4.0
Eos-0.2 Baso-0.3
[**2147-6-22**] 01:00PM BLOOD PT-13.8* PTT-30.5 INR(PT)-1.3
[**2147-6-23**] 02:05AM BLOOD Glucose-164* UreaN-25* Creat-3.2* Na-135
K-3.8 Cl-101 HCO3-23 AnGap-15
[**2147-6-22**] 01:00PM BLOOD ALT-8 AST-19 CK(CPK)-26 AlkPhos-99
Amylase-48 TotBili-0.5
[**2147-6-22**] 05:27PM BLOOD CK(CPK)-29
[**2147-6-23**] 02:05AM BLOOD CK(CPK)-20*
[**2147-6-23**] 02:05AM BLOOD Calcium-7.9* Phos-2.0* Mg-1.9 Iron-13*
[**2147-6-23**] 02:05AM BLOOD calTIBC-112* Ferritn-[**2046**]* TRF-86*
CTA Chest:
1) No evidence of pulmonary embolism.
2) Hilar and mediastinal lymphadenopathy, as previously noted in
CT scan of [**2144-11-3**]. Clinical correlation requested.
Comparison with previous CT scan can be performed when the study
becomes available.
3) Small bilateral pleural effusions, left greater than right,
with compressive atelectatic changes of the left lung.
4) Pneumobilia, probably due to prior biliary procedures.
.....................
echo
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses are
normal. The left ventricular cavity size is normal. Right
ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral
regurgitation may be significantly UNDERestimated.] There is
mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
......................
foot XR FINDINGS: Multiple views of both feet show no evidence
of fracture, dislocation, or bone destruction. No radiopaque
foreign bodies are seen. Diffuse demineralization is identified.
Posterior and plantar calcaneal spurs are present on the left as
well as a plantar calcaneal spur on the right. [**Year (4 digits) **]
calcifications are identified within both feet.
IMPRESSION: No radiographic evidence of bone destruction within
either foot.
Brief Hospital Course:
A/P: 73-yo-woman w/ ESRD admitted w/ fever, chills, tachypnea
and leukocytosis likely [**3-8**] dialysis cath infxn.
1. Fever: On presentation Pt with fever and recent chills
likely [**3-8**] dialysis cath infxn given lack of localizing
symptoms. At that time leukocytosis, fever, hypoxia and
elevated lactate concerning for sepsis, so MICU team involved in
initial evaluation. Following protocol for early directive
treatment, a internal jugular catheter was placed and PT
observed overnight in the MICU. Prior to arrival at [**Hospital1 18**], Pt
recieved dose of vancomycin during dialysis. Perhaps as a
result, blood cultures obtained afterwards were without growth.
Pt covered empiricially with broad spectrum antibiotics:
Vancomycin, Flagyl and gentamicin. Pt remained afebrile and HD
stable in the ICU and quickly transfered to regular medicine
service. Antibiotics narrowed to Vancomycin given primary
concern for coag + staph line infection. Osetomyelitis even
though low suspicion was ruled out with plain film. Pt remained
afebrile so decision made to treat and keep Hickman in place.
Pt discharged to complete 2 week course with Vancomycin dosed at
dialysis.
.
2. Elevated troponin: On admission pt with elevated Tt, most
likely [**3-8**] ESRD. Pt with no recent chest pain, EKG normal, CKs
flat. Normal PMIBI in [**10-6**]. Pt was continued on ASA,
metoprolol, Plavix, statin
.
3. ESRD: [**3-8**] renal artery stenosis. Renal followed during
admission and Pt remained on normal HD q M/W/F regimen.
.
4. Anemia: Initial studies consistent w/ anemia of chronic dz.
As there is certainly a contribution from ESRD. Pt w/ baseline
HCT high 20s and recieved a transfusion of 2units PRBCs on [**6-23**]
for hct <24. Hct remained stable thereafter.
.
5. DM2: Blood glucose well controlled w/ NPH and RISS as per
outpatient regimen.
.
6. COPD: Pt well controlled w/ atrovent and albuterol nebs as
per outpatient regimen.
.
7. Diabetic gastroparesis: Pt well controlled w/ reglan; but
renally dosed to 5mg qid.
Medications on Admission:
1. ASA 81
2. Metoprolol 100 mg p.o. b.i.d.
3. Plavix 75mg daily
4. Reglan 10 tid
5. Atorvastatin 10 mg p.o. q.d.
6. NPH and regular insulin.
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
2. Pantoprazole Sodium 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. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Insulin Regular Human Subcutaneous
9. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) gram
Intravenous once a day: Will need 14 days of antibiotic
treatment which will be given with dialysis.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary Diagnosis:
1.Line Infection, bacteremia
Secondary Diagnosis:
1. Type II Diabetes Mellitus
2. COPD
3. Congestive Heart Failure
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed.
Please continue your hemodialysis as per schedule and have them
check your Vancomycin levels. If less than 15, you should get 1g
Vancomycin.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **]
SURGERY Date/Time:[**2147-7-5**] 10:15
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2147-7-6**] 1:40
Please follow up with your PCP in about 7 days. Please take all
your medications as directed and please have your Vancomycin
level checked during dialysis.
|
[
"0389",
"99592",
"51881",
"496",
"40391",
"4280",
"V5867"
] |
Admission Date: [**2123-5-14**] Discharge Date: [**2123-5-18**]
Date of Birth: [**2073-5-7**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name8 (NamePattern2) 1103**]
Chief Complaint:
uncontrolled pain
Major Surgical or Invasive Procedure:
R total knee replacement
History of Present Illness:
49 y/o s/p R total knee replacement with uncontrolled pain. Pt
was receiving morphine PCA 1 mg q 6 min w/ cont'd pain. Epidural
placed. Pt was comfortable but he was sleepy after epidural
because he received 36 mg morphine at the PACU. In addition he
had episodes of apnea with SBP to 90 requiring phenylephrine to
reach SBP of 100. UOP >30cc/hr throughout. Transferred to [**Hospital Unit Name 153**]
for continued close monitoring.
Past Medical History:
HTN, b/l osteoarthritis
Social History:
lives in [**Location **] with wife. previously functional of ADLs.
initially from [**Country **]. primary language is porteguese, but
he is able to speak english and refuses need for translator.
Family History:
non-contributory
Physical Exam:
Vitals- T 96.7, BP 87/51 (65), HR 90, RR 19, 100% on 3L NC
gen- sleepy but arousable, responds to questions, [**4-4**] pain in R
knee
heent- EOMI. Pinpoint pupils, equal b/l. + mild proptosis and
scleral injection. non-icteric. OP clear. membranes moist
pulm- CTA anteriorly. no r/r/w
CV- RRR. normal S1/S2. no m/r/g
Abd- soft, NT/ND. NABS
EXT- R knee braced in CPM device. immobile. wrapped w/ pressure
gauze and covered w/ ice packs. tube draining sanguinous fluid.
Able to wiggle R toes. palpable DP pulse, w/ warm extremities. L
leg w/ no erythema, swelling or tenderness, SCD in place.
Neuro- alert and oriented to person, place "[**Hospital Ward Name **] building",
time; CN II-XII intact. language appropriate.
Pertinent Results:
[**2123-5-14**] 08:23PM HCT-32.6*
Brief Hospital Course:
The patient was admitted and taken to the OR on [**5-14**] for a right
TKA
Post operatively the patient required large doses of morphine
for pain controle. His respiratory status became depressed on
these dose of morphine. The acute pain service placed an
epidural that provided effective pain controle. After the
epidural was placed his systolic blood pressure dropped to the
low 70s. He was started on pressures and volume resusitated.
He had to be transferred to the MICU that evening because the
PACU is not kept open over night. Initially post operatively
the patient had a large output from his drain. His Knee was
flexed at 60 degrees and ice applied which stopped the output.
POD 1: the patient did well and was started on CPM. His pain
improved and was wheened off the epidural and pressures and
transferred to the floor. He was started on lovenox. Physical
therapy was consulted and worked with him towards goal of being
independent.
POD 2: the dressing was changed and the drain was pulled.
The remainder of his hospital course was unremarkable. Physical
therapy continued to see him daily until safe to discharge.
Medications on Admission:
Meds on transfer:
amlodipine 10mg qday
keflex 1g q8 (x 6 doses)- day 1=[**6-14**]
Lovenox 40 SQ qday (on hold)
HCTZ 25mg qday
Percocet prn
Lisinopril 5mg daily
Hydromorphone 10 mcg/ml + Bupivacaine 0.1% 1 mg/ml ED
Infuse at 8-12 ml/hr
Phenylephrine gtt
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. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous DAILY (Daily) for 24 days.
Disp:*QS box* Refills:*0*
3. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [**3-31**]
hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
4. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
Right knee osteoarthritis
post-op anemia
hypotension
Discharge Condition:
stable
Discharge Instructions:
Please cont with weight bearing as tolerated right leg. Oral
pain medication as needed. Lovenox for anti-coagulation as
needed. Please cont with physical therapy. Please call/return if
any fevers, increased discharge from incision, or trouble
breathing.
Followup Instructions:
Provider: [**Name10 (NameIs) **] GATES, RNC MSN Where: [**Hospital6 29**]
MUSCULOSKELETAL UNIT Phone:[**Telephone/Fax (1) 10657**] Date/Time:[**2123-5-25**] 11:15
Completed by:[**2123-5-18**]
|
[
"2851",
"4019"
] |
Admission Date: [**2155-3-28**] Discharge Date: [**2155-4-15**]
Date of Birth: [**2155-3-28**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 65740**] is the [**2079**]
gram product of a 34 and 0/7 weeks twin gestation born to a
22-year-old G4, P1, now 3 mom.
Prenatal screens - blood type O positive, antibody screen
negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune. GBS negative. Pregnancy
significant for monochorionic, diamniotic twins, preterm
labor at 30 weeks and some concern for discordancy and twin
to twin transfusion syndrome. Mother was beta complete at the
time of delivery. The infant was delivered by cesarean
section for concerns for twin to twin transfusion syndrome.
The infant received Apgars of 8 and 9.
PHYSICAL EXAMINATION: Pink, active, nondysmorphic infant,
well saturated and perfused. Skin without lesions. Lungs
clear. CARDIOVASCULAR: Normal S1 and S2. No murmurs. ABDOMEN:
Benign. NEUROLOGIC: Nonfocal and age appropriate. ANUS:
Patent. HIPS: Normal. Spine intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Known lastname **]
was admitted to the newborn intensive care unit and has been
stable in room air throughout his stay. He has not required
any methylxanthine therapy and otherwise respiratory stable.
His last documented apnea bradycardia episode was on [**2155-4-10**].
CARDIOVASCULAR: No issues.
FLUIDS, ELECTROLYTES AND NUTRITION: Birth weight was [**2079**]
grams. He was initially started on 40 cc per kg per day of
PE20 and advanced rapidly to full feeds at 140 cc per kg per
day over the next 6 days. The infant is currently ad lib
feeding taking in excess of 150 cc per kg per day of breast
milk 24 calorie concentrated with Enfamil powder. Disscharge
weight is 2195 grams.
GASTROINTESTINAL: Peak bilirubin was on day of life 3 at
9.3/0.3. He received phototherapy and his rebound bilirubin
was on [**4-4**] at 6.8/0.3.
HEMATOLOGY: Hematocrit on admission was 42.5. He is currently
on ferrous sulfate supplementation of 0.2 ml PO once daily.
He is also receiving multivitamins of 1 cc PO once daily.
INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC was benign and blood culture remained
negative. The infant was not started on antibiotics. He has
had no other issues with sepsis during this hospital course.
He was briefly on nystatin for a Monilial rash in his diaper
area which has resolved and it was discontinued on [**4-9**].
SENSORY: Audiology hearing screen was performed with
automated auditory brain stem responses and the infant passed
in both ears.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 65741**]. Telephone No.
[**Telephone/Fax (1) 38689**].
CARE RECOMMENDATIONS:
1. Continue ad lib feeding Enfamil or breast milk 24
calorie.
2. Medications: Continue ferrous sulfate supplementation at
0.2 cc PO once daily. Multivitamins of 1 cc PO once
daily.
3. Car Seat Position Screening was performed for 90 minute
screening and the infant passed this test.
4. State Newborn Screens have been sent per protocol and
have been within normal limits.
5. The infant received his hepatitis B vaccine on [**2155-4-9**].
DISCHARGE DIAGNOSES:
1. Premature infant.
2. Rule out sepsis.
3. Hyperbilirubinemia.
4. Apnea bradycardia of prematurity.
5. Circumcision.
[**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern1) **], [**MD Number(1) 54604**]
Dictated By:[**Last Name (NamePattern1) 58682**]
MEDQUIST36
D: [**2155-4-14**] 20:05:42
T: [**2155-4-14**] 22:28:41
Job#: [**Job Number 65742**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2157-6-15**] Discharge Date: [**2157-6-24**]
Date of Birth: [**2084-7-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 281**]
Chief Complaint:
PNA d/t severe TBM resulting in resp distress. transferred from
[**Doctor Last Name 15594**] [**Hospital 107**] hosp to [**Hospital1 18**] for surgical eval
Major Surgical or Invasive Procedure:
Flexible and Rigid Bronchoscopies
dobhoff feeding tube
History of Present Illness:
72yo F transferred for tracheobronchomalacia , aspiration PNA
and large goiter.
Past Medical History:
diabetes, cerebral palsy, MR, UTI, Depression, OA, psoriasis
Social History:
lives in group home. Brother [**Name (NI) 487**] is spokes person
[**Telephone/Fax (1) 67101**] (cell)
Family History:
non-contributory
Physical Exam:
Physical exam on admission:
General: Arrived intubated. MAE purposefully.
HEENT: PERRLA, Neck+ goiter.
Resp: #8 ETT in place. breath sounds course throughout.
COR: RRR S1, S2
ABD: Obese, round, NT, ND, +BS.
Extrem: No C/C/trace edema.
Pertinent Results:
CXR: INDICATION: Large goiter, respiratory failure.
FINDINGS: Left subclavian central venous catheter is unchanged.
Mediastinal widening secondary to a large left goiter again
noted. Pulmonary vasculature is normal indicating resolving
pulmonary edema. Small/moderate left pleural effusion is
enlarging. Marked scoliosis is unchanged.
IMPRESSION: Resolving pulmonary edema.
Enlarging small left pleural effusion.
8.3 3.87* 11.2* 34.1* 88 28.8 32.7 14.7 290
RECEIVED AT 6:50AM
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2157-6-21**] 05:31AM 129* 9 0.7 143 4.0 108 20* 19
PITUITARY TSH
[**2157-6-16**] 03:17AM 0.93
THYROID T4 Free T4
[**2157-6-16**] 03:17AM 6.6 1.1
IMMUNOLOGY Anti-Tg Thyrogl
[**2157-6-16**] 03:17AM LESS THAN 1 324*2
1 LESS THAN 20
[**Last Name (un) **]-INTESTINAL TUBE PLACEMENT (W/FLUORO) [**2157-6-22**] 4:08 PM
Reason: Placement of postpyloris feeding tube
[**Hospital 93**] MEDICAL CONDITION:
72 year old woman with severe tracheobronchomalacia
Placement of postpyloris feeding tube
CT NECK
CLINICAL INFORMATION: Airway obstruction. Goiter.
TECHNIQUE: Post-contrast MDCT from skull base to thoracic inlet.
FINDINGS: The thyroid gland is grossly enlarged, containing
multiple hypodense nodules and foci of calcification. The
enlargement involves particularly the thyroidal isthmus in the
left hemithyroid, which has a large retrosternal component,
extending well into the anterior mediastinum, displacing the
thoracic trachea towards the right (series 2, image 129). As a
result, there are post-brachiocephalic veins bilaterally.
Endotracheal tube and nasogastric tube are in place at the time
of scanning. Opacification of the nasal cavities bilaterally,
and the right maxillary sinus is probably secondary to the
endotracheal intubation. No abnormally enlarged cervical lymph
nodes can be identified. Soft tissue planes are preserved within
the neck. Review of bone windows demonstrates no focal lytic or
sclerotic bony abnormalities. There are bilateral pleural
effusions, more on the left, with underlying atelectasis.
CONCLUSION: Gross retrosternal goiter on the left, displacing
the thoracic trachea, endotracheal tube. No abnormally enlarged
cervical lymph nodes. Bilateral pleural effusions with
atelectasis at the dependent portions of the lungs.
Bilat upper extrem US done on [**2157-6-23**] and found to have thrombus
at left cephalic vein @ ACF to 2cm above. Left brachial patent
w/o thrombus.
CONCLUSION: Gross retrosternal goiter on the left, displacing
the thoracic trachea, endotracheal tube. No abnormally enlarged
cervical lymph nodes. Bilateral pleural effusions with
atelectasis at the dependent portions of the lungs.
Brief Hospital Course:
Pt was accepted from [**Doctor Last Name 15594**] [**Hospital **] Hospital to [**Hospital1 18**] on
[**2157-6-15**] for eval of TBM after aspiration of po's at group home
where she resides which required intubation d/t hypoxia. CT scan
at OSH revealed large goiter possibly contributing to narrowing
of trachea.
Arrived to [**Hospital1 18**] intubated and admitted to the ICU.
Flex Bronch was performed and pt was found to have severe right
and left main stem Tracheobronchial Malacia (TBM). CT scan of
neck done and goiter did not appear to be compressing airway.
Evaluated by thoracic surgery (Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**]) and felt not be
a candidiate for surgical resection and conservative treatment
was recommended.
[**2157-6-17**] Rigid Bronch was performed for controlled extubation in
OR setting for possible stent placement if extubation failed.
Extubation was successful. Remained in ICU for pul toilet.
[**2157-6-18**] Noted to be coughing w/ po's. Kept NPO and swallow eval
performed ar bedside w/ no obious aspiration. Video swallow done
- no aspiration but had great difficulty coordinating breathing
and swallowing efforts. Desat and tacycardic during swallow.
Suggest keep NPO and place post pyloric feeding tube for now and
repeat swallow eval in future (approx one week).
Continued on ceftriaxone and flagyl which was initiated at
[**Hospital3 36606**] for aspiration PNA. These ABX were d/c'd and
started on po augmentin x 7 days on [**2157-6-23**]- thru [**2157-6-30**].
Central line was d/c'd on [**2157-6-23**] after left upper swelling and
erythema was noted. Upper extrem ultrasound was done which
revealed left cephalic thrombus at ACF to 2cm above. No need for
IV anticoagulation- maintained on SQ heparin and pneumoboots.
Presently oob via [**Doctor Last Name **]- debilitated requiring rehab and ongoing
swallow eval and therapy.
requires [**Doctor Last Name **] OOB
Medications on Admission:
Meds on transfer: zyprexa 10', paxil 40', lovenox 40', pepcid
20", flagyl 500''', rocephin, ativan, morphine.
Discharge Medications:
1. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO HS (at bedtime).
2. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4-6H (every 4 to 6 hours) as needed for dyspnea.
5. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q6H
(every 6 hours).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day.
7. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: Five Hundred (500) mg PO TID (3 times a day)
for 7 days.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
PNA d/t severe TBM-not candidate for sugical resection
pulmonary edema
goiter
Discharge Condition:
fair
Discharge Instructions:
Continue pulmonary hygiene, antibiotics, Occupational and
Physical therapy,tube feeds until f/u swallow eval.
elevate left upper extrem -thrombus at left cephalic vein @ACF
about 2cm above- no need for IV heparin.
Followup Instructions:
Contact Dr. [**First Name (STitle) **] [**Name (STitle) **] (interventional pulmonary) for questions
[**Telephone/Fax (1) 3020**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]
Completed by:[**2157-6-24**]
|
[
"51881",
"5070",
"4280",
"4240",
"25000"
] |
Admission Date: [**2149-3-7**] Discharge Date: [**2149-3-10**]
Date of Birth: [**2095-9-11**] Sex: F
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Optiray 350 / metformin
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53 YO F w metastatic melanoma, adrenal insuff on chronic
steroids p/w 3 days of persistant n, v, diarrhea and assoc chest
and abd pain. The patient's husband was recently ill with a
diarrheal illness but he improved and then the patient started
to notice nausea, vomiting and profuse watery diarrhea with no
blood. She has not been able to take any POs since the onset of
her symptoms. She denies fever or chills. She came into the ED
given the persistance of her symptoms.
.
Ypon arrival to the ED, her initial VS were: 98.2 140 115/69 18
98% RA. Exam was notable for a woman in distress actively
vomiting with abdominal TTP R > L. Labs were notable for WBC
10.6, normal creatinine, and a gap of 21 with ketones and 10
WBCs in her urine. CT A/P non con (due to contrast allergy) was
done and showed questionable tip appendicitis. She was
resultantly seen by surgery who felt her presentation was not
c/w appy but rather gastroenteritis. She was given 10u IV
regular insulin, dexamethasone 10mg IV once, morphine, ativan,
reglan, cipro for presumed UTI, tylenol and 4L NS to which she
only put out 300ccs urine. 2 PIVs were placed. VS prior to
transfer were: 126 115/77 24 95%2L. She was admitted to the ICU
for her tachycardia.
.
Upon arrival to the ICU, the patient reports a severe [**8-30**]
bilateral, temporal headache. She has phono and photophobia. She
has not vomited for several hours and her last BM was this
morning. She denies visual changes or neck stiffness. She does
describe chest wall pain since vomiting several times. She
notices this pain mostly when she swallows fluids. She also
reports diffuse abdominal tenderness since shortly after the
onset of her symptoms.
Past Medical History:
ONCOLOGIC HISTORY:
[**2140**]: Diagnosed with malignant melanoma of right shoulder,
negative sentinel lymph node biopsy
[**2144**]: Diagnosed with met melanoma and underwent BCT [**5-27**] with
cisplatin, dacarbazine, vinblastine and IL-2 with disease
progression noted
[**9-26**] - enrolled in MDX-010 trial
[**11-26**]: Received last treatment
[**5-28**]: CT-evidence of disease progression with enlarging right
paratracheal and retrocaval nodes.
[**2146-7-6**]: Restarted on therapy with MDX-010 (C2W1). CT on [**7-5**]
showed slight increase in size of right paratracheal node.
[**2146-9-7**]: Completed 3 treatments of MDX-010
[**11-27**]: CT showed minimal interval progression
[**2147-3-8**]: CT showed interval disease progression in the form of
retrocaval node enlargement in the upper abdomen.
[**2147-5-24**]: Last dose of CTLA-4 Ab infusion.
[**6-/2147**]: CT Torso -minimal change with no evidence of new
metastatic focus.
[**2147-10-11**]: Ipilimumab on the compassionate access trial,
protocol 07-350, started.
[**12/2147**]: Found to have autoimmune hypophysitis secondary to
Ipilimumab (CTLA-4 antibody). Protocol discontinued.
[**1-/2148**]: Signed consent for Plexxikon. However, was found not
to
have specific BRAF mutation.
[**2148-3-27**]: Started the Phase I RAF 265 clinical trial with dose
reduction x 2 for nausea and vomiting and neuropathy. Therapy
was
held on [**2149-2-5**] due to atrial flutter (unrelated to study drug)
requiring cardiac ablation and could not be restarted after
previous two dose reductions.
.
OTHER PAST MEDICAL HISTORY:
metastatic melanoma
aflutter s/p ablation
HTN
Lower extremity DVT initially on coumadin but recieved IVC
filter with recurrent hemoptysis and subsequent PE despite
lovenox and filter
C-section x3
CCY
tonsillectomy/adenoidectomy
neuropathy
Social History:
Married w/ three children. She is a housewife. She quit smoking
29 years ago 1.5 ppd for 2 yrs and she reports no EtOH.
Family History:
Brother - melanoma in 20s. Mother with HTN, breast cancer @ 65
and has DMII. Father with MI in 60s.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.5 129/70 120 27 91% on RA
General: Alert, oriented, in acute distress, almost in tears
with severe headache-related pain
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, cushingoid, JVP not appreciated although difficult
exam, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, few
basilar rales
CV: Regular, tachycardic, normal S1 + S2, no murmurs, rubs,
gallops; reproducible sternal/sub-sternal chest wall pain; no
subq emphysema
Abdomen: soft, obese mild, diffuse tenderness, non-distended,
bowel sounds present but decreased, no rebound tenderness or
guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
[**2149-3-7**] 10:40AM BLOOD WBC-10.6 RBC-4.87 Hgb-15.8 Hct-45.1
MCV-93 MCH-32.6* MCHC-35.2* RDW-14.3 Plt Ct-221
[**2149-3-7**] 10:40AM BLOOD Neuts-72.3* Lymphs-21.5 Monos-4.4 Eos-0.7
Baso-1.2
[**2149-3-7**] 10:40AM BLOOD Glucose-290* UreaN-11 Creat-1.0 Na-134
K-3.0* Cl-95* HCO3-18* AnGap-24*
[**2149-3-7**] 10:40AM BLOOD ALT-66* AST-52* AlkPhos-101 TotBili-1.1
.
PERTINENT LABS:
[**2149-3-7**] 10:40AM BLOOD cTropnT-<0.01
[**2149-3-7**] 09:09PM BLOOD CK-MB-2 cTropnT-<0.01
[**2149-3-7**] 10:59AM BLOOD Lactate-3.0*
[**2149-3-7**] 03:35PM BLOOD Lactate-1.2 K-3.6
[**2149-3-7**] 09:22PM BLOOD Lactate-1.4
.
DISCHARGE LABS:
[**2149-3-10**] 06:08AM BLOOD WBC-6.1 RBC-3.80* Hgb-12.6 Hct-35.2*
MCV-93 MCH-33.0* MCHC-35.7* RDW-14.2 Plt Ct-196
[**2149-3-10**] 06:08AM BLOOD Glucose-159* UreaN-14 Creat-0.8 Na-145
K-3.4 Cl-111* HCO3-24 AnGap-13
[**2149-3-9**] 07:25AM BLOOD ALT-42* AST-35 AlkPhos-75 TotBili-0.4
[**2149-3-10**] 06:08AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.7
[**2149-3-7**] 09:47PM BLOOD %HbA1c-11.4* eAG-280*
.
EKG: Sinus tachycardia to 142. Nl axis, normal intervals. PRWP.
Sub-mm ST depression in V5/V6.
.
MICROBIOLOGY:
[**2149-3-7**] Blood Cx: pending
[**2149-3-7**] Urine Cx: pending
.
IMAGING:
[**2149-3-7**] CXR: Large right paratracheal and right perihilar
masses compatible with known metastatic disease. No focal
consolidations to suggest pneumonia. No free air under the
diaphragms.
.
[**2149-3-7**] CT Abdomen/Pelvis w/o con:
1. The proximal appendix is air filled and normal in size. The
distal appendix is borderline enlarged, measuring 7.5 mm,
demonstrates no intraluminal air, and there is equivocal
periappendiceal fat stranding. Early tip appendicitis cannot be
entirely excluded and clinical correlation recommended.
2. Stable appearance of the right retrocaval node, as detailed
above.
3. Hepatic steatosis.
Brief Hospital Course:
53 year old woman with metastatic melanoma, adrenal
insufficiency, and NIDDM presenting with 3d of nausea, vomiting
and abdominal pain found to have sinus tachycardia and severe
headache.
.
# Tachycardia: Review of recent outpatient vital signs suggests
patient's baseline HR usually in the 90s-110s. With recent poor
PO intake, her additional tachycardia is likely related to
hypovolemia in the setting of her GI illness. History of nausea
and vomiting suggests that she might not have been getting her
metoprolol which is also likely contributing. Her HR has
returned to the 90s with fluid resuscitation and her home
metoprolol dosing. Although the patient does have an underlying
malignancy and is thus at a higher risk for PE, there is no
indication for CTA at this time since the tachycardia has
resolved.
.
# Headache: Patient had a severe bilateral headache upon
presentation which improved with rest, hydration, and small
amounts of dilaudid. No indication for urgent head imaging at
this time. Patient is scheduled for an upcoming outpatient head
CT.
.
# Nausea/vomiting/diarrhea: Likely secondary to a viral
gastroenteritis considering sick contacts and symptomatic
improvement. No new meds. No clear food precipitants. CT
abdomen/pelvis negative for appendicitis or other acute
pathology. LFTs wnl. Symptomatic management with reglan and
zofran. The patient's symptoms have resolved and she is
tolerating a regular diet.
.
# Chest Discomfort: Notably worsened with food/drinking. Felt
secondary to acute worsening of GERD due to significant vomiting
worsening esophageal acidity and inability to keep down her H2
blocker. Cardiac enzymes negative and ekg w/o ischemic changes.
Improved with improvement of vomiting and H2 blocker.
.
# U/A: Suggestive of UTI so patient was given a dose of
ciprofloxacin in the ED. She is asymptomatic so further
antibiotics held in the MICU. Urine culture grew 10,000 to
100,000 CFU of alpha-hemolytic strep. Since patient was not
symptomatic, this was not treated further.
.
# Adrenal insufficiency: Continued home prednisone 6mg daily.
.
# HTN: Continued metoprolol.
.
# Diabetes type 2: A1c: 11.4%. Patient has never been treated
for diabetes before. Monitored via insulin sliding scale
initially, though blood sugars poorly controlled. Added Lantus
with improvement in blood sugars. Provided extensive diabetic
teaching and instruction on Lantus use as she was sent home on
18 units of lantus daily. She has close follow up with her [**Month/Day/Year 3390**]
and [**Name9 (PRE) **] for further management.
.
# Neuropathy: Continued gabapentin.
.
# Code Status: Full Code.
Medications on Admission:
Prescription meds-
GABAPENTIN - (Dose adjustment - no new Rx) - 300 mg Capsule - 3
Capsule(s) by mouth fhree times daily
HYDROCODONE-ACETAMINOPHEN [VICODIN] - (Prescribed by Other
Provider: [**Name Initial (NameIs) 3390**]) - 5 mg-500 mg Tablet - 1 Tablet(s) by mouth 4-6
hours as needed for pain
METOCLOPRAMIDE - (Prescribed by Other Provider) - 10 mg Tablet
-
1 Tablet(s) by mouth two times a day as needed for nausea
METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth three
times a day
MIRTAZAPINE - 45 mg Tablet - 1 Tablet(s) by mouth once a day
POTASSIUM PHOSPHATE, MONOBASIC [K-PHOS ORIGINAL] - 500 mg
Tablet,
Soluble - 2 Tablet(s) by mouth twice a day
PREDNISONE - 1 mg Tablet - 1 Tablet(s) by mouth daily
PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
.
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH TEST] - Strip - FOUR TIMES A
DAY AS INSTRUCTED
CALCIUM CARBONATE [CALCIUM 500] - (OTC) - 500 mg (1,250 mg)
Tablet - 1 Tablet(s) by mouth daily Take separately from MVI
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Capsule - 1 Capsule(s) by mouth daily
EUCERIN LOTION - (OTC) - - Apply to skin daily as needed for
prn
MULTIVITAMIN-CA-IRON-MINERALS - (Prescribed by Other Provider)
-
Tablet - 1 Tablet(s) by mouth once a day
PYRIDOXINE - 50 mg Tablet - 1 Tablet(s) by mouth daily
RANITIDINE HCL - (OTC) - 150 mg Capsule - 1 Capsule(s) by mouth
twice daily
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO three
times a day.
2. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for nausea.
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
5. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lantus Solostar 100 unit/mL (3 mL) Insulin Pen Sig: Eighteen
(18) units Subcutaneous at bedtime.
Disp:*2 pens* Refills:*2*
8. Lantus Pen Needles
Dispense one box
To be used with Insulin Pen
Refills: Two
9. hydrocodone-acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain: Do not exceed 4 grams of
tylenol in 24 hours.
10. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
once a day.
11. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
12. pyridoxine 50 mg Tablet Sig: One (1) Tablet PO once a day.
13. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. blood sugar diagnostic Strip Sig: One (1) Box
Miscellaneous four times a day as needed for Glucose monitoring:
To be used with ONE TOUCH TEST glucometer.
Disp:*2 box* Refills:*2*
16. insulin glargine 100 unit/mL Solution Sig: Eighteen (18)
Units Subcutaneous at bedtime: Please use this solution with
syringe if you do not have access to the Lantus Pen.
Disp:*1 Bottle* Refills:*2*
17. insulin syringe-[**Name Initial (NameIs) **] U-100 Syringe Sig: One (1)
syringe Miscellaneous at bedtime: To be used to draw up Lantus
solution from bottle. .
Disp:*8 Syringes* Refills:*2*
18. potassium phosphate, monobasic 500 mg Tablet, Soluble Sig:
One (1) Tablet, Soluble PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 392**] [**Last Name (NamePattern1) 269**]
Discharge Diagnosis:
Primary:
Gastroenteritis
Diabetes
Secondary:
Melanoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted due to vomiting and diarrhea which was felt to
be gastroenteritis as this completely resolved prior to your
discharge. You were monitored briefly in the ICU because your
heart rate was very fast. This improved when you received fluids
through your IV.
Your blood sugars were very high during your hospital stay and
you were started on insulin. You were taught how to give
yourself insulin and you will have a visiting nurse help you
further with monitoring of your blood sugars. It is important
that you check your blood sugars in the morning and each time
prior to your meals and document these blood sugars in a note
book.
It is very important that you keep your follow up appointments
with your doctors as [**Name5 (PTitle) **] [**Name5 (PTitle) **] need very close monitoring of your
insulin regimen.
You should continue all of your medications with the following
important changes:
1. START Lantus 18 units to be taken at night every day
2. OK to continue potassium supplementation as already
prescribed as you were receiving a lot of extra potassium in the
hospital. You should discuss with your doctor that you are
taking this and have your potassium levels monitored closely.
It is very important to make sure your sugar does not get too
low, if your blood sugar is 51 to 70 mg/dL, eat 10 to 15 grams
of fast-acting carbohydrate (eg, [**12-22**] cup fruit juice, 6 to 8
hard candies, 3 to 4 glucose tablets).
If you are less than 50 mg/dL, eat 20 to 30 grams of fast-acting
carbohydrates. (e.g. 1 cup of fruit juice, [**12-5**] hard candies,
[**5-28**] glucose tablets)
***It is important that you keep all of your appointments that
are listed below.***
***I have provided you with information on diabetes care.***
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2149-3-12**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2149-3-12**] at 2:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10837**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2149-3-12**] at 2:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 1924**], [**Name8 (MD) 10827**] NP
Location: [**Hospital 20086**] MEDICAL GROUP
Address: [**Street Address(2) 20087**], 2F, [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 7164**]
Appointment: Tuesday [**3-18**] at 11AM
Department: MEDICAL SPECIALTIES
When: MONDAY [**2149-4-14**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 13645**], M.D. [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
***You are currently on a wait list for an earlier appointment,
as none are available presently. If an appointment opens up, the
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|
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"2762",
"53081",
"25000",
"4019",
"42731",
"V1582"
] |
Admission Date: [**2171-11-30**] Discharge Date: [**2171-12-4**]
Date of Birth: [**2119-2-22**] Sex: M
Service: CCU
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
gentleman who was transferred from an outside hospital ([**Hospital3 6454**] Hospital) with a history of coronary artery disease and
a history of high low-density lipoprotein and low
high-density lipoprotein.
The patient developed substernal chest pain at 8 p.m. on
[**11-29**]. The pain had no radiation. The patient took 975
mg of aspirin at that time. The pain continued. He took
another dose of aspirin in the early morning hours on the day
of admission, but the pain continued. The pain waxed and
waned for [**9-15**] in intensity to [**5-16**] in intensity and then
back up to [**9-15**] in intensity again.
The patient went to [**Hospital3 1280**] Hospital for what he described
as these burning symptoms. The patient denied any nausea,
vomiting, or diaphoresis. He denied any back pain. He
denied shoulder or jaw pain. He also had no shortness of
breath, no orthopnea, no paroxysmal nocturnal dyspnea, and no
lower extremity edema. He had no complaints of melena or
bright red blood per rectum.
At [**Hospital3 1280**] Hospital, his blood pressure was 157/101 and
his heart rate was 56. He was given sublingual nitroglycerin
as well as morphine which provided a partial relief of
symptoms. His pain further decreased to [**2-15**] in intensity
after intravenous nitroglycerin and additional morphine were
given. The patient was also started on an intravenous
heparin drip. The patient was not given a beta blocker,
however, because his heart rate was ranging from between 39
and 44, and his blood pressure was in the 100s/60s.
The patient arrived to Coronary Care Unit on an intravenous
heparin drip, intravenous Integrilin, as well as a
nitroglycerin drip. The patient arrived chest pain free and
denied any additional symptoms. He denied shortness of
breath, chest pain, back pain, nausea, and vomiting.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Hypertension.
2. Hypercholesterolemia; high low-density lipoprotein and
low high-density lipoprotein as noted above.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION: The patient was not taking any
medications other than aspirin prior to admission.
MEDICATIONS ON TRANSFER: On transfer, the patient had been
given 30 mg of by mouth Plavix, 40 mg of Zocor, 40 mg of by
mouth Protonix times one, a nitroglycerin drip at a rate of
1.18 at the time, heparin 950 units per hour, and he was also
on an Integrilin drip.
SOCIAL HISTORY: The patient's social history is pertinent
for a former smoker; he quit tobacco 20 years ago after a
20-pack-year history. The patient drinks socially. He is a
field supervisor for the electric company.
FAMILY HISTORY: Family history is pertinent for his father
with angina in his 40s and his mother who is status post a
coronary artery bypass graft.
REVIEW OF SYSTEMS: On review of systems, the patient denied
any sick contacts. [**Name (NI) **] denied any complaints of bowel or
bladder problems. [**Name (NI) **] reports being vigorous at work (which
is outside). The patient has had no problems with
ambulation. No headache, nausea, or vomiting. No
constipation. No recent travel history.
PHYSICAL EXAMINATION ON PRESENTATION: On presentation to
the Coronary Care Unit, the patient's heart rate was 56, his
blood pressure was 120/65, his respiratory rate was 15, and
his oxygen saturation was 98% on 2 liters via nasal cannula.
In general, the patient was a well-developed and
well-nourished gentleman in no apparent distress. Head,
eyes, ears, nose, and throat examination revealed the pupils
were equal, round, and reactive to light. The mucous
membranes were moist. His speech was fluent. His head was
normocephalic and atraumatic. The neck was supple. No
palpable adenopathy. Jugular venous pulsation was
approximately 9 cm. There were no carotid bruits
auscultated. The lungs were clear on examination with no
wheezes. However, he did have some faint right-sided basilar
crackles. Cardiovascular examination was notable for normal
first heart sounds and second heart sounds. No third heart
sound or fourth heart sound. The abdomen was soft,
nontender, and nondistended. There were no bruits. There
were normal active bowel sounds. No palpable organomegaly.
Extremity examination revealed no evidence of clubbing,
cyanosis, or edema. Dorsalis pedis pulses were 2+
bilaterally.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram at [**Hospital3 6454**] Hospital was notable for a sinus rhythm at 40 beats per
minute. There were no ST-T wave changes noted.
Electrocardiogram here were also revealed sinus bradycardia,
heart rate was 55, and a normal axis. He did have some low
voltage in lead III but no Q wave and no ST-T wave changes.
There was normal R wave progression.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
from [**Hospital3 1280**] Hospital were notable for a peak creatine
kinase of 353, a peak MB of 52.5, and a peak troponin of
2.12. The patient's hematocrit there was 47.5.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
patient was continued on the Integrilin, the heparin,
aspirin, Plavix at 75 mg once per day, and continued on a
statin. Attempts were made to start the patient on a beta
blocker. These were only marginally successful given the
patient's bradycardia as well as a relatively asymptomatic
hypotension. The patient was stable. The patient was
admitted for observation over [**12-1**] and underwent a
cardiac catheterization on [**12-2**].
The cardiac catheterization was notable for the following.
The left ventriculography was notable for a left ventricular
ejection fraction of 57%. Wall motion was noted to be normal
with normal mitral valve and aortic valve. Coronary artery
anatomy was notable for a 70% discrete lesion in the mid left
anterior descending artery as well as a 100% lesion in the
mid circumflex. The left circumflex was crossed with a wire,
the balloon was inflated, and a cypher stent was deployed.
Post procedure angiography revealed TIMI-III flow. The
patient left the Cardiac Catheterization Laboratory in
excellent condition.
The patient was continued on the aspirin, and Plavix, and
beta blocker, and statin. The patient was also started on an
ACE inhibitor of captopril 6.25 mg by mouth four times per
day.
However, the patient's course (on the morning of [**12-3**])
was notable for right visual field deficits of both eyes in
the context of receiving his morning beta blocker. This
persisted, although no presence of any headaches were noted
at the time. The patient was also completely ambulatory and
had no focal neurologic findings on examination. Concern was
raised, however, of a possible embolic event. Therefore, the
Neurology Service was consulted.
Neurology initially recommended a magnetic resonance imaging
of the head; however, given the stent placement, a magnetic
resonance imaging was not possible. Therefore, a computed
tomography without contrast was performed. The head computed
tomography performed on [**12-3**] revealed no acute
intracranial pathology on the scan.
The patient also underwent carotid ultrasounds on [**12-4**].
These revealed a normal left internal carotid artery and
minimal right internal carotid artery plaque without any
significant stenosis.
Given these negative results, however, there was still
concern of a possible embolic event. Therefore, the decision
was made in consultation with Neurology to initiate Aggrenox
therapy on this patient with followup in the [**Hospital 878**] Clinic
in two to three months subsequently. Therefore, the
patient's final medications were adjusted to reflect this.
DISCHARGE DIAGNOSES: Acute myocardial infarction.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was instructed to follow up with his
outpatient cardiologist.
2. The patient was instructed to have an outpatient stress
test in six weeks after discharge.
3. The patient was instructed to follow up in the [**Hospital 878**]
Clinic in two to three months.
MEDICATIONS ON DISCHARGE: (Medications on discharge included
the following)
1. Plavix 75 mg by mouth once per day.
2. Simvastatin 40 mg by mouth once per day.
3. Sublingual nitroglycerin as needed (for chest pain).
4. Lisinopril 5 mg by mouth once per day.
5. Atenolol 25 mg by mouth once per day.
6. Enteric-coated aspirin 81-mg tablets three tablets by
mouth every day.
7. Aggrenox 25/200-mg tablets one tablet by mouth twice per
day.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 8442**]
MEDQUIST36
D: [**2172-1-15**] 18:14
T: [**2172-1-18**] 12:53
JOB#: [**Job Number 50461**]
|
[
"41071",
"41401",
"2724"
] |
Admission Date: [**2139-3-23**] Discharge Date: [**2139-3-31**]
Date of Birth: [**2069-9-14**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: This is a 79-year-old male with
multiple medical problems CAD status post CABG in [**2129**] with
known metastatic melanoma, who presented to an outside
hospital with shortness of breath and right leg pain.
Patient had a positive Myoview as an outpatient and was going
to be arranged for outpatient catheterization. However, on
Friday he became acutely short of breath. Reportedly grabbed
an inhaler from a stranger and used it feeling better.
Was admitted to an outside hospital on Friday and noted to
have a troponin-I peak at 0.15, CK 143 with a MB of 1.9. A
BNP was 768. He had no fever or chills. He had multiple
falls last week, which were attributed to his chronic
Meniere's disease and dizziness. Recent Myoview demonstrated
reversibility in the anterior apical/inferoseptal area with
global hypokinesis with an EF of 27%. At the outside
hospital, the patient also had a head CT, which showed old
lacunar infarcts in the basal ganglia bilaterally. Bilateral
periventricular subcortical white matter hypodensities
consistent with small vessel ischemia. No acute hemorrhage
or mass effect. In addition, the patient had a lower
extremity ultrasound, which was negative for DVT.
PAST MEDICAL HISTORY:
1. History of TIAs.
2. Question of Meniere's disease.
3. Dizziness, chronic.
4. Hypercholesterolemia.
5. Melanoma Stage III B status post resection with metastatic
disease to the lymph nodes.
6. Recurrent cellulitis.
7. Asthma.
8. Hypertension.
9. Cervical disk disease.
10. Right CEA in [**2133**].
11. CAD status post CABG x5 in [**2129**] with LIMA to LAD, SVG to
OM, SVG to diag, SVG to AM PDA.
12. History of bradycardia in the 30s with ventricular
bigeminy. Recent catheterization on [**7-20**] revealed a 90% SVG
to diag, which was stented. Patient was entered on the PRIDE
study.
13. Status post MI in [**5-20**]. Echocardiogram on [**6-19**]
revealed an EF of 40-50% with inferior hypokinesis,
moderate-to-severe MR, moderate-to-severe TR, and biatrial
enlargement.
MEDICATIONS:
1. Cozaar 50 b.i.d.
2. Aspirin.
3. Nitroglycerin prn.
4. Lopressor 12.5 b.i.d.
5. Lasix 20 p.o. q.d.
6. Plavix 75 p.o. q.d.
7. Lipitor 20 p.o. q.d.
8. Paxil 40 p.o. q.d.
9. Singulair 10 p.o. q.d.
10. Wellbutrin 100 b.i.d.
11. Diclox 500 b.i.d.
12. Detrol two q.h.s.
13. Cardura 2 q.h.s.
14. Elavil 25 q.h.s.
15. Floredil.
16. Pulmicort.
FAMILY HISTORY: Brother died of a MI in his 50's.
SOCIAL HISTORY: He lives with his wife. His grandson
occasionally lives with him. He quit tobacco. No alcohol or
drugs. He quit tobacco 30 years ago.
ALLERGIES: Iodine dye and shellfish.
PHYSICAL EXAM: Temperature 98.7, blood pressure 158/80,
pulse of 73, respirations 18, and saturating 93% on room air.
General: Alert and disoriented, oriented x1. HEENT: Right
pupil was larger than his left, which is chronic. Moist
mucous membranes. Jugular venous pressure at 8 cm. Heart
was regular, S1, S2, no murmurs. Lungs: Decreased air
movement at the bases, no crackles. Abdomen was soft, obese,
nontender, and bowel sounds present. Extremities: Right
lower extremity with 2+ pitting edema to the thigh, increased
warmth, erythema of the right foot and patches of erythema of
the right leg and trace edema in the left lower extremity.
LABORATORIES: Potassium 4.1, BUN 13, creatinine 1.1, bicarb
30. Hematocrit 35.4, platelets 238.
EKG showed a sinus rhythm at a rate of 92 with a right bundle
branch block.
Patient was admitted and his hospital course was significant
for the following issues: Patient was supposed to undergo
catheterization on the 5th, however, this was postponed until
the 6th. On the night of the 5th, the patient received some
IV diuresis. His shortness of breath was thought to be
likely due to CHF essentially due to ischemia versus
exacerbation of his asthma and COPD. He was diuresed with
some improvement in his shortness of breath. He was
maintained on his [**Last Name (un) **] and Atrovent nebulizers. He was
premedicated for catheterization with Solu-Medrol.
The following day he went for a cardiac catheterization with
severe native three-vessel disease, severe biventricular
diastolic dysfunction, moderate pulmonary hypertension,
depressed cardiac index, culprit stenoses in the SVG to AM
PDA. Patient received two bare-metal stents to the SVG to
PDA. He was also noted to have elevated filling pressures on
the catheterization, both left and right-sided. He returned
to the floor after his catheterization, and was noted to be
very disoriented, very aggressive sitting up. His 8 French
sheath still in his right femoral artery.
Six to eight persons were required to keep the patient still.
He received 10 of IV Haldol, 50 of Fentanyl with some
calming effect, however, became even more aggressive and
refused to lie still. A code purple was called, and the
patient was put in leather restraints. Decision was made to
electively intubate the patient since he needed to lay still
for eight hours given the risk of bleeding in his right
groin, and the concern of an expanding hematoma in his right
thigh. Anesthesia was called for intubation, and the patient
was transferred to the CCU for further management. The
family was appraised of these developments.
In the CCU, the patient was gently hydrated. His hematocrit
was noted to be stable with no acute drop. He was quickly
weaned from the vent and extubated the following morning, and
returned to the floor.
An echocardiogram on [**3-25**] revealed an EF of 25%, elongated
left atrium, markedly dilated right atrium, moderate LVH,
overall left ventricular systolic function was severely
depressed with global hypokinesis. Right ventricular
systolic function also appeared depressed, mild AR, mild MR
with no pericardial effusion, just borderline pulmonary
artery systolic hypertension.
The patient was then transferred back to the floor, where he
remained disoriented, but alert and cooperative. His
disorientation was thought to likely be secondary to
delirium, secondary to medication toxicity, or steroids, or
Benadryl received prior to the catheterization. Upon return
to the floor, he was restarted on his psychiatric
medications, but benzodiazepines and narcotics were held.
Regarding his CAD, he had status post stents x2 to the PDA.
He was continued on atorvastatin, metoprolol, and losartan,
aspirin, and Plavix. He had a small groin hematoma, which
was stable and his hematocrit remained stable throughout the
rest of his hospital course.
CHF: The patient had severe diastolic and systolic
dysfunction by cardiac catheterization, and appeared somewhat
fluid overloaded. He was initially on 40 of IV Lasix b.i.d,
which was changed to p.o. once the patient no longer required
oxygen. He was continued on metoprolol for heart rate
control given his history of diastolic dysfunction. A chest
x-ray on [**3-26**] revealed low lung volumes with bibasilar
atelectasis, but no evidence of fluid overload.
Fever: The patient had spiked a fever to 101.5 while in the
CCU. He was continued on diclox for his chronic cellulitis,
which he takes chronically b.i.d. He had no further fevers
for at least 48 hours prior to discharge. Blood cultures
showed no growth to date. Sputum culture was also negative.
Multiple urine cultures were also negative.
Asthma: The patient was continued on albuterol, ipratropium,
and Montelukast, and also restarted on fluticasone b.i.d.
BPH: Patient had a Foley in place. He was continued on
doxazosin and Detrol.
Prior to discharge, the patient was still somewhat confused,
however, oriented x2-3. He denied any chest pain or
shortness of breath. He was seen by Physical Therapy and
Occupational Therapy, who recommended rehab. The patient was
asked to followup with Dr. [**Last Name (STitle) 93785**], his PCP, [**Name10 (NameIs) **] an appointment
was made for [**4-8**] at 1 p.m. He is also asked to followup
with Dr. [**Last Name (STitle) 11493**] within two weeks.
FINAL DIAGNOSIS: Coronary artery disease status post two
stents.
Patient also has an appointment with the Oncology Unit on
[**4-1**] at 9:45.
DISCHARGE CONDITION: Good. Ambulating without O2 with
assistance.
DISCHARGE MEDICATIONS:
1. Aspirin 325.
2. Clopidogrel 75 p.o. q.d.
3. Montelukast 10 p.o. q.d.
4. Bupropion 100 b.i.d.
5. Dicloxacillin 500 b.i.d.
6. Paroxetine 20 p.o. q.d.
7. Atorvastatin 20 p.o. q.d.
8. Albuterol 90 mcg 1-2 puffs q6.
9. Ipratropium 1-2 puffs q6.
10. Metoprolol 25 mg b.i.d.
11. Losartan 50 mg b.i.d.
12. Doxazosin 2 mg p.o. q.h.s.
13. Pantoprazole 40 p.o. q.d.
14. Fluticasone 110 two puffs b.i.d.
15. Furosemide 20 p.o. q.d.
DISCHARGE STATUS: He was discharged to rehab for physical
therapy and further occupational therapy.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Last Name (NamePattern1) 10195**]
MEDQUIST36
D: [**2139-3-27**] 08:15
T: [**2139-3-27**] 08:18
JOB#: [**Job Number 93786**]
|
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"4019",
"2720",
"49390"
] |
Admission Date: [**2199-7-31**] Discharge Date: [**2199-8-3**]
Date of Birth: [**2117-6-7**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Erythromycin Base / Amoxicillin
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
Fever/Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
82F with history of UC, PSC s/p biliary stent, COPD and recent
SBP s/p exlap/adhesion lysis admitted with abdominal pain and
fever, concern for cholangitis on levophed for hypotension. Mrs.
[**Known lastname **] was admitted to [**Hospital1 18**] [**Date range (1) 87276**] for SBP requiring ex-lab
with adhesion lysis, c/b post-op ileus. During that admission,
she also underwent ERCP for removal of biliary stent [**7-24**] that
was placed one month earlier for PSC - post-removal imaging
showed normal CBD/CHD and right hepatic duct with known
stricture. Mrs. [**Known lastname **] was ultimately discharged to rehab on [**7-27**].
On [**7-29**] patient developed fever, chills, nausea and emesis after
a meal, with no associated abdominal pain. On [**7-30**] (day she went
to ED), continued nausea, fever and new RUQ abdominal pain.
Passing flatus, BM in afternoon. No chest pain, shortness of
breath, cough, diarrhea, sore throat, dysuria. She was sent by
ambulance for ocnern of intra-abdominal process.
.
In the ED, initial vs were: T 97.4 P 92 BP 104/58 O2 sat. 93% on
4L. Exam notable for peripheral edema, RUQ discomfort. She was
noted to be hypotensive to SBP 80's, recieved 2L IVF, central
line placed and started on levophed for concern of septic shock.
SUrgery was consulted, CT A/P with no significant change from
prior except for interval removal of biliary stent. CTA chest
with pulmonary embolism in the left lower lobe segmental
arteries. She was given Vanc/Cipro/Flagyl and started on
heparin. Transferred to ICU for further management.
.
On the floor, patient with minimal discomfort.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss. Denies headache,
sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies constipation. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
Ulcerative colitis status post hemicolectomy in [**2194**]
Primary sclerosing cholangitis, dx by MRI in [**3-/2199**]; recent labs
include CEA =2.4 (wnl), CA [**07**]-9 <0.8 (negative)
SBO [**6-/2199**] s/p exlap, incisional hernia repair and adhesion
lysis c/b post-op ileus
ERCP removal of biliary stent
COPD
Hypertension
Glaucoma
Small left cavernous carotid aneurysm detected in [**2198-1-19**]
GERD
Osteopenia
Status post hysterectomy
s/p cholecystectomy '[**71**]
s/p left ankle tendon transplant and calcaneal osteotomy '[**84**]
Mixed right parotid tumor resection '[**85**]
Cataracts s/p surgery
Social History:
She does not smoke or drink alcohol. Her husband was a physician
and all three sons are physicians. She lives in [**State 108**] in the
winter and in [**Location (un) 86**] in the summer time.
Family History:
No family history of IBD.
Physical Exam:
Upon admission:
Vitals: T: 96.3 BP: 104/51 P: 75 R: 25 O2: 94% 4L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
no thrush
Neck: supple, JVP not elevated, no LAD
Lungs: decreased air movement, otherwise CTAB with no wheeze or
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: minimal discomfort in RUQ with pain more localized
toward mid-axillary line. soft, non-distended, bowel sounds
present, no rebound tenderness or guarding, recent surgical scar
intact with no sign of infection.
GU: + foley
Ext: edema in bilateral lower extremities to knee, warm, well
perfused, 2+ pulses, no clubbing, cyanosis. no palpable cords.
Pertinent Results:
Labs upon admission:
[**2199-7-30**] 08:00PM BLOOD WBC-34.6*# RBC-3.62* Hgb-11.3* Hct-34.0*
MCV-94 MCH-31.3 MCHC-33.4 RDW-13.9 Plt Ct-386
[**2199-7-31**] 03:54AM BLOOD Neuts-91.1* Lymphs-5.7* Monos-3.0 Eos-0.2
Baso-0.1
[**2199-7-30**] 07:50PM BLOOD PT-14.7* PTT-28.1 INR(PT)-1.3*
[**2199-7-30**] 07:50PM BLOOD Glucose-123* UreaN-9 Creat-0.6 Na-137
K-3.3 Cl-100 HCO3-24 AnGap-16
[**2199-7-30**] 07:50PM BLOOD ALT-28 AST-59* AlkPhos-132*
[**2199-7-31**] 03:54AM BLOOD ALT-25 AST-47* AlkPhos-104 TotBili-1.0
[**2199-7-30**] 07:50PM BLOOD Lipase-22
[**2199-7-31**] 03:54AM BLOOD Albumin-2.8* Calcium-7.5* Phos-3.4
Mg-1.0*
[**2199-7-30**] 08:26PM BLOOD D-Dimer-2741*
[**2199-7-30**] 09:47PM BLOOD pO2-56* pCO2-45 pH-7.36 calTCO2-26 Base
XS-0
[**2199-7-30**] 08:13PM BLOOD Lactate-1.5
[**2199-7-30**] 10:02PM BLOOD Hgb-10.1* calcHCT-30 O2 Sat-88 COHgb-2
MetHgb-0
Chest/Abd CTA [**7-30**]: IMPRESSION:
1. Puklmonary emboli within the left lower lobe segmental
arteries,
visualized despite suboptimal bolus due to hand injection
through central
line. Additional smaller emboli may also be present.
2. Bilateral pleural effusions with associated atelectasis. No
evidence of
pneumonia.
3. Irregular intrahepatic biliary ductal dilation, compatible
with history of
primary sclerosing cholangitis. A biliary stent has been
removed. Compared
to [**2199-7-20**], there is likely no change in this process.
4. Status post cholecystectomy.
5. Left renal cyst.
6. No evidence of bowel obstruction. No free fluid or free air,
abscess, or
other postoperative complication status post recent lysis of
adhesions.
Micro: [**7-30**] Blood cxs x2: No growth
Labs at discharge:
[**2199-8-3**] 06:36AM BLOOD WBC-5.5 RBC-3.05* Hgb-9.5* Hct-28.4*
MCV-93 MCH-31.0 MCHC-33.4 RDW-13.0 Plt Ct-282
[**2199-8-3**] 06:36AM BLOOD Glucose-106* UreaN-4* Creat-0.5 Na-136
K-3.7 Cl-101 HCO3-28 AnGap-11
Brief Hospital Course:
82F with history of ulcerative colitis, primary sclerosing
cholangitis status-post biliary stenting, COPD admitted with
acute cholangitis and found to have an acute PE
#Acute cholangitis: Patient was initially admitted to the ICU
for hypotension and was fluid resuscitated and required
transient vasopressor support. She was treated with
ciprofloxacin and metronidazole which was continued on discharge
for a full 2 week course. Surgery and GI were consulted who felt
that no intervention was necessary as acute cholangitis was
probably related to recent ERCP and further intervention would
only increase infection risks. Additionally, it was not felt
that cholangitis was due to any focal stricture/obstruction.
#Acute pulmonary embolism: Left lower lobe segmental PE was
found on imaging and patient was started on LMWH bridge to
Coumadin. Pt was not hypoxic with her PEs. She was discharged to
have INR followed by her PCP [**Last Name (NamePattern4) **].[**Doctor Last Name 87277**] office who would
determine when LMWH could be discontinued. INR on discharge was
1.5.
#Primary sclerosing cholangitis:
Patient has been followed by Hepatology, but will make an
appointment with the Liver clinic following discharge.
#Hypertension: Given initial hypotension and infection the
patient's Lisinopril was held during hospitalization and not
restarted upon discharge as she was not hypertensive while
hospitalized. Patient was instructed to follow up with her PCP
as she will likely need to have her lisinopril restarted once
infection is completely resolved.
#Left carotid artery cavernous sinus aneurysm: Patient had been
evaluated by Neurosurgery previously for evaluation of aneurysm
and was found to have a 7x6mm carotid cavernous sinus aneurysm.
Case was discussed with the patient's Neurosurgeon who felt that
risk of rupture was very low and that if rupture occurred it
would occur in the cavernous space and not the brain. Therefore,
it was felt that the benefits of anticoagulation outweighed the
risks and that the risk of recurrent/worsening PE was higher
than an aneurysmal bleed.
#Dispo: Patient was discharged home with 24 hour care, to get
home PT. She will also get VNA services for assistance with LMWH
injections.
#CODE: Full
Medications on Admission:
Reglan 10mg po AC
Tylenol 650 q4h po prn
Albuterol q4h prn
CaCO@ 650 po TID
Spiriva 1 inh daily
Dorzolamide HCL 2% both eye [**Hospital1 **]
Omeprazole 20mg po daily
Lisinopril 20mg po daily
Betaxolol 0.25% [**Hospital1 **] both eyes
Bimatroprost 1 drop qhs both eyes
Zofran prn
Asmanex 2 puffs daily
Discharge Medications:
1. enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
Q12H (every 12 hours) for 7 days.
Disp:*14 syringes* Refills:*0*
2. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 2
days.
Disp:*2 Tablet(s)* Refills:*0*
3. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM for 10 days: Please follow up with your PCP to see if this
dose needs to be adjusted.
Disp:*10 Tablet(s)* Refills:*0*
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB.
6. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
7. betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
8. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
9. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 12 days.
Disp:*25 Tablet(s)* Refills:*0*
11. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 12 days.
Disp:*38 Tablet(s)* Refills:*0*
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. calcium carbonate 650 mg calcium (1,625 mg) Tablet Oral
14. Asmanex Twisthaler 110 mcg (30 doses) Aerosol Powdr Breath
Activated Sig: One (1) puff Inhalation twice a day.
15. Reglan 10 mg Tablet Sig: One (1) Tablet PO with meals and at
night: Please discuss with your PCP how long you need to be on
this medication.
16. Held medication
Your lisinopril has been held since you had an infection. As you
heal from your infection your blood pressure may rise and you
may need to restart your lisinopril. Please discuss with your
PCP at your next appointment when you should restart your
lisinopril.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute cholangitis
Acute pulmonary embolism
Primary sclerosing cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 18**] with cholangitis. You were treated
with antibiotics and evaluated by the Gastroenterology and
Surgical teams. Your symptoms improved with antibiotics and you
are being discharged to complete a two week course of
Ciprofloxacin and Metronidazole. Please take the full amount of
the prescribed antibiotics.
You were also found to have a blood clot in your lungs and are
being treated with anticoagulation medication. You are being
discharged on an injection (Lovenox) as well as Coumadin. Your
PCP's nurse practitioner will call you on Monday to set up a
time to check your INR. On Monday you should also call your PCP
to make [**Name Initial (PRE) **] follow up appointment in the next 1-2 weeks to have
you blood pressure and overall clinical status checked.
Your PCP will decide when you can stop your Lovenox injections
depending on your INR. Your INR on discharge was 1.5
You also have some residual swelling from the IV fluids you
received. You have been given two doses of Lasix (diuretic) to
help you remove this fluid. Please take your first dose on the
afternoon of discharge and another dose the day after discharge.
Followup Instructions:
Dr.[**Doctor Last Name 87277**] NP will contact you to set up a time to check
your INR. If Dr.[**Doctor Last Name 87277**] office can follow your INRs, your
VNA may be able to draw your INR when she gives you your Lovenox
injections.
You should call Dr.[**Doctor Last Name 87277**] office to set up a follow up
appointment in the next 1-2 weeks.
You should also call the [**Hospital1 18**] Liver Center to set up an initial
appointment with a hepatologist to follow your primary
sclerosing cholangitis.
|
[
"4019",
"496",
"53081"
] |
Admission Date: [**2158-11-15**] Discharge Date: [**2159-1-2**]
Date of Birth: [**2113-9-2**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Amoxicillin / Darvocet-N 100 / Sulfonamides / Demerol
/ Dilaudid
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Abnormal labs
Major Surgical or Invasive Procedure:
L [**First Name3 (LF) 18371**] HD catheter placement
PICC placement
Temporary HD catheter placement
History of Present Illness:
Patient is a 45 yo male with type 1 diabetes c/b esrd since [**2152**]
on tiw dialysis, multiple amputations who was sent to the ED for
abnormal potassium and glucose. The labs were originally done
b/c patient was to get thrombectomy today for his av fistula.
Dialysis was able to access the fistula, however, surgery
requested a venogram before the holiday weekend. In addition
patient's blood sugar is elevated to 485. He is admitted for
aggressive electrolyte managment and venogram to r/o clot in av
fistula.
.
Patient has no complaints, no cough/sob/f/c/n/v/cp/urinary/bowel
sx
Past Medical History:
HTN
Hyperchole
Hx of CHF but last TTE [**11-23**] lvh and ef 50-55%, mild mr [**First Name (Titles) **] [**Last Name (Titles) 18372**]l enlargement
gastroparesis
s/p b/l bka's and mult finger amputations
hx of neuropathy
R AV fistula
Depression
Gerd
s/p right hip arthroplasty
hx of mssa bacteremia from graft infection [**11-23**]
Cath [**2152**] no flow limiting disease
Social History:
Patient used to work as carpenter, plumber, and dishwasher but
has not worked for years. He continues to smoke 1 pack every
three days. He has a 30-pack-year history of tobacco. He
denies the use of alcohol or any recreational drugs.
Family History:
The patient reports one brother with hypertension but could not
elaborate further regarding family history.
Physical Exam:
T 96 HR 73 RR 16 O2 98%
Gen: awake, chronically ill appearing, NAD
HEENT: neck supple, eomi, anicteric, jvp flat
Lungs: CTA ant
Heart: s1 s2 2/6 sem
abd: soft nt/nd +bs
Ext: sym bka, R graft undergoing dialysis
Neuro: aox3
Pertinent Results:
[**2158-11-15**] 09:21PM GLUCOSE-135* UREA N-65* CREAT-7.5*#
SODIUM-134 POTASSIUM-6.3* CHLORIDE-103 TOTAL CO2-22 ANION GAP-15
[**2158-11-15**] 09:21PM CALCIUM-9.6 PHOSPHATE-2.4* MAGNESIUM-2.3
[**2158-11-15**] 09:21PM FDP-0-10
[**2158-11-15**] 09:21PM FIBRINOGE-165
[**2158-11-15**] 05:00PM UREA N-31*
[**2158-11-15**] 02:55PM UREA N-70*
[**2158-11-15**] 01:43PM TYPE-[**Last Name (un) **] PH-7.21*
[**2158-11-15**] 01:43PM GLUCOSE-471* LACTATE-0.9 NA+-128* K+-7.6*
CL--92* TCO2-27
[**2158-11-15**] 01:43PM freeCa-1.26
[**2158-11-15**] 01:30PM UREA N-88* CREAT-8.8*
[**2158-11-15**] 01:30PM CK(CPK)-48
[**2158-11-15**] 01:30PM cTropnT-0.21*
[**2158-11-15**] 01:30PM CK-MB-NotDone
[**2158-11-15**] 01:30PM CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-2.6
[**2158-11-15**] 01:30PM WBC-3.3* RBC-5.53 HGB-13.6* HCT-43.9 MCV-79*
MCH-24.5* MCHC-30.9* RDW-18.5*
[**2158-11-15**] 01:30PM NEUTS-50 BANDS-0 LYMPHS-35 MONOS-6 EOS-9*
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2158-11-15**] 01:30PM PLT COUNT-71*
[**2158-11-15**] 09:00AM GLUCOSE-485* UREA N-87* CREAT-8.6*#
SODIUM-126* POTASSIUM-7.7* CHLORIDE-89* TOTAL CO2-27 ANION
GAP-18
[**2158-11-15**] 09:00AM WBC-3.4* RBC-5.22# HGB-12.7* HCT-41.0
MCV-79*# MCH-24.3*# MCHC-30.8* RDW-18.5*
[**2158-11-15**] 09:00AM PLT SMR-VERY LOW PLT COUNT-75*#
[**2158-11-15**] 09:00AM PT-15.6* PTT-30.0 INR(PT)-1.7
.
MR Venogram:
1. Initial venogram demonstrated stenoses of the left
brachiocephalic vein. Based on the diagnostic findings, it was
decided that the patient would benefit from and was a good
candidate for angioplasty. The left brachiocephalic vein was
angioplastied to 10mm with acceptable angiographic result.
2. A 14.5-French 20-cm long cuff-to-tip tunneled dual-lumen
hemodialysis catheter was placed via the left subclavian vein
with tip in the right atrium. The catheter can be used
immediately.
3. Successful placement of a 8.5-French x 16 cm quadruple-lumen
central venous catheter with by way of the right common femoral
vein with tip in the right common iliac vein. The catheter can
be used immediately.
.
MR [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18371**]:
IMPRESSION: Large amount of subcutaneous and intramuscular edema
within the left [**Last Name (NamePattern4) 18371**] as described, without drainable fluid
collection. Findings are nonspecific yet could be related to
postsurgical change, however superimposed infection cannot be
excluded.
.
Echo:
Conclusions:
1.The left atrium is mildly dilated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis or regurgitation
present.
5.The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen.
6.There is no pericardial effusion.
.
Bone marrow biopsy:
Non-specific lymphoid profile; no phenotypic evidence of
increased myeloblasts or of lymphoma is seen in this limited
panel. correlation with clinical findings and morphology (see
separate report) is recommended. Flow cytometry
immunophenotyping may not detect [**Doctor Last Name **] lymphomas due to topography,
sampling or artifacts of sample preparation. Please refer to
S06-571.
.
MR Chest:
CONCLUSION:
1. Normal flow demonstrated in the right or left internal
jugular veins, moderate narrowing of the stented left
brachiocephalic vein, but the SVC and left subclavian veins
remain patent.
2. Thin linear potential filling defect within the left
subclavian vein could represent partially duplicated venous
system or non occlusive thrombus. Direct correlation with
ultrasound is advised.
.
CXR:
1. Clear lungs.
2. Mild cardiomegaly.
3. Emphysema.
Brief Hospital Course:
A/P: Patient is a 45 yo m with type 1 DM c/b esrd on dialysis,
and mult other medical problems who presents with hyperglycemia,
and hyperkalemia.
.
# ESRD on HD:
ESRD with HD Tu, Th, Sat. The patient was originally admitted
because of access issues w/ his AV fistula. Venogram of the
fistula revealed significant stenosis of the fistula and
renal/transplant/IR have all been coordinating care to arrange
alternative access. A MR venogram was obtained to better
evaluate the central venous structures prior to planning his
access. In the meantime, the patient had a tunnelled groin HD
catheter that was used. However, on [**2158-11-24**] the patient became
acutely febrile to 104. At this time, renal and IR were
consulted and the decision was made to remove his groin HD
catheter and to obtain only a temporary PICC w/out further HD
access. Renal was comfortable with the patient missing his
scheduled Saturday HD session and planned to readdress his
access issue on [**11-27**]. Because of access issues, a L femoral HD
graft was placed. This procedure was, unfortunately,
complicated by persistent fevers. His blood cultures grew MDR
klebsiella only sensitive to meropenem from the 15-17th.
Despite abx he continued to be febrile for the next week. An
MRI of the L [**Month/Day (4) 18371**] showed no abscess but a WBC scan showed
increased uptake at the site of the graft. Because of this,
transplant removed the L [**Month/Day (4) 18371**] graft on [**12-15**]. He went w/out HD
for the week and then access was established with a new temp
cath triple lumen VIP line in the R groin on [**12-18**], and a triple
lumen catheter in the R groin on [**12-26**]. Patient has been
receiving meropenem through the triple lumen post-HD. HD is
currently being done using the L subclavian HD tunneled
catheter.
.
# Klebsiella cellulitis:
Transplant surgery and wound care were following and caring for
L groin wounds inhouse. The cellulitis over L groin has greatly
improved in erythema, edema, warmth, and patient's pain was well
controlled without pain meds. Klebsiella that was swabbed from
the wound (does not necessarily correlate with infectious
organism causing cellulitis) was resistant to all but zosyn,
meropenem, imipenem. Blood cultures were negative since
[**2158-12-6**]. The patient has been on Meropenem since [**2158-12-17**], and
will be continued until [**2159-1-5**], which is 3 weeks after the L
groin graft had been removed on [**2158-12-15**]. Pt had been spiking
fevers to 101 until L groin graft was removed and meropenem was
started. Vanco was given [**Date range (1) 18373**]. MRI L [**Date range (1) 18371**] showed no
fluid collections/abscess.
.
# IV access:
Patient has a HD cath in L subclavian vein placed by IR, who had
to do angioplasty and stent to open L subclavian vein. The
patient has no venous access in the R subclavian vein according
to MR venogram which was repeated.
.
# Fever:
As above, the patient became acutely febrile to 104 on [**2158-11-24**].
His blood cultures grew only strep viridans and he was treated
at HD w/ vancomycin. He remained afebrile w/ negative cultures
for several days before his graft was placed but developed MDR
klebsiella bacteremia in the immediate aftermath of graft
placement. B/c of his amoxicillin allergy, he was desensitized
to meropenem in the MICU and was continued on this [**Doctor Last Name 360**].
Despite this therapy, he continued to spike fevers and his graft
was eventually removed following a WBC showing uptake at the
graft site. After removal of the L groin graft, fever
disappeared within 24-48 hrs, and did not return.
.
# Hyperglycemia:
The patient has a hx of brittle diabetes type 1, with an initial
BG of 485 on presentation. He was seen by [**Last Name (un) **] in the past
but has not f/u with them since [**2156**]. He states that he likes
to keep his glu>200 at home b/c he develops severe hypoglycemic
episodes if he is more closely controlled. He was placed back
on his last known insulin dose (10u AM NPH), continued to
demonstrate hyperglycemia, and his NPH was eventually titrated
up to 12u qAM and 4u qPM. Around this time, he became acutely
febrile to 103 and, since this time, he has had several
hypoglycemic episodes, most often in the early AM. He was
followed by [**Last Name (un) **] throughout his stay, and his eventual insulin
dose was 8 NPH at breakfast and 8 NPH at dinner, with iss.
.
# Elevated Troponin:
patient is not having chest pain currently. He has had elevated
troponins in past, cardiology had seen him in [**11-23**] and
recommended an outpatient stress. Several EKGs did not show
significant change.
.
# Hyponatremia:
The patient was originally hyponatremic and this was attributed
to his severe hyperglycemia. It corrected with better blood
glucose control.
.
# Decreased platelets:
The patient has a baseline of 150-200k that was noted to be 71
during his admission. He also had an elevated PT/INR.
Hematology evaluated the paitent and eventually did a
bone-marrow bx that showed only a hypocellular marrow that was
not c/w MDS. It was thought that his new thrombocytopenia might
be [**12-21**] drug reaction but he reported no new medications in the
past year. His levels were closely followed an self-resolved
through his admission.
.
# Hypertension:
He was treated with Coreg and was discharged on 18.5 [**Hospital1 **]. He
had intermittent problems w/ hypotension in the setting of his
infectious episodes and his antihypertensives were held during
this time.
.
# Depression:
He was continued on his outpt sertraline although heme-onc said
that this medication would be the first to stop if his plts
remain low in the future.
.
# Hypothyroidism:
We continued his outpatient synthroid throughout his admission.
Medications on Admission:
Levothyroxine Sodium 175 mcg PO Q SAT, SUN
Acetaminophen 325-650 mg PO Q4-6H:PRN
Loperamide HCl 2 mg PO QID:PRN
Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN
Metoclopramide 5 mg PO TID
Artificial Tears 1-2 DROP OU QID:PRN
Minoxidil 2.5 mg PO BID
Atorvastatin 40 mg PO DAILY
NIFEdipine CR 60 mg PO BID
Bisacodyl 10 mg PO DAILY:PRN
Nephrocaps 1 CAP PO DAILY
Brimonidine Tartrate 0.15% Ophth. 2 DROP OU QHS
Nitroglycerin Ointment 2% 0.5 in TP Q6H:PRN SBP > 160
Carvedilol 12.5 mg PO BID
Oxazepam 10 mg PO HS
Calcium Carbonate 1000 mg PO TID W/MEALS
Oxycodone-Acetaminophen [**11-20**] TAB PO Q4-6H:PRN
Clonazepam 0.5 mg PO BID
Pantoprazole 40 mg PO Q12H
Doxercalciferol 1 mcg PO QHD
Paroxetine HCl 20 mg PO QHS
Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP OU [**Hospital1 **]
Prochlorperazine 10 mg PO/IV Q6H:PRN
Docusate Sodium 100 mg PO DAILY
Sarna Lotion 1 Appl TP [**Hospital1 **]:PRN
Epoetin Alfa 15,000u QHD
NPH 10 units SC QAM
RISS
Sevelamer 1600 mg PO TID
Lactulose 30 ml PO BID
Sucralfate 1 gm PO TID
Lactic Acid 12% Lotion 1 Appl TP ASDIR
Timolol Maleate 0.5% 1 DROP OU [**Hospital1 **]
Levothyroxine Sodium 150 mcg PO Q MON, TUES, WED, [**Last Name (un) **], FRI
Topiramate 25 mg PO BID
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: Per guidelines
Injection ASDIR (AS DIRECTED).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-20**]
Drops Ophthalmic QID (4 times a day) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO Q MON,
TUES, WED, [**Last Name (un) **], FRI ().
8. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO Q SAT,
SUN ().
9. Brimonidine 0.15 % Drops Sig: Two (2) Drop Ophthalmic QHS
(once a day (at bedtime)).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
13. Sucralfate 1 g Tablet Sig: One (1) Tablet PO TID (3 times a
day).
14. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
15. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical
ASDIR (AS DIRECTED).
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours) as needed.
19. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
20. Doxercalciferol 0.5 mcg Capsule Sig: Two (2) Capsule PO QHD
(each hemodialysis).
21. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed for 10 days.
23. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
24. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Eight
(8) units Subcutaneous Qbreakfast.
25. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Eight
(8) units Subcutaneous Qdinner.
26. Carvedilol 6.25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
27. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous DAILY (Daily) for 3 days.
Discharge Disposition:
Extended Care
Facility:
Emerald Court Health & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Primary diagnosis: Klebsiella cellulitis
Secondary diagnosis: DM1, ESRD on HD
Discharge Condition:
Fair, VSS stable, Klebsiella cellulitis much improved in
erythema, edema, warmth. Patient is comfortable and moving
around halls in the wheelchair.
Discharge Instructions:
Please return to the emergency room if you experience increasing
leg pain, fever, chills, chest pain, shortness of breath, or
other concerning symptoms.
Followup Instructions:
1. [**Last Name (un) **] Diabetes and Primary Care: Dr. [**First Name (STitle) **] [**Name (STitle) **],
[**Telephone/Fax (1) 9979**]
2. Transplant Surgery: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2159-1-4**] 11:00 AM
3. Infectious Disease: [**Telephone/Fax (1) 457**], [**2159-1-16**], 2:00 PM, Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 18374**]
4. Primary Care: [**Telephone/Fax (1) 250**], if you would like further [**Hospital1 18**]
primary care followup
Completed by:[**2159-1-2**]
|
[
"40391",
"2767",
"2761",
"5070",
"4280",
"311",
"2720",
"53081",
"2449"
] |
Admission Date: [**2156-1-23**] Discharge Date: [**2156-1-28**]
Date of Birth: [**2086-6-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillin G / Keflex
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
CABG X 4 (LIMA>LAD, SVG>Diag>OM, SVG>RCA [**1-23**]
History of Present Illness:
Ms. [**Known firstname **] [**Known lastname 4460**] is a 69 year old female who recently was
catheterized secondary to a complaint of angina. The
catheterization revealed sever three vessel disease and was
referred to [**Hospital3 **] Medical Center for surgical evaluation.
Past Medical History:
HTN
Bronchiectasis
Chronic back pain due to injury
Social History:
Smoked 1ppd x 50yrs. Negative EtOH use or IVDU.
Family History:
Father had MI at age 62.
Physical Exam:
At the time of discharge, Ms. [**Known lastname 4460**] was found to be in no acute
distress. She was awake, alert, and oriented. Upon ausculation
of her chest, her lungs were clear bilaterally and her heart was
of regular rate and rhythm. No sternal drainage or erythema was
noted. Her abdomen was soft, non-tender, and non-distended.
Ms. [**Known lastname 70450**] extremities were warm with trace edema. Her leg
incisions were clean and dry.
Pertinent Results:
[**2156-1-27**] 07:40AM BLOOD WBC-14.2*
[**2156-1-27**] 07:40AM BLOOD UreaN-19 Creat-0.9 K-5.3*
[**2156-1-26**] 06:00AM BLOOD WBC-15.6* RBC-3.63* Hgb-10.9* Hct-32.1*
MCV-88 MCH-29.9 MCHC-34.0 RDW-15.1 Plt Ct-238
Brief Hospital Course:
On [**2156-1-23**] Ms. [**Known lastname 4460**] [**Last Name (Titles) 1834**] a Coronary Artery Bypass times
four vessels (LIMA to LAD, SVG to Diag, SVG to distal RCA).
This procedure was performed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**], M.D. The
patient tolerated the procedure well and was transferred in
stable condition to the surgical intensive care unit.
In the surgical intensive care unit she was seen in consultation
by the pulmonary service for her multiple pulmonary issues
including bronchiectasis, emphysema, lung nodules, sinusitis,
and recent pneumonia. She was successfully extubated by
post-operative day one. Her pressors were weaned and oral blood
pressure regimen was mazimized. She was gently diuresed. By
post-operative day 2 seh was ready for transfer to the surgical
step down floor.
On the surgical step down floor Ms. [**Known lastname 70450**] chest tubes and
epicardial wires were removed. She was seen in consultation by
the physical therapy service. By post-operative day five she
was ready for discharge to home.
Medications on Admission:
lopressor 75 ", omeprazole 20, lisinopril 5, lipitor 80, HCTZ
25, tazadone 50 , hydrocodone APAP, Aspirin 325
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 7 days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
11. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*1 mdi* Refills:*2*
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
13. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day) as needed.
Disp:*120 Troche(s)* Refills:*0*
14. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
15. Zithromax 500 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] [**Location (un) 5503**]
Discharge Diagnosis:
CAD
COPD
HTN
Chronic back pain
OA
Hiatal Hernia
L adrenal adenoma
Discharge Condition:
good
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] if any change in respiratory status (sputum
production, shortness of breath, wheezing...etc.)
may shower, no bathing or swimming for 1 month
no creams, lotions or powders to any incisions
no driving for 1 month
no lifting > 10# for 10 weeks
Followup Instructions:
with Dr. [**Last Name (STitle) 47403**] in [**2-14**] weeks
with Dr. [**Last Name (STitle) 914**] in [**4-15**] weeks
with Dr. [**Last Name (STitle) 5310**] in [**2-14**] weeks
with Dr. [**Last Name (STitle) **] in [**4-15**] weeks (can be when you come in to see
Dr. [**Last Name (STitle) 914**]
Make an appointment with Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] for 6 months for follow
up of carotid stenosis
Completed by:[**2156-1-28**]
|
[
"41401",
"4019"
] |
Admission Date: [**2162-10-16**] Discharge Date: [**2162-10-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 year-old gentleman with history of ESRD on HD, CAD, CHF,
presents with 3 day history of epigastric pain, nausea,
vomiting, and diarrhea. He has not had much of an appetite in
the last two days and has been spending a lot of time in the
bathroom. He notes an uncomfortable feeling in his epigastrum,
though is unable to further clarify the character of the pain.
Patient notes that he has additionally had two days of cough,
though denies fevers, sweats headache, dyspnea, sore throat, or
myalgias. He has had some mild chills. He has had no known sick
contacts. [**Name (NI) **] was recently discharged from the hospital on
[**2162-9-20**] after a 3 day stay for new onset dysarthria and
worsening LUE weakness. At that time his neurologic symptoms
were attributed to poor PO intake prior to presentation and
representation of prior CVA symptoms.
Vital signs upon presentation to the ED were T 97.6, HR 80, BP
173/65, O2Sat 100% 2L. Initial labs showed serum potassium of
6.3. Did not have peaked T waves on EKG at presentation, though
had a QRS prolongation to 120 ms [**First Name (Titles) 767**] [**Last Name (Titles) 5348**] of 100 ms.
Additionally had new TWI in leads V1 and V2. Received calcium
gluconate, insulin and dextrose, 1 amp bicarb, and aspirin. Due
to concern for intra-abdominal process, was started on zosyn and
vancomycin. Received a CT abdomen and RUQ U/S that both showed
gallstone at gallbladder neck, though no definitive evidence of
acute cholecystitis per ultrasound. Surgery consulted and felt
that empiric antibiotics were appropriate. Was given an aspirin
due to concern for cardiac process and had a set of cardiac
enzymes sent. Prior to transfer to the floor vitals were: T 97,
HR 81, BP 154/70, RR 20, O2Sat 99% 2L NC.
ROS:
(+)ve: nausea, vomiting, epigastric pain, diarrhea, chills,
cough, loss of appetite, weight loss, LUE weakness
(-)ve: fever, sweats, hemoptysis, dyspnea, orthopnea, PND,
constipation, lower extremity edema, myalgias, arthralgias
Past Medical History:
1) ESRD on HD (M/W/F) s/p AVF placement
2) Coronary artery disease s/p balloon angioplasty > 5 years ago
3) CVA >10 years ago w/ residual left-sided weakness and left
facial droop
4) Hypertension
5) Congestive heart failure (TTE [**2162-4-22**]: LVEF 35-40%)
6) BPH w/ elevated PSA
7) Nephrolithiasis
8) Thrombocytopenia of unclear etiology, stable
9) s/p abdominal surgery for unclear reasons, believed by
patient to be gastric cancer resection
10) h/o Bell's palsy
Social History:
Lives with daughter in [**Name (NI) 669**], MA.
Tobacco: Quit smoking [**1-20**] month ago and used to smoke [**12-22**]
cigarretes per day for 60 years.
EtOH: Prior use with 3-4 beers per day, but quit >20 years ago
not
remembering exact date.
Illicits: Denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Father died
of cirrhosis, mother of cancer (unknown site).
Physical Exam:
VITAL SIGNS: T 97.5, HR 85, BP 158/66, RR 30, O2Sat 100% 2L NC
GENERAL: NAD, thin elderly gentleman
HEENT: PERRL (3 to 2 mm bilaterally), EOMI, bilaterally equal
arcus senilis, visual acuity intact with ability to read small
text at a distance,
NECK: no [**Doctor First Name **],
CARDIAC: RR, nl S1, nl S2, no M/R/G
LUNGS: Basilar crackles clearing partially with cough
ABDOMEN: Thin, BS+, soft, tender epigastrum and RUQ to deep
palpation, non-distended, no rebound or guarding
EXTREMITIES: No LE edema
SKIN: No rashes
NEURO: Oriented to date, day, place, person. Strength 5/5 at
hips, knee flexion and extension, ankle dorsiflexion and
plantarflexion, Strength 5/5 along RUE and [**2-21**] along LUE, LUE
with palpable thrill over AV fistula
PSYCH: Mood and affect appropriate
Pertinent Results:
Admission Labs:
[**2162-10-16**] 10:18AM WBC-5.4 RBC-4.22* HGB-11.3* HCT-36.3* MCV-86#
MCH-26.8* MCHC-31.1 RDW-16.8*
[**2162-10-16**] 10:18AM PLT SMR-VERY LOW PLT COUNT-69*#
[**2162-10-16**] 10:18AM NEUTS-81.3* LYMPHS-12.3* MONOS-6.0 EOS-0.2
BASOS-0.2
[**2162-10-16**] 10:18AM CK-MB-NotDone cTropnT-0.18*
[**2162-10-16**] 10:18AM GLUCOSE-122* UREA N-57* CREAT-8.7*#
SODIUM-146* POTASSIUM-6.3* CHLORIDE-99 TOTAL CO2-20* ANION
GAP-33*
[**2162-10-16**] 10:49AM LACTATE-7.2*
[**2162-10-16**] 10:18AM CK-MB-NotDone cTropnT-0.18*
[**2162-10-16**] 10:18AM ALT(SGPT)-33 AST(SGOT)-47* CK(CPK)-83 ALK
PHOS-123* TOT BILI-0.7
[**2162-10-16**] 10:18AM LIPASE-10
Discharge Labs:
[**10-19**]: WBC-4.8 RBC-4.03* Hgb-11.0* Hct-33.9* MCV-84 MCH-27.2
MCHC-32.4 RDW-16.8* Plt Ct-80*
[**10-19**]: Glucose-129* UreaN-24* Creat-5.4*# Na-143 K-3.6 Cl-98
HCO3-32 AnGap-17
[**10-18**]: CK(CPK)-78
[**10-19**]: Calcium-8.6 Phos-4.0# Mg-2.1
[**10-19**]: Lactate-2.2*
[**2162-10-16**] Chest Xray: Cardiomegaly, pulmonary edema, and small
effusions suggest mild cardiac failure. Recommend repeat PA and
lateral after diuresis to evaluate for coexistent infection.
[**2162-10-16**] CT Abdomen/Pelvis:
IMPRESSIONS:
Small bilateral pleural effusions, right greater than left.
Distended gallbladder with multiple gallstones, including one in
the
gallbladder neck. Trace pericholecystic fluid and gallbladder
wall edema,
although without definite gallbladder free wall thickening.
Cholecystitis is a concern. This can be further evaluated via
ultrasound or hepatobiliary scan. Extensive atherosclerotic
calcifications throughout the aorta and major mesenteric
branches, although mesenteric arteries are without stenosis or
thrombosis evident. Due to suboptimal contrast administration,
venous structures are not opacified. However, there are no
secondary signs of venous thrombus. There is no evidence of
bowel ischemia. Very high grade stenosis of the proximal right
superficial femoral artery. Stable appearance of simple and
hyperdense renal cysts.
Diffusely enlarged prostate gland with prominent median lobe,
with multiple proteinaceous/hemorrhagic nodules. This is
consistent with BPH, although tumor is not definitively
excluded.
[**2162-10-16**] Liver or Gallbladder Ultrasound
1. Enlarged but compressible gallbladder with gallstones; stone
in the
gallbladder neck was not definitely impacted. Asymmetric
perihepatic
gallbladder wall edema. Findings are not typical for acute
cholecystitis, and are likely because of hepatic dysfunction,
possibly from vascular congestion.
2. Patent portal vein. SMV not well visualized due to overlying
bowel gas.
Brief Hospital Course:
87 year-old gentleman with history of ESRD on HD, CAD, CHF, who
presented with 3 day history of epigastric pain, nausea,
vomiting, and diarrhea.
#. Gastroenteritis and cholelithiasis: He presented with 3 days
of nausea, vomiting, diarrhea, and loss of appetite. It was
felt to most likely be a gastroenteritis. CT did not show
obvious source of infection and no evidence of bowel ischemia.
However, the gall bladder had an atypical appearance. Follow-up
RUQ ultrasound did not show acute cholecystitis. Surgery was
consulted as the clinical picture could suggest an
intermittently obstructing stone and biliary colic. He
underwent bowel rest, serial lactates, and empiric treatment
with Unasyn. He was also ruled out for MI and his lactate
downtrended. Symptoms resolved and patient tolerated a normal
diet at discharge.
#. Hyperkalemia: Upon presentation to the ED, his serum
potassium was 6.3 and EKG was noted to have QRS prolongation to
120 with recent [**Month/Day/Year 5348**] QRS of 100 on EKG dated [**2162-9-18**]. He
was given calcium gluconate, bicarb, insulin and D50. Repeat
potassium in ED was 4.6 prior to transfer to the ICU. He
underwent hemodialysis overnight and his serum potassium
returned to [**Location 213**].
#. CAD: He was ruled out for MI and was continued on isosorbide
mononitrate, lisinopril, aspirin, metoprolol, and simvastatin.
# Chronic Renal Disease on HD: Pt received HD while hosptalized.
#. Congestive heart failure, systolic: He appeared clinically
euvolemic to dry upon examination on discharge, and through
admission without evidence of JVP elevation.
#. Prophylaxis: He was given SC heparin for DVT prophylaxis.
#. Code Status: He was full code during this hospitalization.
#. Contact: With [**First Name8 (NamePattern2) 77233**] [**Name (NI) **] (Daughter) [**Telephone/Fax (1) 77234**]
Key Follow up:
On abdominal CT the following were found:
1. Very high grade stenosis of the proximal right superficial
femoral artery.
2. Diffusely enlarged prostate gland with prominent median lobe,
with multiple
proteinaceous/hemorrhagic nodules. This is consistent with BPH,
although
tumor is not definitively excluded.
Medications on Admission:
1) Isosorbide Mononitrate 30 mg Tablet SR 24 hr 1 PO daily
2) Lisinopril 5 mg PO daily
3) Metoprolol Tartrate 12.5 mg [**Hospital1 **] PO daily
4) Nitroglycerin 0.3mg Tablet, SL
5) Omeprazole 40 mg DAILY
6) Simvastatin 40 mg PO at bedtime
7) Trazodone 50 mg Tablet PO at bedtime
8) Acetaminophen 650 mg PO q6hrs as needed for fever or pain
9) Aspirin 325 mg PO once a day
10) Iron AspGl & PS Cm-Vit C-Ca-SA 150 mg-50 mg-50 mg 1 Capsule
PO
daily
11) Multivitamin Tablet 1 PO daily
12) Acetaminophen-Codeine 300 mg-30 mg 1 Tablet PO at bedtime
PRN
pain
13) Docusate Sodium 100 mg PO BID PRN constipation
Discharge Medications:
1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
at bedtime as needed for pain: Do not take this medication and
consume alcohol. Do not take this mediation and drive. .
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: Call doctor if
you develop chest pain. .
12. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
13. Iron AspGl & PS Cm-Vit C-Ca-SA [**Medical Record Number 77235**] mg Capsule Sig: One
(1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary: Gallstones (Symptomatic Cholelithiasis)
Discharge Condition:
Mental Status:Clear and coherent
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure caring for you while you were hospitalized
with abdominal pain, nausea, vomiting, and diarrhea. During your
stay evaluation showed that you had a gallstone that was thought
to be contributing to this pain. Your gallbladder was further
evaluated and you were found to not have a gallbladder
infection. Further, during your hospitalization you received
hemodialysis in keeping with your outpatient schedule. At
discharge you should follow up with your primary care physician
to further discuss the abdominal pain which brought you to the
hospital and your other chronic medical problems. [**Name (NI) **] will also
need to follow up with general surgery regarding these
gallstones and the need to have your gallbladder removed. Weigh
yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3
lbs.
No changes were made to your medication regimen.
Please return to the hospital or contact your physician if your
abdominal pain recurrs, you develop chest pain, shortness of
breath, blood in your bowel movements, dark black bowel
movements, major changes in your bowel or bladder habits, or
other changes that concern you.
Followup Instructions:
General Surgery; [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. Phone:[**Telephone/Fax (1) 6554**]
Date/Time:[**2162-11-1**] 12:30
Primary Care: [**Name6 (MD) 21154**] [**Last Name (NamePattern4) 21155**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2162-11-1**] 3:50
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2162-11-30**] 10:00
|
[
"40391",
"2762",
"4280",
"41401",
"2767",
"2875"
] |
Admission Date: [**2133-12-1**] Discharge Date: [**2133-12-4**]
Date of Birth: [**2074-10-24**] Sex: M
Service: MEDICINE
Allergies:
Interferons
Attending:[**First Name3 (LF) 8115**]
Chief Complaint:
LUE burning
Major Surgical or Invasive Procedure:
T1 Corpectomy and anterior cervical plating [**2133-12-3**]
History of Present Illness:
Mr. [**Known lastname 26438**] is a 59 yo with a PMHx s/f Cirrhosis secondary to
hepatitis C and metastatic HCC who presents for evaluation of
cord compression with resulting LUE "burning". Mr. [**Known lastname 26438**] had
been undergoing day 9 of XRT to his R shoulder and R hip for
pain related to metastatic lesions and complained to his
radiation oncologist of new onset burning symptoms in his LUE.
As a result of these symptoms an MRI was performed which
demonstrated a T1 lesion with cord compression. Mr. [**Known lastname 26438**]
also notes decreased strength on the L.
He has been noting burning and a relative loss of strength
on the LUE for approximately 1.5-2weeks which has progressively
worsened. He denies neck pain/back pain, incontinence of
stool/urine, fevers/chills, or other symptoms of
paresthesias/weakness elsewhere.
.
In the ED, Mr. [**Known lastname 26438**]' vitals were 96.6 66 151/95 18 100% on
RA, exam notable for no saddle anesthesia, but decreased rectal
tone. There he endoresed LUE paresthesias. He was given
dexamethasone 10mg and dilaudid 1 mg in the ED. CT of T and C
spine was obtained which demonstrated compression fracture at T1
with retropulsoin into the canal.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies blurry vision, diplopia, loss of vision,
photophobia. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations, lower
extremity edema. Denies cough, shortness of breath, or wheezes.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
melena, hematemesis, hematochezia. Denies dysuria, stool or
urine incontinence. Denies rashes or skin breakdown. All other
systems negative.
Past Medical History:
[**Known firstname **] [**Known lastname 26438**] developed hepatocellular
carcinoma in the setting of hepatitis C cirrhosis. Screening
ultrasound [**2132-11-29**] raised concern for a mass in the
right liver, and his AFP was elevated at 56.9. MRI [**2132-12-20**]
showed a mass in segment V measuring 2.9 x 3.2 x 2.8 cm with
arterial enhancement and wash-out, consistent with
hepatocellular
carcinoma. Also seen was a thrombus in the subsegmental branch
of the right posterior portal vein. CT torso on [**2132-12-30**]
identified a 3.2 cm mass with arterial enhancement and wash-out
in segment VI/VII. Also seen were two 2-mm right lower lobe
pulmonary nodules as well as a fracture in the right 10th rib.
Bone scan was negative for metastases. EGD on [**2132-12-17**] showed
grade II varices which were banded. Mr. [**Known lastname 26438**] was treated
with transarterial chemoembolization [**2133-1-27**] to the right
liver, having received 60 mg doxorubicin without complications.
He underwent repeat TACE on [**2133-7-2**], again without
complication. Despite this his AFP continued to rise, and bone
[**2133-10-12**] identified numerous lesions concerning for bone
metastases. Bone biopsy performed [**2133-10-29**], confirmed the
finding of metastatic hepatocellular carcinoma. Mr. [**Known lastname 26438**]
was prescribed sorafenib 400 mg b.i.d. beginning [**2133-11-4**], but
discontinued after one dose due to nausea/vomiting.
.
.
PAST MEDICAL HISTORY:
Mr. [**Known lastname 26438**] lives with his wife and two daughters. [**Name (NI) **]
previously worked in construction, but has been out of work
since [**34**]/[**2129**]. Tobacco: One-half pack per day for more than 40
years, continues to smoke. Alcohol: History of abuse,
none since [**2111**]. Illicits: History of abuse, none since [**2111**].
Social History:
Mr. [**Known lastname 26438**] lives with his wife and two daughters. [**Name (NI) **]
previously worked in construction, but has been out of work
since [**34**]/[**2129**]. Tobacco: One-half pack per day for more than 40
years, continues to smoke. Alcohol: History of abuse,
none since [**2111**]. Illicits: History of abuse, none since [**2111**].
Family History:
His mother died at age 72 with metastatic breast cancer. His
father is alive without health concerns. His sister has
diabetes mellitus.
Physical Exam:
ADMISSION EXAM:
.
Vitals - T: 96.6 BP: 140/80 HR: 60 RR: 18 02 sat: 98% on RA
GENERAL: disgruntled gentleman, pacing around the room in
C-collar, talkative/conversant
SKIN: warm and well perfused, no excoriations, venous stasis
changes in b/l LE, no rashes
HEENT: in C collar, AT/NC, EOMI, PERRLA, anicteric sclera, pink
conjunctiva, patent nares, MMM, good dentition, nontender supple
neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, strength 5/5 diffusely, no
cyanosis, clubbing or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, sensation intact in b/l UE/LE in all
major dermatomes.
.
DISCHARGE EXAM:
.
Vitals - 98.2/98.4 134/82 (120s-150s/50s-80s) 69 (50s-60s) 18
100%R
GENERAL: NAD, in [**Location (un) 2848**]-J, talkative/conversant
SKIN: warm and well perfused, greyish/blue chronic discoloration
of the lgs
HEENT: in [**Location (un) 2848**]-J collar, AT/NC, EOMI, PERRLA, anicteric sclera,
pink conjunctiva, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXT: 2+ pulses, chronic appearing bluish/grey changes of the LE
bilaterally. no edema
NEURO: [**5-14**] diffusely, CN 2-12 intact. No sensory deficits
PULSES: 2+ DP pulses bilaterally
Pertinent Results:
ADMISSION LABS:
.
[**2133-12-1**] 08:25AM BLOOD WBC-1.9* RBC-4.36* Hgb-13.9* Hct-40.4
MCV-93 MCH-32.0 MCHC-34.5 RDW-13.6 Plt Ct-43*
[**2133-12-1**] 08:25AM BLOOD Neuts-78.9* Bands-0 Lymphs-9.2* Monos-9.3
Eos-2.0 Baso-0.5
[**2133-12-1**] 08:25AM BLOOD PT-14.2* PTT-30.6 INR(PT)-1.2*
[**2133-12-1**] 08:25AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-136
K-5.2* Cl-99 HCO3-32 AnGap-10
[**2133-12-1**] 08:25AM BLOOD ALT-237* AST-323* TotBili-2.0*
[**2133-12-1**] 08:25AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
[**2133-12-1**] 08:31AM BLOOD K-4.0
.
DISCHARGE LABS
.
[**2133-12-4**] 05:45AM BLOOD WBC-1.1* RBC-3.18* Hgb-10.4* Hct-29.7*
MCV-93 MCH-32.5* MCHC-34.9 RDW-13.7 Plt Ct-53*#
[**2133-12-4**] 05:45AM BLOOD Glucose-81 UreaN-16 Creat-0.6 Na-136
K-3.8 Cl-102 HCO3-27 AnGap-11
[**2133-12-4**] 05:45AM BLOOD Calcium-7.8* Mg-1.8
.
CT SPINE [**2133-12-1**]:
IMPRESSION:
1. Cortical irregularity of the inferior endplate of T12,
possibly extending into posterior elements, likely representing
metastatic disease and better evaluated on recent MRI.
2. Lucencies within the vertebral bodies of T5, T8 and T11 also
corresponding to signal abnormality seen on recent MR and likely
representing metastatic disease. No evidence of cord compression
in the thoracic spine from T2 through T12.
3. Pathologic fracture of T1, as described on the cervical spine
CT from the same day.
4. Coarse calcifications of the liver, likely from prior TACE
procedure.
5. Incompletely imaged spleen, which appears enlarged.
.
[**2133-12-2**] T-SPINE XRAY IN THE OR: Limited evaluation of the
upper thoracic spine due to overlying soft tissue and bony
structures. Surgical instrument is seen at the C6-C7 disc space.
Status post T1 corpectomy and anterior fusion from C7 to T2. The
hardware appears intact. Please see the operative report for
further details.
.
[**2133-12-3**] C/T SPINE XRAY:
CERVICAL SPINE, THREE VIEWS: C1 through T1 are demonstrated on
the lateral
view. No prevertebral swelling is identified. Cervical lordosis
is
preserved. Vertebral body heights are intact. There is
intervertebral disc
space narrowing of C4-5. No cervical body vertebral fracture is
identified. Grade 1 retrolisthesis of C4 on C5 is present. No
focal lytic or sclerotic lesions.
THORACIC SPINE, TWO VIEWS: The patient is status post T1
corpectomy with
anterior fusion and cage placement from C7-T2. Hardware is
intact without
signs of complication. The alignment is normal. The remainder of
the
thoracic spine is unremarkable. The visualized lung fields are
normal.
IMPRESSION: Anterior fusion from C7-T2 and cage placement status
post T1
corpectomy without hardware complication.
.
Spine Tumor Pathology [**2133-12-2**]: Pending
Brief Hospital Course:
Mr. [**Known lastname 26438**] is a 59 year old with a PMHx s/f Cirrhosis
secondary to hepatitis C and metastatic HCC who presents for
evaluation of cord compression with resulting LUE "burning".
.
# Cord Compression from metastatic HCC: Likely secondary to T11
retropulsion from metastatic HCC. Pt with parastesias and pain
in his arms. Pt was given 10mg IV dexamethasone in the ED and
was maintained on dexamethasone 4mg q6h on admission. Pain was
controlled with MScontin and oxycodone as well as gabapentin for
neuropathic pain. On [**12-2**] he was brought to the OR for a T1
Corpectomy with cervical plating. He tolerated the procedure
well without complication. He spent 1 night in the SICU and was
called back out to the oncology floor on [**2133-12-3**].
Post-operatively he denied any parastesias or pain. His
strength remained [**5-14**] throughout during the admission. After
surgery he was ambulating well and advanced his diet. He
remained in a [**Location (un) 2848**]-J collar and will remain in it for 6 weeks
post op. He will follow up in spine clinic in 2 weeks. He was
given instructions to follow up with his oncologist. He
remained on his MS contin 60mg [**Hospital1 **], PRN oxycodone, and
gabapentin for pain on discharge. Given his baseline
thrombocytopenia he received a total of 7 units of platelets
throughout admission including in the operative setting. Spine
surgery recommended keeping his Plt>50 for 3 days post
operatively. On POD #2 he was at 53, so he received a unit of
platelets prior to discharge. He was cleared by Neurosurgery
and was deemed suitable to discharge.
.
# Cirrhosis with thrombocytopenia: Pt was continued on his
nadolol. His thrombocytopenia was likely secondary to his
Cirrhosis, and he received 7U of platelets during admission to
maintain Plt>50 in the perioperative setting to reduce risk of
bleed (see above section).
.
# Hypertension: Initially held HCTZ/Lisinopril given that he
was heading to the OR. These were restarted without
complication on discharge.
.
TRANSITIONAL ISSUES:
.
# Pathology from OR tumor specimen still pending
# Pt given instructions to follow up with spine surgery in 2
weeks after discharge
# He was encouraged to make a follow up appointment with his
primary oncologist
# Platelets should be monitored as an outpatient.
Medications on Admission:
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times
per day
LISINOPRIL-HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider)
- 20 mg-12.5 mg Tablet - 1 Tablet(s) by mouth
MORPHINE - (Dose adjustment - no new Rx) - 30 mg Tablet
Extended Release - 2 Tablet(s) by mouth q 12 hour
NADOLOL - 40 mg Tablet - 1 Tablet(s) by mouth daily
OXYCODONE - 5 mg Tablet - [**1-11**] Tablet(s) by mouth q4-6hours as
needed for shoulder pain
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth q
8 hour as needed for nausea/vomiting (take 1 pill with morphine)
Medications - OTC
MAGNESIUM OXIDE - (Prescribed by Other Provider) - Dosage
uncertain
Discharge Medications:
1. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q12H (every 12 hours).
2. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. lisinopril-hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours.
Discharge Disposition:
Home
Discharge Diagnosis:
T1 Spinal cord compression
Metastatic Hepatocellular carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 26438**],
You were admitted to the hospital for compression of your spinal
cord due to your cancer. You underwent surgery to decompress
your spinal cord. You did well with this and are ready for
discharge. You received several units of platelets during
admission to decrease the risk of post-operative bleeding.
Immediately after the operation:
- Activity:You should not lift anything greater than 10 lbs
for 2 weeks. You will be more comfortable if you do not sit in a
car or chair for more than ~45 minutes without getting up and
walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
- Swallowing: Difficulty swallowing is not uncommon after
this type of surgery. This should resolve over time. Please
take small bites and eat slowly.
- Cervical Collar / Neck Brace: You need to wear the brace
at all times.
- Wound Care:Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.
- You should resume taking your normal home medications.
Followup Instructions:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]. Ph
[**Numeric Identifier 18919**]
o At the 2-week visit we will check your incision, take
baseline x rays and answer any questions.
o We will then see you at 6 weeks from the day of the
operation.
Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.
[**Name6 (MD) **] [**Name8 (MD) 4908**] MD [**MD Number(2) 8116**]
|
[
"3051",
"2875"
] |
Admission Date: [**2139-10-30**] Discharge Date: [**2139-11-30**]
Date of Birth: [**2139-10-30**] Sex: M
Service: Neonatology
This is an interim dictation summary covering the time period
from [**10-30**] to [**2139-11-27**].
HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 53572**] #3 is a 1075 gram boy
born at 28-5/7 week gestational age to a 40-year-old G3 P0
mother with prenatal screens: Maternal blood type O
positive, antibody negative, GBS unknown, hepatitis B surface
antigen negative, RPR nonreactive. Prenatal course is
remarkable for donor egg in-[**Last Name (un) 5153**] fertilization with
subsequent twinning of one embryo resulting in quadruplet
pregnancy.
Mother was admitted at 24 weeks with cervical shortening and
treated with betamethasone. She was followed by serial
monitoring. The decision was made to deliver because of
progressive preeclampsia. Delivery was by C section under
spinal anesthesia with Apgars of 8 and 8.
PHYSICAL EXAM: Initial physical exam remarkable for preterm
infant in moderate respiratory distress, pink color, soft
anterior fontanel, normal facies, intact palate, moderate
retractions, fair air entry, no murmur, present femoral
pulses, flat, soft, nontender abdomen without
hepatosplenomegaly, normal phallus, testes in canal, stable
hips, normal perfusion, normal tone and activity for
gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Baby had initial respiratory distress,
otherwise intubated and received Surfactant x2 for
respiratory distress syndrome. He was successfully extubated
to CPAP on day of life #4, weaned to nasal cannula on day of
life 10, and weaned to room air on day of life #26. He is
currently breathing comfortably in room air saturating
greater than 92%. He is being treated with caffeine for
apnea of prematurity typically with 1-6 apneic or bradycardic
episodes daily.
Cardiovascular: [**Known lastname **] had some initial hypotension
requiring two normal saline boluses, but no vasopressors. He
had a murmur on day of life #3 and was diagnosed clinically
with a patent ductus arteriosus. He was treated with his
first course of indomethacin from day of life three to four,
but the murmur persisted and a small PDA was confirmed by
echocardiogram on day of life #5. He received a second
course of indomethacin with decrease of his murmur and
resolution of clinical symptoms of patent ductus arteriosus.
He continues to have a soft cardiac murmur consistent with a
peripheral pulmonic stenosis murmur. Subsequent to his
initial NICU course, he has maintained normal blood pressures.
Fluids, electrolytes, and nutrition: [**Known lastname 43073**] birth
weight was 1075 grams. He initially received parenteral
nutrition. Enteral feeds were initiated on day of life #9,
and advanced without difficulty to his current enteral feeds
of 150 cc/kg/day of mother's milk and premature Enfamil
supplemented 28 kilocalories/ounce and ProMod by gavage
feeding. He has had some intermittent spittiness, which has
not required medical therapy.
GI: [**Known lastname **] was treated with phototherapy for
hyperbilirubinemia from day of life #3 until day of life #14
with a peak bilirubin on day of life six of 6.9 and most
recent bilirubin on [**11-19**] of 2.5.
Hematology: [**Known lastname 43073**] blood type is not known, and he
has not received a transfusion. His most recent hematocrit
on [**11-16**] was 31.5 with a reticulocyte count of 9%.
Infectious disease: [**Known lastname **] was initially treated with
48 hours of ampicillin and gentamicin on admission until
blood cultures remained negative for 48 hours. He has not
had any subsequent infectious disease issues.
Neurology: Head ultrasound performed on [**11-6**] (day of
life #7) was negative. He is due for a routine one month
repeat head ultrasound.
Sensory: [**Known lastname **] has not yet received his hearing
screening. He is due for his first ophthalmologic
examination within the next few days.
Routine healthcare maintenance: [**Known lastname **] has not yet
received his one month hepatitis B immunization. On his
routine newborn state screen, he initially had a low thyroxin
level, which was repeated on [**11-13**], with normal
results.
CONDITION: Stable.
PRIMARY PEDIATRICIAN: Has not yet been chosen.
DISCHARGE DIAGNOSES:
1. Prematurity at 28-5/7 weeks gestational age.
2. Status post initial hypertension.
3. Status post patent ductus arteriosus treated with two
courses of Indocin.
4. Status post respiratory distress syndrome treated with
Surfactant.
5. Status post hyperbilirubinemia.
[**First Name8 (NamePattern2) 39464**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Name8 (MD) 50790**]
MEDQUIST36
D: [**2139-11-30**] 05:48
T: [**2139-11-30**] 06:40
JOB#: [**Job Number 53578**]
|
[
"7742",
"V290"
] |
Admission Date: [**2179-7-26**] Discharge Date: [**2179-9-26**]
Date of Birth: [**2113-6-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
fatigue, anemia, renal failure
Major Surgical or Invasive Procedure:
Renal biopsy, Exploratory laparotomy with removal of the left
kidney and repair of an aortic puncture, plus renal vein
laceration x2, abdominal closure with Kentuckypatch;
plasmapheresis; abdominal wash-out, placement of gastrostomy
tube, placement of jejunostomy tube, placement of right
subclavian hemodialysis catheter; Insertion of right internal
jugular Perma-Cath; arteriovenous fistula placement. Exploratory
laparotomy (for: 1. Intra-abdominal abscess, 5 L. 2. Gangrene
of the gallbladder. 3. Perforated proximal transverse colon.
4. Questionable perforated duodenal ulcer.)
History of Present Illness:
HPI: This is a 66 y/o M with h/o Churg [**Doctor Last Name 3532**] Sd who is
transfered from outside hospital with hyperkalemia and acute
renal failure.
.
Patient refers that over the last 3-4 days he was having
increase of cough production with yellow sputum. No fevers or
chills associated.
He was also feeling very weak, lack of energy, malaise, fatigue
and feeling short of breath with very small activities. He also
reported abdominal distention, feeling bloated and very low po
intake. + nausea and vomit. Low appetite. Decreased urine
output.
He went to PCP and labs were checked that showed high K and ARF.
Apparently chest x ray also with fluid overload.
He had Ct Scan with contrast done 2 weeks ago (see below) and
reports taken Ibuprofen up to 1800/day for pain. No weight gain,
no leg swelling.
He was given kayexalate, insulin dextrose, calcium gluconate and
he was transfered to [**Hospital1 18**] for further manatment.
.
Of note, Patient with dx of Churg [**Doctor Last Name **] Sd about 2 years ago.
He was taken prednisone and slowly tappering it off. He
eventually stopped it on the first of [**Month (only) **]. Few weeks at the end
of this [**Doctor Last Name 2949**], when taking QOD he describes feeling worst the
days that he did not take it.
He also states that he has had episodes of small superficial
"clots" about 3 in the last year, first in the behind the knee,
another one in the right groin, and last one in the left armpit.
He underwent per his hem onc doctor [**Last Name (Titles) 67516**] a CT Scan of
the abdomen about 2 weeks ago which was normal and also chest x
ray normal
.
Review of systems:
+ cough as above
+ mild headache, intermittent left sided.
Constipation +
No arthralgias or joint pain
+ difficulty getting out of bed in the mornings- thought to be
associated to his steroids use
.
This patient was due to be transfered for a physical therapy
institution. However, On the evening prior to transfer, the
patient began to notice some mild abdominal distention. Physical
examination revealed a mildly tympanitic abdomen and no change
in his vital signs. The patient continued to tolerate oral
feedings without difficulty. On the morning of the surgical
procedure, which was [**2179-9-21**], the patient demonstrated
further abdominal
distention. Work-up included a KUB which revealed an 11 cm
gas-filled structure in the midabdomen, and CT scan revealed
this to be free of intraperitoneal air. The patient was
therefore scheduled for urgent laparotomy. Findings included:
Gangrene of the gallbladder with obscuration of structures in
the right upper quadrant, question of perforation of a duodenal
ulcer, 5 L intraperitoneal abscess, and a 2.5 cm perforation of
the proximal transverse colon.
.
Past Medical History:
PMH: Churg [**Doctor Last Name 3532**] dx 2 years ago
Asthma for 35 years
.
PSH: Sinus surgeris x2
Hernia repair x 1
Social History:
Lives with his wife. Lives 6 months in [**State **] works as dentist,
other six months in [**Hospital1 6687**]. He had 9 children. One son is
general surgeon
Negative tobacco use, Ocassional alcohol
Family History:
Father died of leukemia
Mother died at [**Age over 90 **] years old
Two children with MS
Physical Exam:
On admission
Vitals: T:98.6 145/85 P: 75 R: 20 BP: 145/85 SaO2: 96%
General: Awake, alert in non apparent distress
HEENT: Non-icteric, + JVD ~10cm, dry oral mucosa
Pulmonary: Decrease breath sounds in the bases. Few cracles.
Cardiac: RRR, nl s1-s2, no murmurs, no rubs
Abdomen: soft, mild tenderness in the RUQ, slighly decrease
bowel sounds.
Extremities: mild ankle edema. distal pulses preserved
Skin: no rashes or lesions noted.
Neurologic: alert, oriented x3, no asterixis, reflexes
preserved bilaterally. strength 5/5
Pertinent Results:
OSH:
WBC 8.3 Hb8.9 HCT 26, Plat 64 Diff N 62% L 25.6
Na 131 K 5.2 Chloride 105, HCO3 17 Gluc 97 BUN 110 Creat 6.4
Cal 8.0
Bil T 1.8 Alb 3.0 Alk phosph 78, AST 34, AlT 17 ,
U/A spec graity 1025, gluc neg, keton trace PH 5.0 urobili 0.2
Prot >300
RBC 50-75 WBC [**1-26**]
.
At [**Hospital1 18**]:
On admission ([**2179-7-26**]):
CBC: WBC-7.5 (Differential: Neuts-67 Bands-2 Lymphs-10*
Monos-13* Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0)
RBC-2.97* Hgb-8.5* Hct-24.3* MCV-82 MCH-28.5 MCHC-35.0 RDW-16.4*
Plt Ct-47*
.
Blood Smear: Hypochr-NORMAL Anisocy-1+ Poiklo-1+ Macrocy-NORMAL
Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Schisto-1+
Bite-OCCASIONAL
.
Coagulation measurement: PT-13.1 PTT-25.6 INR(PT)-1.1; Plt
Ct-47*; Fibrinogen-452*
.
Chemistries: Glucose-93 UreaN-115* Creat-6.0* Na-136 K-5.1
Cl-105 HCO3-17* AnGap-19
.
Liver function tests: ALT-13 AST-30 LD(LDH)-881* AlkPhos-68
TotBili-1.8* DirBili-0.4* IndBili-1.4 ALT-12 AST-28
LD(LDH)-942* AlkPhos-66 Amylase-45 TotBili-1.5; Lipase-31;
TotProt-6.0* Calcium-8.3* Phos-9.0* Mg-2.8*; Albumin-3.0*
Iron-58 Hapto-<20* calTIBC-211 Ferritn-834* TRF-162*
.
Other: VitB12-359 Folate-13.3; CRP-123.5*; PEP-NO SPECIFI
b2micro-24.4* IgG-1441 IgA-145 IgM-79; Lactate-1.1; ESR-56*
Parst S-NEGATIVE; Ret Aut-1.3
.
ABG: ([**2179-7-27**]) Temp-37.1 pO2-79* pCO2-28* pH-7.35 calTCO2-16*
Base XS--8 NOT INTUBATED
.
Hospital Course:
Serum Free Calcium ranged from 0.37 ([**2179-7-30**]) to 1.36
([**2179-8-3**]) and the most recent level at 0.95 ([**2179-8-18**])
Serum Hemoglobin/Hematocrit levels on admission were Hgb-8.5
Hct-24.3 on [**2179-7-26**] and ranged from Hgb-12.0 Hct-34.9
([**2179-7-30**]) to Hgb-12.0 Hct-34.9 ([**2179-7-30**]) with the most recent
levels Hgb-8.4 Hct-25.9 ([**2179-9-18**]).
.
WBC ranged from 4.7 ([**2179-8-30**]) to 42.8* ([**2179-8-8**]) with
the most recent level 14.2 ([**2179-9-18**])
Platelets ranged from 32 ([**2179-7-27**]) to 243 ([**2179-9-6**]) with
the most recent level 100 ([**2179-9-18**])
Na ranged from 129 ([**2179-8-7**]) to 148 ([**2179-9-12**]) with the
most recent 141 ([**2179-9-18**])
K ranged from 3.4 ([**2179-8-12**]) to 5.7 ([**2179-9-6**]) with the
most recent 4.4 ([**2179-9-18**])
Cl ranged from 93 ([**2179-8-12**]) to 115 ([**2179-9-12**]) with the
most recent 110 ([**2179-9-18**])
Bicarbonate ranged: 11 ([**2179-7-30**]) to 31 ([**2179-8-23**]) with
most recent 19 ([**2179-9-18**])
BUN ranged: 57 ([**2179-8-3**]) to 129 ([**2179-8-8**]) with most
recent 79 ([**2179-9-18**])
Creatinine ranged: 1.3 ([**2179-9-18**]) to 8.4 ([**2179-7-30**])
Calcium ranged: 6.6 ([**2179-8-18**])to 9.1 ([**2179-8-9**]), most
recent 7.7 ([**2179-9-18**])
Magnesium ranged: 1.7 ([**2179-8-24**]) to 2.9([**2179-7-28**]), most
recent 2.0 ([**2179-9-18**])
Phosphate ranged:2.9 ([**2179-9-15**]) to 13.0 ([**2179-7-30**]), most
recent 3.8
([**2179-9-18**])
Glucose ranged: 78 ([**2179-8-11**]) to 308 ([**2179-7-30**]), most
recent 142 ([**2179-9-18**])
INR ranged: 1.1 ([**2179-7-26**]) to 4.0 ([**2179-8-15**]), most recent
1.3 ([**2179-9-18**])
.
Serum lactate level on admission was Lactate-1.1 ([**2179-7-27**]) and
ranged from Lactate-1.5 ([**2179-8-8**]) to Lactate-7.1 ([**2179-7-30**])
with most recent level of Lactate-2.8 ([**2179-9-18**])
.
.
CULTURES:
[**2179-8-24**] URINE CULTURE
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
This isolate is an extended-spectrum beta-lactamase (ESBL)
producer and should be considered resistant to all penicillins,
cephalosporins, and aztreonam. Sensitive only to Meropenem and
Imipenem
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). 10,000-100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
.
[**2179-9-9**] URINE CULTURE
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
This isolate is an extended-spectrum beta-lactamase (ESBL) -
Sensitive only to Meropenem and Imipenem
.
[**2179-9-15**] URINE CULTURE: NO GROWTH.
.
PATHOLOGY:
[**2179-7-30**]: Renal Biopsy, needle:
1. Immune complex glomerulonephritis, most consistent with
lupus nephritis. 2. Thrombotic microangiopathy
Light Microscopy: The specimen consists of renal cortex only
containing approximately 13 glomeruli, of which 3 are globally
sclerotic. The remainder show variable mild-moderate
endocapillary proliferation with accompany neutrophils. One
fresh cellular crescent is seen. Most also show congestion,
thrombosis, and focal necrosis, with karyorrhectic debris.
There is mild interstitial fibrosis and tubular atrophy. Mild
chronic inflammation accompanies the scarring, but is also seen
in preserved areas. No granulomatous interstitial inflammation
is seen. Arterioles show mild intimal fibroplasia. Arteries
show mild mural thickening, and hyaline change. No necrotizing
vasculitis is seen.
Immunofluorescence: The specimen consists of renal cortex only,
containing approximately 7 glomeruli, of which none are globally
sclerotic. There is granular mesangial, peripheral capillary
loop, [**Doctor Last Name **] capsule, vascular, and tubular basement membrane
staining for IgG ([**3-27**]+), C1q (3+), IgA (trace-1+), IgM
(trace-1+), Kappa ([**2-26**]+) and lambda ([**2-26**]+). Two glomeruli show
[**2-26**]+ C3, others are negative. Vessels show trace C3. Albumin is
non-contributory. Two glomeruli show fibrin thrombi, all others
show segmented staining.
Comment: The immunofluorescence findings, particularly the "full
house" and Clq positivity together with the extensive vascular &
tubular basement membrane positivity, strongly argue that this
patient's immune complex glomerulonephritis is lupus nephritis.
Of course, thrombotic microangiopathies may supervene on lupus
nephritis, and often portend a bad prognosis. Although Churg
[**Doctor Last Name 3532**] syndrome may involve the kidney, when it does, it
typically demonstrates very different findings (pauci-immune
crescentic glomerulonephritis) than the lesions in this sample.
ELECTRON MICROSCOPY (C-4313): Fine structural studies of three
glomeruli, which show occlusive endocapillary proliferation but
no obvious thrombosis, reveal extensive foot process effacement.
Occasional subepithelial and intramembranous electron dense
deposits are seen. The capillary lumens are occluded by
hypercellularity, some of which are likely leukocytes.
Endocapillary, mesangial, and subendothelial electron dense
deposits are seen, together with cytoplasmic swelling. No
electron lucent widening of the subendothelial space is noted.
Focal mesangial interposition is identified. Tubuloreticular
structures are not seen. Electron dense deposits are also seen
along [**Doctor Last Name **] capsule and tubular basement membranes.
These findings confirm an immune complex glomerulonephritis, and
exhibit the multi-site deposition that is typical of lupus
nephritis. While classic findings of a thrombotic
microangiopathy are not seen in these particular [**Hospital1 **], this may
be due to the morphology being altered by the extensive immune
complex related changes, as well as to sampling (no thrombi seen
in these glomeruli).
.
.
[**2179-7-30**]: LEFT KIDNEY (Left Nephrectomy):
Thrombotic microangiopathy, see note.
Endocapillary proliferative glomerulonephritis with cellular
crescents seen in less than 10% of the glomeruli.
Probable biopsy site with no associated inflammation or
hemorrhage.
Significant hemorrhage seen in renal hilum only.
Major arteries and veins with chronic injury (intimal
fibroplasia) and no active vasculitis.
Note: No hemorrhage or inflammation is seen in the presumed area
of biopsy. By report, only one needle biopsy core of renal
parenchyma was obtained, approximately 3 hours prior to the
nephrectomy, and the kidney was found, at operation, to be
poorly perfused. Please see renal biopsy report (S06-[**Numeric Identifier 67517**]) for
details on this patients renal disease. PAS, MT, and [**Doctor Last Name **]
special stains reviewed.
[**2179-8-4**] PORTION OF OMENTUM: Focal fat necrosis and recent
hemorrhage.
.
IMAGING:
RENAL U.S. [**2179-7-27**]
REASON FOR THIS EXAMINATION: Rule out hydronephrosis
The right kidney measures 11.7 cm and the left kidney 11.4cm.
Both kidneys are unremarkable without evidence of
hydronephrosis, stones
or mass. The urinary bladder is decompressed. Incidental note
is made of gallbladder sludge but no wall thickening or
pericholecystic fluid.
IMPRESSION: No evidence of hydronephrosis.
.
ABDOMEN U.S. (COMPLETE) [**2179-7-29**]
REASON FOR THIS EXAMINATION: size and texture of spleen
INDICATION: 66-year-old man with left upper quadrant pain and
flank pain. Evaluate size and texture of spleen.
Comparison is made to prior study of [**2179-7-27**]. The liver is
normal in size and without focal lesions. The common bile duct
is unremarkable measuring 6 mm. The gallbladder is filled with
sludge, but has no wall thickening or pericholecystic fluid.
The right kidney measures 11.2cm. The parenchyma of the right
kidney is unremarkable. The left kidney
measures 12.8 cm. There is no hydronephrosis or stones. The
spleen is normal in size measuring 11.5 cm and is of homogeneous
echogenicity.
IMPRESSION: 1. Normal appearance of both kidneys. No evidence
of hydronephrosis. 2. Normal-sized spleen. 3. Gallbladder
filled with sludge. No evidence of cholecystitis.
.
CHEST (PA & LAT) [**2179-7-27**]
REASON FOR THIS EXAMINATION: r/o volume overload
INDICATION: Acute renal failure and shortness of breath.
The heart is mildly enlarged. There is upper zone vascular
redistribution, and there are diffuse bilateral interstitial
opacities with numerous septal lines. Small bilateral pleural
effusions are present, right greater than left. Additionally,
there is evidence of previous granulomatous infection with
calcified lymph nodes in the left hilum, aorticopulmonary
window, and a small calcified left upper lobe granuloma. An
asymmetrical area of opacity in the right perihilar region is
likely due to asymmetrical edema, and less likely a superimposed
process such as aspiration or infection.
IMPRESSION: Diffuse interstitial edema, associated small
bilateral pleural effusions.
.
ABDOMEN (SUPINE ONLY) [**2179-7-27**]
REASON FOR THIS EXAMINATION: r/o obstruction
INDICATION: Abdominal distention.
Supine radiographs of the abdomen demonstrate a nonobstructive
bowel gas
pattern. If there is clinical suspicion for free
intraperitoneal air, either an upright or lateral radiograph
would be recommended. Within the imaged portions of the lung
bases, there are interstitial abnormalities likely due to
diffuse interstitial edema as revealed on recent chest
radiograph of earlier the same date.
.
CT CHEST W/O CONTRAST [**2179-7-29**]
REASON FOR THIS EXAMINATION: characterize lung parenchyma and
pleural space, infiltrates, edema, effusions, masses
CONTRAINDICATIONS for IV CONTRAST: creatinine elevated
INDICATION: Churg-[**Doctor Last Name 3532**] syndrome. Cough.
Multidetector CT of the chest was performed without intravenous
or oral
contrast administration. Images are presented for display in
the axial plane at 5-mm and 1.25-mm collimation.
There are multifocal lung abnormalities including smoothly
thickened septal lines, as well as multifocal areas of
ground-glass attenuation. Some of the ground-glass opacities
are spherical (for example right upper lobe) (image 21, series
3), and others are more confluent. The confluent ground-glass
opacities are most prominent in the central, perihilar regions
coursing along bronchovascular bundles. There are also two
broad band-like areas of linear opacification in both perihilar
regions with some associated mild volume loss. The central
airways are patent. Areas of multifocal bronchial wall
thickening.
There is mediastinal lymphadenopathy. The largest node is in
the subcarinal region measuring 3 cm x 1.6 cm in diameter.
Additional enlarged nodes are present throughout the
paratracheal portions of the mediastinum. There is also one
hyperdense calcified node in the left prevascular space in
conjunction with a small calcified left upper lobe granuloma and
additional calcified hilar and AP window nodes. Heart is upper
limits of normal in size. There is a small pericardial effusion
and there are also small dependent bilateral pleural effusions.
Within the imaged upper abdomen, the adrenal glands are normal.
There is
nonspecific stranding of the mesentery. Numerous small
abdominal and
retroperitoneal lymph nodes are present.
There are no suspicious lytic or blastic skeletal lesions.
Additional note is made of bilateral retrocrural lymphadenopathy
as well as numerous small nodes in the posterior mediastinum
just above the diaphragm level and adjacent to the GE junction.
Additional small nodes are present in the pericardial region.
IMPRESSION:
1. Multifocal septal thickening, ground-glass opacities and
bronchial wall thickening, likely due to provided history of
Churg- [**Doctor Last Name 3532**] syndrome.
2. Bilateral dependent small pleural effusions, with small
anterior loculated component of the left effusion. Small
pericardial effusion.
3. Multiple lymph nodes throughout the mediastinum (largest in
subcarinal
area), hila, and imaged portion of the abdomen. This could be
due to
mediastinal eosinophilic lymphadenopathy from Churg-[**Doctor Last Name 3532**]
syndrome, but it is difficult to fully exclude lymphoma.
Followup scans after treatment for Churg-[**Doctor Last Name 3532**] would be
helpful to assess for resolution.
4. Evidence of previous granulomatous exposure.
.
[**2179-7-30**] NEEDLE BIOPSY OF LEFT KIDNEY BY NEPHROLOGIST
Reason: ATN vs HUS vs Churgg [**Doctor Last Name 3532**] exacerbaction
BIOPSY GUIDANCE: Ultrasound guidance was provided to the
nephrology service during performance of biopsy of the right
native kidney. Five passes were made under ultrasound guidance.
The patient experienced pain following the procedure and was
transferred to the CT Suite for further evaluation. The CT scan
has demonstrated perirenal hematoma. This was not imaged during
the biopsies or immediately following the biopsies using
ultrasound.
IMPRESSION: Son[**Name (NI) 493**] guidance provided to nephrology service
for obtaining core biopsies of the left native kidney.
.
CT PELVIS W/O CONTRAST [**2179-7-30**]
Reason: s/p kidney biopsy with sever pain
INDICATION: Status post renal biopsy, with severe left-sided
pain. Evaluate for hematoma.
CONTRAINDICATIONS for IV CONTRAST: Cr 7.9
COMPARISON: None.
TECHNIQUE: MDCT acquired contiguous axial images were obtained
from the lung bases to the pubic symphysis. Multiplanar
reconstructions were performed.
CT OF THE ABDOMEN WITHOUT CONTRAST: Bilateral small pleural
effusions are seen at the lung bases. There is a small
pericardial effusion also noted. Within the left lung base,
there are areas of ill-defined patchy opacity, which likely
reflect changes from the patient's known Churg-[**Doctor Last Name 3532**] disease.
On this non-contrast enhanced study, the liver, gallbladder,
right kidney, and right adrenal gland are normal.
There is a large area of fat stranding and soft tissue density
material
surrounding the left kidney, and within the posterior pararenal
space and
extending along Gerota's fascia anteriorly, consistent with a
perinephric
hematoma. The left kidney is markedly displaced anteriorly.
The hematoma extends from the level of the diaphragm within the
retroperitoneum inferiorly to the level of the superior portion
of the bladder, and the left pelvic side wall. The spleen and
pancreas are also displaced anteriorly. No free intraperitoneal
air is seen.
.
CT OF THE PELVIS WITH IV CONTRAST: There is extensive
retroperitoneal
hematoma surrounding the left kidney, as described above.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified.
CT RECONSTRUCTIONS: Multiplanar reconstructions were essential
in delineating the anatomy and pathology.
IMPRESSION:
1. Extensive retroperitoneal and perinephric hematoma,
displacing the left kidney anteriorly.
2. Small bilateral pleural effusions and pericardial effusion.
3. There are patchy opacities within the left lower lobe, which
are likely related to patient's known Churg-[**Doctor Last Name 3532**] disease.
.
CHEST XRAY: LINE PLACEMENT [**2179-7-30**]
INDICATION: Check position of CVL. COMPARISON: [**2179-7-27**].
Compared to the prior study, there is a right CVL with the tip
in the SVC and there is a left entering Swan-Ganz with tip in
the right pulmonary outflow tract. Bilateral patchy densities
are seen, left greater than right, the left being newer and
suspicious for. Upper lungs also shows increased density
compared to the prior study and a followup film is recommended.
There is no PTX. The patient has been intubated since the prior
study, with the tip of The ETT 3.6 cm above the carina. The
heart size is within normal limits.
IMPRESSION:
No PTX with two CVLs placed as described above.
New patchy density in the left mid lung field, which would be
consistent with pneumonia in the appropriate clinical setting.
Increased density in the upper lung fields bilaterally.
Followup is recommended to see if this process evolves further.
.
CHEST (PORTABLE AP) [**2179-8-1**]
Reason: Acute increased 02 requirement
SINGLE AP PORTABLE VIEW OF THE CHEST
REASON FOR EXAM: Acute increased O2 requirement. Patient with
hemoperitoneum with nephrectomy and history of Churgh-[**Doctor Last Name 3532**]
syndrome.
Comparison is made with prior study dated [**2179-7-30**].
FINDINGS: There has been improvement in the moderate pulmonary
edema. The endotracheal tube tip is located 7.6 cm above the
carina (3cm above the standard position). Swan-Ganz catheter
tip is in the right pulmonary outflow tract. Unchanged position
of the right SCV Line in the lower third of the SVC. The feeding
tube is folded in the stomach, its tip facing the GE junction.
The heart size is normal. Unchanged small left pleural effusion
IMPRESSION: Interval improvement in the moderate pulmonary
edema Folded feeding tube in the stomach. Unchanged small left
pleural effusion.
.
CHEST (PORTABLE AP) [**2179-8-2**]
REASON FOR THIS EXAMINATION: new decrease in oxygen saturations
CHEST, SINGLE AP FILM
IMPRESSION: Increase in size of left pleural effusion and, even
allowing for rotation of the chest to the left, likely increased
collapse of left lower and left upper lobes. Small ill-defined
focal opacity, right midzone for which re-evaluation on followup
is suggested.
.
BILATERAL LOWER EXTREMITY VENOUS DOPPLER, [**2179-8-3**]
COMPARISON: None.
INDICATION: Rule out DVT. History of left common femoral line.
FINDINGS: The common femoral, superficial femoral, and
popliteal veins are patent bilaterally demonstrating normal
color flow, compressibility, and augmentation. There is no
evidence of intraluminal venous thrombus. A central line is
seen in the left common femoral vein.
IMPRESSION: No evidence of deep venous thrombosis of the lower
extremities bilaterally.
.
CHEST (PORTABLE AP) [**2179-8-6**]
INDICATION: Hemoperitoneum status post ex lap and nephrectomy
with desats.
COMPARISON: [**2179-8-4**].
FINDINGS: An endotracheal tube is in place with tip terminating
6.6 cm from the carina. Left subclavian venous access catheter
with tip in upper SVC, and right subclavian venous access
catheter with tip in mid SVC, are in unchanged position. Since
the previous examination, the left mid lung consolidation has
improved and there is continued left lower lobe atelectasis and
pleural effusion. The right lung is clear and there is no
pneumothorax.
IMPRESSION:
1. Improved left mid lung consolidation. Stable left pleural
effusion and left lower lobe atelectasis.
2. Lines and tubes in satisfactory position.
.
FLUOROSCOPIC GUIDED EXCHANGE OF NEW DIALYSIS CATHETER [**2179-8-8**]
INDICATION FOR EXAM: The patient with left subclavian
hemodialysis catheter that is not working.
PROCEDURE AND FINDINGS: The procedure was performed by Dr.
[**Last Name (STitle) 15785**] and Dr. [**Last Name (STitle) 4686**], the attending radiologist, who was
present and supervising
throughout the procedure. Initially, both ports were aspirated
with a 4 mL syringe. Since the lateral port could not be
aspirated, a fluoroscopic image of the thorax was performed
demonstrating the tip of the catheter in the left
brachiocephalic vein. An Amplatz guidewire was advanced through
the patent port into the superior vena cava.
The catheter then was pulled out through the guidewire with
compression of the right subclavian vein. A new 14.5 French
dual-lumen tunneled dialysis catheter was then advanced into the
right internal jugular vein and the tip placed into the distal
superior vena cava under flouroscopic guidance. The catheter
was secured to the skin with 0 Prolene sutures. There were no
immediate complications during the procedure.
IMPRESSION: Successful exchange of a hemodialysis catheter with
a new 14.5 French 23 cm dual-lumen tunneled dialysis catheter
placed through right internal jugular vein approach. The line
is ready for use.
.
BILATERAL LOWER EXTREMITY ULTRASOUND: [**2179-8-9**]
INDICATION: History of left common femoral line. Evaluate for
DVT.
COMPARISON: [**2179-8-3**].
Grayscale and Doppler ultrasound of the right and left common
femoral, superficial femoral, and popliteal veins were
performed. Normal flow, augmentation, compressibility, and
waveforms are demonstrated. No intraluminal thrombus is
identified. Please note that the left common femoral vein was
examined distally and was not examined proximally
due to the presence of a left groin bandage.
IMPRESSION: No evidence of DVT in the right or left lower
extremity vessels examined. Note that the left common femoral
vein at the level of the bandage was not examined.
.
ABDOMEN (SUPINE ONLY) [**2179-8-13**]
INDICATION: 66-year-old man with renal failure and abdominal
distension.
Comparison is made with abdominal radiograph dated [**2179-7-30**].
Note is made of dilated small bowel gas in the left lower
quadrant, measuring up to 5 cm. Colon gas is seen distally,
without marked dilatation. No evidence of free air is
identified on this abdominal radiograph.
IMPRESSION: Dilated small bowel gas up to 4 cm in left lower
quadrant;
however, distal colon gas is seen without dilatation. This may
represent
partial obstruction or ileus. If there is a high clinical
concern, CT of the abdomen can be performed.
.
RIGHT UPPER EXTREMITY ULTRASOUND: [**2179-8-17**]
INDICATION: Increasing upper extremity swelling. Evaluate for
DVT in the right arm.
Grayscale and Doppler examination of the right internal jugular,
subclavian, axillary, brachial, basilic and cephalic veins were
performed. Normal flow, augmentation, compressibility where
appropriate and waveforms are demonstrated. No intraluminal
thrombus is identified. There is a catheter in place within the
right subclavian vein.
IMPRESSION: No evidence of DVT in the right upper extremity.
.
BILATERAL LOWER EXTREMITY ULTRASOUND: [**2179-8-20**]
INDICATION: [**Hospital 24084**] hospital stay and immobility. Patient
with GI bleed. Evaluate for DVT.
COMPARISON: [**2179-8-9**].
Grayscale and Doppler son[**Name (NI) 867**] of the right and left common
femoral, superficial femoral, and popliteal veins were
performed. Normal flow, augmentation, compressibility and
waveforms are demonstrated. No intraluminal thrombus is
identified.
IMPRESSION: No evidence of DVT in either lower extremity.
.
Portable AP chest radiograph [**2179-8-25**]
REASON FOR EXAMINATION: Postoperative evaluation of the patient
after
nephrectomy.
Compared to [**2179-8-8**].
The patient was extubated in the meantime interval. The right
subclavian
double lumen catheter terminates 1 cm below the cavoatrial
junction. There is left pleural effusion which seems to be
slightly decreased in comparison to the previous film with
adjacent left lower lobe atelectasis. The consolidation due to
infectious process cannot be excluded. There is some worsening
of the right lower lobe discoid atelectasis.
IMPRESSION: Left pleural effusion with adjacent left lower lobe
atelectasis. Worsening of the right lower lobe atelectasis.
.
RENAL U.S. [**2179-8-28**]
INDICATION: 66-year-old man with lupus-like kidney disease
worsening renal function. Evaluate for hydronephrosis, bladder
obstruction, or other renal pathology.
COMPARISON: [**2179-7-27**].
The right kidney measures 13.0 cm. The left kidney has been
removed. There is no evidence of hydronephrosis or stones
within the right kidney. Within the urinary bladder is a small
linear echogenic structure measuring approximately 4 to 5 cm in
length that likely represents a bladder fold. Incidentally
noted is a gallbladder partially filled with sludge.
IMPRESSION: 1. No evidence of hydronephrosis or stones. 2.
Status post left kidney removal.
.
SPLEEN ULTRASOUND [**2179-8-28**]
INDICATION: 66-year-old male with acutely drop in platelet
count. Evaluate for splenic congestion/splenomegaly.
The spleen is at the upper end of normal size limits measuring
12 cm. Normal echotexture is demonstrated throughout the spleen
with no focal abnormalities. No perisplenic fluid is
demonstrated.
IMPRESSION: Normal sized spleen at the upper limits of normal
with no focal abnormalities identified.
.
SHOULDER [**2-26**] VIEWS NON TRAUMA [**2179-8-28**]
HISTORY: Right shoulder pain. Rule out fracture.
IMPRESSION: Three views of the right shoulder show no fracture,
dislocation, or abnormality of the adjacent ribs or pleura.
There is mild degenerative spurring at the acromioclavicular
joint.
.
CHEST (PORTABLE AP) [**2179-9-4**]
INDICATION: Placement of a tunneled catheter.
A single AP view of the chest is obtained on [**2179-9-4**] at 16:18
hours and is compared with the prior radiograph performed on
[**2179-8-26**]. A right-sided
internal jugular hemodialysis catheter is seen with its tip
projecting over the expected location of the mid SVC. No
pneumothorax is seen. A small left pleural effusion is present.
There is also increased density in the left retrocardiac area
consistent with airspace disease/atelectasis, which appears to
have improved slightly since the prior examination. Linear
atelectasis in the right lower lobe is essentially unchanged.
There is no evidence of failure.
IMPRESSION:
1. Hemodialysis catheter with the tip projecting over the mid
SVC.
2. Persistent asbestos disease and/or atelectasis on the left
side, improving slightly.
3. Small left pleural effusion, unchanged.
4. Right lower lobe linear atelectasis, unchanged.
.
.
.
.
Brief Hospital Course:
**Patient passed away on [**2179-9-26**] at [**2098**].**
.
A/P: 66 year old man with history of Churg-[**Doctor Last Name 3532**] presents with
cough, malaise found to be in acute renal failure, hyperkalemia,
and hemolytic anemia/thrombocytopenia. On [**2179-7-30**], the patient
underwent a left kidney biopsy, developed flank pain immediately
post biopsy, with CT demonstrating a retroperitoneal hematoma.
The patient was transferred to the medical intensive care unit,
at which time he developed hypotension, requiring resuscitation
with blood products. His belly became distended and he was
taken emergently to the operating room. Emergent exploratory
laparotomy was performed, with removal of the left kidney,
repair of an aortic puncture and renal vein lacerations, and
abdominal closure via [**State 19827**] patch. Pt returned to the OR on
[**2179-8-4**] for abdominal wash-out, placement of gastrostomy tube,
placement of jejunostomy tube, placement of right subclavian
hemodialysis catheter. He then returned to the OR for an
urgenet laparatomy on [**2179-9-21**]. The remainder of his
hospital course is described by system below. Patient passed
away on [**9-26**] at [**2098**].
.
.
Neuro
Pt has remained neurologically intact throughout the course.
Pain management has been the most significant neurologic issue,
with control obtained by Oxycodone-Acetaminophen and
Hydromorphone PRN. Overall, the patient was alert and orientated
to time, person and place throughout his stay at [**Hospital1 18**]. He was
calm and cooperative during his stay, and with no obvious
neurological deficit (generalized weakness present on lower
extremities bilaterally present during the majority of his
stay).
.
.
Pulmonary
Pt had acute on chronic exacerbations of his asthma as an
inpatient, which were treated directly by albuterol prn and
secondarily by the prednisone for his renal condition. After
his exploratory laparotomy on [**2179-7-30**], his abdomen was closed
using the [**State 19827**]-patch technique and he was kept intubated and
transferred to the ICU. After he returned to the OR for
definitive abdominal closure, patient was gradually weaned off
the ventilator. He was extubated on [**2179-8-12**].
.
.
Cardiac
Although the patient developed a post-operative atrial
fibrillation and Atrial flutter (from [**8-6**] - [**8-14**]), he was
rate-controlled without further issues, although he did
experience coumadin sensitivity (subsequently discontinued);
from [**8-14**] to the present, pt remained in normal sinus rhythm on
Metoprolol 25 mg PO.
.
.
GI
Beyond post-operative bowel rest per routine, pt has not
experienced significant GI difficulties. He tolerated full
diets thoughout the bulk of his inpatient stay, including at
discharge. Of note, pt's LFTs and amylase has been elevated
since the emergent surgery, with unclear etiology (possibly due
to intraoperative manipulation)and clinical significance,
certainly requiring continued monitoring an evaluation. The
patient was also seen by the nutrition service during his stay
at [**Hospital1 18**]. During the time period during which he had a G-tube in
place, they reccomended supplemental tube feeds promoted with
fibre, a regular diet with boost, and a calorie count. The
patient did have a poor appetite when he was first admitted to
the hospital and was encouraged to increase his oral intake,
which he did so gradually. On [**9-15**], the patient's G-tube was
removed by Dr. [**Last Name (STitle) **].
.
.
Renal
Pt presented with acute renal failure of new onset, unknown
origin, and with unknown baseline Cr. Pt exhibited a pre-op BUN
in the 80s and Cr in the 4-5 range. Initial laboratory testing
also revealed heavy proteinuria with heavy intact RBC load,
suggestive of active nephritis, also with urine eos and a
hemolytic anemia. Although renal failure can occur with Churg
[**Doctor Last Name 3532**], it is unusual to have it occur so rapidly; and while
hemolytic anemia has also been seen with Churg [**Doctor Last Name 3532**], it is a
rare complication (more commonly, one sees anemia of chronic
disease).
This constellation of findings c/w nephritis but inconsistent
with Churg [**Doctor Last Name 3532**] prompted further evaluation by renal biopsy.
Pt underwent renal bx on [**2179-7-30**], which was complicated as stated
above. The pathology report noted that immunofluorescence
findings, particularly the "full house" and Clq positivity
together with the extensive vascular & tubular basement membrane
positivity, strongly argue that this patient's immune complex
glomerulonephritis is lupus nephritis. It also noted that,
although Churg [**Doctor Last Name 3532**] syndrome may involve the kidney, when it
does, it typically demonstrates very different findings
(pauci-immune crescentic glomerulonephritis) than the lesions in
this sample. Electron microscopy analysis of three glomeruli
showed occlusive endocapillary proliferation but no obvious
thrombosis, and revealed extensive foot process effacement.
Occasional subepithelial and intramembranous electron dense
deposits were seen. The capillary lumens were occluded by
hypercellularity, some of which were likely leukocytes.
Endocapillary, mesangial, and subendothelial electron dense
deposits were seen, together with cytoplasmic swelling. No
electron lucent widening of the subendothelial space was noted.
Focal mesangial interposition was identified. Tubuloreticular
structures were not seen. Electron dense deposits are also seen
along [**Doctor Last Name **] capsule and tubular basement membranes. These
findings confirmed an immune complex glomerulonephritis, and
exhibited the multi-site deposition that is typical of lupus
nephritis. While classic findings of a thrombotic
microangiopathy were not seen in these particular [**Hospital1 **], this
may be due to the morphology being altered by the extensive
immune complex related changes, as well as to sampling (no
thrombi seen in these glomeruli). Following his nephrectomy and
Pt received several courses of HD for his RF and associated
electrolyte abnormalities, but as his renal function improved,
he was weaned from HD and was not HD-dependent at D/C,
Prednisone, a prominent aspect of his pre-admit Churg-[**Doctor Last Name 3532**]
regimen, was utilized throughout his stay for the purpose of
controlling his SLE-like nephritis. .
.
Heme
Pt was admitted with Hct 24, and throughout his course,
displayed a waxing and [**Doctor Last Name 688**] normocytic anemia, with elevated
LDH, elevated total bilirubin (although >4 and combined with
elevated direct bili and haptoglobin) and smears revealing
schistocytes suggestive of a microangiopathic process, possibly
secondary to his preexisting Churg-[**Doctor Last Name 3532**]. Although the exact
etiology of his anemia remains unclear, he was treated with
Epoetin Alfa (10,000 UNIT SC given M,W,F) and folate. Pt also
displayed waxing and [**Doctor Last Name 688**] thrombocytopenia (40,000 to 240,000
throughout stay), a finding of unclear etiology but likely
secondary to Churg-[**Doctor Last Name 3532**]. Pt was negative for anti-heparin
antibodies making HIT unlikely, but because plt count increased
after d/c'ing heparin, anticoagulation was peformed using
fondaparinux. Because HUS was considered as a possible cause of
this hemolytic, uremic, thrombocytopenic process, pt received
plasmapharesis until discontinued due to pathology report
indicating SLE-like nephritis. Although stable, his Hct remains
in the mid-20s at D/C. At D/C, he was given 2 units of pRBC. On
[**9-3**], the patient underwent a fistula placement. His Perma-cath
was removed by Dr.[**Name (NI) 670**] transplant team.
.
.
ID
Pt had one urine culture on [**2179-8-24**] (white count = 6.1), which
grew Klebsiella pneumoniae sensitive only to imipenem and
meropenem. He began antibiotic treatment with meropenem. A
second urine culture on [**2179-9-3**] (white count = 14.9) showed no
growth. The third urine culture on [**2179-9-9**] (white count = 18.5)
grew out Klebsiella pneumoniae, again sensitive to meropenem and
imipenem. At this point, it was reccomended by the Renal service
to re-start antibiotic treatment, with possible failure of prior
antibiotic treatment. Dr [**Known lastname 67518**] was started on meropenem for a
total of 10 days. No growth was shown on a fourth urine culture
done on [**2179-9-15**] (white count = 17.7) (to confirm no further
bacterial growth after antibiotic treatment).
.
.
Rheum
The Rheumatology service consulted this patient on [**2179-7-27**] to
find out if the patient??????s renal failure and hemolytic anemia was
related to his Churg-[**Doctor Last Name 3532**] diagnosis. At this point, symptoms
included wheezing, DOE, cough, pleuritic chest pain, myalgias,
headache, constipation, Raynaud??????s phenomenon, rhinitis, but the
patient denied arthritis, and rashes. At this point, it was felt
by rheumatology that the patient was likely having a
Churg-[**Doctor Last Name 3532**] flare and reccomended to treat with prednisone 1
mg/kg per day. They suggested a renal biopsy, which was then
obtained. The following tests were performed during this
hospital stay:
- [**2179-8-11**] Hepatitis C Virus Antibody - Negative;
- [**2179-8-17**] HIV antibody - negative;
- [**2179-7-28**] Complement levels C3 5* mg/dL, C4 1* mg/dL;
- [**2179-7-27**] Beta-2 Microglobulin - 24.9 mg/L;
- [**2179-8-6**] Double Stranded DNA - negative;
- [**2179-7-28**] Anti-Neutrophil Cytoplasmic Antibody - Negative;
- [**2179-8-30**] Parathyroid Hormone - 29 pg/mL;
- [**2179-8-2**] Thyroid Stimulating Hormone - 1.1 uIU/mL;
- [**2179-8-6**] Anticardiolipin Antibody IgG 5.4 GPL
- [**2179-8-6**] Anticardiolipin Antibody IgM - 8.6 MPL;
- [**2179-7-27**] IGE - 497 H; [**2179-7-27**] FREE KAPPA;
- [**2179-7-27**] SERUM - 169.0 MG/L, FREE LAMBDA;
- [**2179-7-27**] SERUM 128.0 MG/L, FREE KAPPA/LAMBDA RATIO 1.32.
A renal biopsy was consistent with immune-complex disease, per
the rheumatology service (though atypical given age, sex and
labs). The patient then underwent immunosuppresion via high dose
steroids, tapered to 80mg IV qday. On [**2179-8-30**], the patient
continued to receive Cellcept, the dosage changed to 1000mg [**Hospital1 **]
PO as well as continued prednisone of 100 mg daily. His
prednisone dosing was planned for 80mg PO qd for 14 days
starting on [**2179-9-5**], and then switching to 60mg PO qd for 14
days, followed by a re-evaluation on furthur dosing
requirements. On [**9-15**], this regimen was changed to 140mg qd for
3 days, followed by 120mg qd, along with Cellcept at 1g [**Hospital1 **].
.
.
Endocrine
This patient's prednisone regimen was changed and adjusted as
necessary throughout his hospital course. Initially, he was
started at prednisone 1 mg/kg per day. This was followed by 100
mg daily; this was then changed to 80mg PO qd for 14 days
starting on [**2179-9-5**], and then switching to 60mg PO qd for 14
days, followed by a re-evaluation on furthur dosing
requirements. On [**9-15**], this regimen was changed to 140mg qd for
3 days, followed by 120mg qd, along with Cellcept at 1g [**Hospital1 **]. The
final reccomendations are as follows per the renal service:
120mg prednisone [**9-21**], [**9-24**], [**9-26**], then 100mg prednisone [**9-28**], [**9-30**],
[**10-2**], and then 80mg qd [**10-4**], [**10-6**], [**10-8**], and finally, 60mg qd for
a while until seen by Dr [**First Name (STitle) 10083**]; throughout this regimen,
Cellcept is to be continued at 1g [**Hospital1 **]. The patient was on a
sliding insulin scale during the initial time period of his
hospital stay.
Medications on Admission:
- Prilosec
- Ibuprofen up to 1800/day
- Was on prednisone until [**6-24**]
Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed) as needed for dry eyes.
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-25**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
6. Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): Please HOLD for HR<60; SBP<100.
11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
Injection QMOWEFR (Monday -Wednesday-Friday).
12. Calcium Carbonate 1,250 mg (500 mg) Tablet Sig: One (1)
Tablet PO TID (3 times a day): Please give between meals.
13. Prednisone 20 mg Tablet Sig: Six (6) Tablet PO Q48H (every
48 hours): Take on [**2179-9-21**]; [**2179-9-24**]; [**2179-9-26**].
14. Prednisone 20 mg Tablet Sig: Five (5) Tablet PO Q48H (every
48 hours): Take on [**2179-9-28**]; [**2179-9-30**]; [**2179-10-2**].
15. Prednisone 20 mg Tablet Sig: Four (4) Tablet PO Q48H (every
48 hours): Take on [**2179-10-4**]; [**2179-10-6**]; [**2179-10-8**].
16. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO Q48H (every
48 hours): Start on [**2179-10-10**].
17. Hydromorphone 2 mg/mL Syringe Sig: 0.5-2 mg Injection Q4-6H
(every 4 to 6 hours) as needed for breakthrough severe pain.
18. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane TID (3 times a day) as needed.
19. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: 2.5 milligrams
Subcutaneous DAILY (Daily).
20. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Sliding
Scale As Directed Subcutaneous Sliding Scale As Directed.
21. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 18346**]
Discharge Diagnosis:
Acute renal failure, hyperkalemia, hemolytic anemia,
thrombocytopenia with renal biopsy that was complicated by
aortic and left renal vein injury.
Discharge Condition:
Patient passed away on [**9-26**] at [**2098**].
Discharge Instructions:
N/A. Patient passed away on [**9-26**] at [**2098**].
Followup Instructions:
N/A. Patient passed away on [**9-26**] at [**2098**].
Completed by:[**2179-9-27**]
|
[
"5845",
"4280",
"5990",
"0389",
"42731",
"99592"
] |
Admission Date: [**2170-1-10**] Discharge Date: [**2170-1-10**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
CODE STROKE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84 yo F with h/o HTN, s/p PM placement, high cholesterol
who presents as a code stroke. She was last seen well shortly
after 11pm. She went to the bathroom, daughter heard a thump,
and found her down on the ground, left face droop and left sided
weakness. EMS was called at 2310. They found her with a BP of
240/110, FS 117. She was awake with slurred words, but talking
appropriately, asking for a tissue. She had left sided weakness
and possibly numbness as her left hand is blistered, it was
pressed against a radiator. She decompensated en route to the
ED.
CODE STROKE called at 11:57 pm and patient was seen immediately
by neuro ED resident. Patient had decompensated, became
unresponsive, agonal breathing and was being intubated during my
evaluation. Eyes were open but she was not following commands or
speaking. Paroxysmal labored breathing. Bilateral extensor
posturing of the arms.
Per the daughter, she had no complaints prior to this event.
SHe
was doing very well, aerobic dancing. Currently, the daughter
would like to await the arrival of her brother before making any
decisions.
Past Medical History:
s/p PM placement for syncope
HTN
high cholesterol
"borderline DM"
s/p CCY
No h/o stroke, seizures.
Social History:
Daughter [**0-0-**]. Cell is in OMR. Patient lives with
daugther, but is independent in all activities, aerobic dancer.
Widowed. Former psych social worker. [**Name (NI) **] drugs/etoh/tob.
Family History:
sister with stroke at an early age, recovered
Physical Exam:
PE:
Vitals: 262/145 93
GEN: labored breathing (pre intubation)
HEENT: + emesis after extubation
NECK: C collar in place
CHEST: coarse BS bilaterally
CV: mildly tachycardic
ABD: softly distended
EXTREM: no edema, cool extremities, blisters left hand skin
NEURO:
MENTAL STATUS: eyes open but no verbal output, not following
commands, extensor posturing to pain arms.
CRANIAL NERVES:
Pupil exam: 2mm and unresponsive
EOM exam: unable to test dolls (c collar)
Fundi: + papilledema bilaterally, no clear disc margins
Corneal reflex: initially had corneal reflex on the right,
bilaterally absent after intubation
Facial symmetry: obscured view from intubation.
Gag reflex: unable to test at this time
MOTOR: Increased tone in all 4 extremities, left leg slightly
externally rotated. Extensor posturing bilateral upper
extremities to light touch.
SENSORY: extensor postures bilateral arms, no response in legs
REFLEXES: a 2+ brisk throughout arms, 3+ knees, ankles are
tight,
upgoing toes bilaterally.
Pertinent Results:
[**2170-1-10**] 12:00AM FIBRINOGE-307
[**2170-1-10**] 12:00AM PLT COUNT-432
[**2170-1-10**] 12:00AM PT-12.2 PTT-25.9 INR(PT)-1.0
[**2170-1-10**] 12:00AM WBC-14.7*# RBC-4.73 HGB-14.6 HCT-40.6 MCV-86
MCH-31.0 MCHC-36.1* RDW-13.8
[**2170-1-10**] 12:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2170-1-10**] 12:00AM CK-MB-3 cTropnT-<0.01
[**2170-1-10**] 12:00AM CK(CPK)-58 AMYLASE-54
[**2170-1-10**] 12:00AM UREA N-18 CREAT-0.7
[**2170-1-10**] 12:12AM HGB-15.2 calcHCT-46
[**2170-1-10**] 12:12AM GLUCOSE-163* LACTATE-2.7* NA+-144 K+-4.2
CL--105 TCO2-23
[**2170-1-10**] 04:45AM O2 SAT-99
[**2170-1-10**] 04:45AM TYPE-ART RATES-20/ TIDAL VOL-500 PEEP-5
O2-100 PO2-325* PCO2-29* PH-7.42 TOTAL CO2-19* BASE XS--3
AADO2-361 REQ O2-64 -ASSIST/CON INTUBATED-INTUBATED
[**2170-1-10**] 05:38AM URINE RBC-3* WBC-2 BACTERIA-NONE YEAST-NONE
EPI-<1
[**2170-1-10**] 05:38AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2170-1-10**] 05:38AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2170-1-10**] 05:38AM PT-12.9 PTT-23.7 INR(PT)-1.1
[**2170-1-10**] 05:38AM PLT SMR-NORMAL PLT COUNT-347
[**2170-1-10**] 05:38AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2170-1-10**] 05:38AM NEUTS-79.2* BANDS-0 LYMPHS-16.6* MONOS-3.6
EOS-0.4 BASOS-0.2
[**2170-1-10**] 05:38AM WBC-16.1* RBC-4.76 HGB-14.4 HCT-41.1 MCV-86
MCH-30.3 MCHC-35.1* RDW-13.7
[**2170-1-10**] 05:38AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2170-1-10**] 05:38AM URINE HOURS-RANDOM
[**2170-1-10**] 05:38AM TRIGLYCER-203* HDL CHOL-47 CHOL/HDL-3.7
LDL(CALC)-85
[**2170-1-10**] 05:38AM CALCIUM-8.4 PHOSPHATE-2.9 MAGNESIUM-1.5*
CHOLEST-173
[**2170-1-10**] 05:38AM CK-MB-NotDone cTropnT-<0.01
[**2170-1-10**] 05:38AM ALT(SGPT)-31 AST(SGOT)-39 CK(CPK)-94
[**2170-1-10**] 05:38AM GLUCOSE-176* UREA N-18 CREAT-0.9 SODIUM-142
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-21* ANION GAP-18
CT HEAD WITHOUT IV CONTRAST: There is a large intraparenchymal
hemorrhage extending from the right basal ganglia superiorly
into the right frontoparietal lobes. There is surrounding
adjacent edema and significant mass effect, with shift of the
midline. There appears to be a subfalcine herniation, and
compression of the right lateral ventricle and associated
compression of the temporal [**Doctor Last Name 534**] of the left lateral ventricle,
with mild dilatation of the occipital [**Doctor Last Name 534**] and temporal horns of
the left lateral ventricle. No intraventricular or extraaxial
hemorrhage is identified. There is effacement of the
interpeduncular cistern. There is no evidence of cerebellar
tonsillar herniation.
Soft tissue and osseous structures are within normal limits.
IMPRESSION: There is a large 8.9 x 5.4 cm intraparenchymal
hemorrhage, centered within the right basal ganglia and right
frontal and parietal regions, with significant mass effect and
leftward shift of normally midline structures. There is partial
effacement of the interpeduncular cistern.
The results were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7673**] immediately after
the study was performed.
Performed because the patient had fallen:
CT C-SPINE: No fracture or spondylolisthesis is identified.
There is extensive degenerative change at multiple levels. No
prevertebral soft tissue swelling is seen. The patient is
intubated. A central line can be seen within the left subclavian
vein. Within the visualized portion of lung apices, no
pneumothorax is seen. Biapical increased pulmonary markings are
noted. There are hypodensities within both lobes of the thyroid,
which are not completely characterized.
IMPRESSION:
1. No fracture or malalignment is identified. Degenerative
change seen at multiple levels.
2. There are hypodensities within both lobes of the thyroid
gland.
PORTABLE AP CHEST RADIOGRAPH: An ET tube is seen, with the tip
positioned approximately 5 cm above the carina. There is mild
hyperinflation of the ET tube cuff. Mediastinal and cardiac
contours are within normal limits. There is mild upper lung zone
redistribution, however, this may be related to position. The
pulmonary vasculature is otherwise within normal limits. No
pleural effusions or pneumothorax is seen. The pacemaker is seen
overlying the left hemithorax with leads positioned overlying
the right atrium and ventricle. There is an overlying trauma
board, which obscures underlying structures, however, no
definite fractures are identified. Clips can be seen within the
right upper quadrant from prior cholecystectomy.
IMPRESSION: ET tube is seen approximately 5 cm above the carina.
There is hyperinflation of the ET tube cuff.
Brief Hospital Course:
The patient is a 84 yo woman with history of hypertension, high
cholesterol, heart disease status post pacemaker, and
"borderline diabetes," who was admitted to the [**Hospital3 **]
Medical Center after being found down in the bathroom by her
daughter with a left facial droop and slurring her speech. She
deteriorated in the ambulance ride on the way to the hospital,
requiring intubation when she arrived in the emergency room.
She was found to have a very large subcortical hemorrhage
(>100cc) with subfalcine herniation and effacement of the
basilar cistern. Her exam showed fixed pupils at 2mm,
papilledema, and spontaneous extensor posturing, with a trace
right corneal reflex, brisk deep tendon reflexes throughout,
initially suggested some retained brainstem function.
Neurosurgery at the time felt that the prognosis was very poor
and that surgical intervention was not indicated. By morning,
her pupils remained fixed, with no signs of brainstem activity,
absent deep tendon reflexes throughout. Her blood pressure
began to fall and she required pressors; her urine output
ceased, and she was not overbreathing the ventillator. A family
meeting was held with Ms. [**Known lastname 99516**] daughter and son, who had
driven from [**Name (NI) 531**]. Due to the very poor overall prognosis
with this intracranial hemorrhage, thought potentially related
to either hypertension, or an underlying lesion (vascular or
less likely, neoplastic), her family decided to change the goal
to comfort care. She was extubated and taken off pressors at
3:20PM and expired shortly afterwards, at 3:46PM. Exam at the
time showed fixed pupils at 3mm, midline, no spontaneous heart
sounds or breath sounds, absent brainstem reflexes, absent deep
tendon reflexes. Her family was at the bedside at the time.
They declined autopsy. The medical examiner was informed, as
she had been in the hospital less than 24 hours; they declined
the case.
Medications on Admission:
MEDS:
atenolol
ativan
lipitor
paxil
evista (?)
pacemaker
Discharge Medications:
EXPIRED
Discharge Disposition:
Expired
Discharge Diagnosis:
Cause of death: respiratory arrest secondary to hemorrhagic
stroke
Discharge Condition:
EXPIRED
Discharge Instructions:
EXPIRED
Followup Instructions:
EXPIRED
Completed by:[**2170-1-10**]
|
[
"4019",
"2720",
"25000"
] |
Admission Date: [**2159-1-17**] Discharge Date: [**2159-2-2**]
Date of Birth: [**2092-4-27**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2927**]
Chief Complaint:
Lethargy, sleepiness, urinary incontinence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 26812**] is a 66yo W with a history of longstanding tobacco
abuse, EtOH Abuse (3 drinks/night per family), lower back pain
s/p placement of thecal morphine pump, recent history of
recurrent pneumonia/bronchitis, HTN, HLD, GERD, anemia who was
brought to the [**Hospital1 18**] ED for complaints of altered mental status
and urinary incontinence. Her history started two weeks ago
approximately when she developed her third pneumonia of the year
and she was hospitalized at [**Hospital **] Hospital for the same,
treated with IV antibiotics and discharged to rehab. During her
short rehab stint, she developed an episode of "shakiness", high
blood pressures to the 200s systolic, and visual disturbances
characterized as flashes of light in the peripheral visual
fields, odd shadows/contours around objects in her field as well
as patchy areas of blindness. During this episode, she was
confused. They improved her blood pressure and 12 hours after
the onset of symptoms her visual disturbance improved. She
received CT imaging (which "ruled out" stroke), as well as
carotid US imaging which showed the presence of a right sided
70% stenosis
of the carotid artery. She was once again discharged to rehab.
Over the past two days prior to her ED presentation this time,
she was noted to be once again shaky, confused, lethargic and
displaying urinary incontinence. She was noted to be quite
perseverative and repeating herself, but was comprehending well
and the language that she used ultimately made sense. For these
complaints, the patient's family insisted that she brought to
the [**Hospital1 18**].
Past Medical History:
Chronic pain (has morphine pump) failed back syndrome
HTN
HLD
Failed back/ chronic pain on morphine pump
depression
GERD
Anemia
GI bleed
ETOH abuse (last drink 2 weeks ago)
Right hydronephrosis
R carotid stenosis 70%
Social History:
Patient has a long history of alcohol abuse ([**1-19**] drinks/night).
Current long standing smoker. Prior to her recent
hospitalizations, she was living at home.
Family History:
No history of seizures, strokes.
Physical Exam:
On Admission:
Vitals: T: 98.1 P: 88 R: 16 BP:140/98 SaO2:93% on 2l
General: Awake,NAD.
HEENT: NC/AT.
Neck: No nuchal rigidity
Pulmonary: + Wheezing, + rales
Cardiac: RRR.
Abdomen: soft, NT/ND.
Extremities: No edema .
Neurologic:
-Mental Status:
Not following commands. EYEs open, tracks my face. Says
"[**Known firstname **]"
-Cranial Nerves:
Pupils reactive b/l. + blink to threat from lateral sides. Face
appreciated as symmetric, did not grin or smile for me.
-Motor: Paratonia + Tremor b/l hands/ fine tremor.
Strength (antigravity) Drift more prominent on the right lower
extremity which per family his her painfull leg.
-Sensory: + grin to pinch
-DTRs: [**Name2 (NI) **] 1 symmetric.
Plantar response was mute bilaterally.
On Discharge:
Vitals: 97.6 106/48 74 20 96% RA
General: Awake and alert, cooperative, NAD.
HEENT: NC/AT.
Neck: No nuchal rigidity
Pulmonary: CTAB
Cardiac: RRR.
Abdomen: soft, NT/ND
Extremities: No edema
Neurologic:
Mental status: Awake and alert, oriented to hospital and [**Location (un) 86**]
but not date. Speech fluent. Follows commands but with some
perserveration.
CN: PERRL, EOMI, face symmetric
Motor: No pronator drift, strength intact throughout
Sensation: Intact to light touch throughout
Reflexes: Equal and symmetric, plantars downgoing
Coordination: Intact FNF b/l
Pertinent Results:
Admission Labs
[**2159-1-17**] 11:15AM BLOOD WBC-8.8 RBC-4.02* Hgb-12.4 Hct-36.6
MCV-91 MCH-30.9 MCHC-33.9 RDW-14.0 Plt Ct-204
[**2159-1-17**] 11:15AM BLOOD Neuts-59.0 Lymphs-34.9 Monos-5.3 Eos-0.3
Baso-0.5
[**2159-1-17**] 11:15AM BLOOD PT-10.8 PTT-26.8 INR(PT)-1.0
[**2159-1-17**] 11:15AM BLOOD Glucose-85 UreaN-35* Creat-1.0 Na-142
K-4.0 Cl-102 HCO3-37* AnGap-7*
[**2159-1-18**] 01:43AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.7 Cholest-141
[**2159-1-18**] 01:43AM BLOOD %HbA1c-6.1* eAG-128*
[**2159-1-18**] 01:43AM BLOOD Triglyc-128 HDL-53 CHOL/HD-2.7 LDLcalc-62
LDLmeas-68
[**2159-1-17**] 07:58PM BLOOD Ammonia-26
[**2159-1-17**] 07:58PM BLOOD TSH-3.5
[**2159-1-17**] 11:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2159-1-17**] 11:27AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2159-1-17**] 11:27AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2159-1-17**] 11:27AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
Reports:
EEG [**2159-1-17**]: IMPRESSION: This is an abnormal continuous ICU
monitoring study because of intermittent epileptic discharges
bilaterally in the posterior quadrants. These epileptic
discharges, at times, occur in a generalized distribution and
occasionally become briefly periodic. These findings are
indicative of independent areas of cortical irritability in the
posterior quadrants that are potentially epileptogenic as well
as
generalized cortical irritability. In addition, the background
is
diffusely slow, indicative of a mild diffuse encephalopathy of
non-specific etiology. Note is made of sinus bradycardia through
most
of the recording.
CXR [**2159-1-17**]: Patchy left base opacity most likely represents
atelectasis,
although underlying aspiration not excluded.
NCHCT [**2159-1-17**]:
Severely limited evaluation due to streak artifact from EEG
cables, within
those limitations, no large, obvious acute intracranial process.
NCHCT, CTA Head/Neck [**2159-1-18**]:
1. No acute intracranial process.
2. Mixed hard and soft plaques at the carotid artery
bifurcations; moderate
narrowing of the right proximal internal carotid artery due to
the plaque.
3. Right-sided thyroid nodule. Recommend thyroid ultrasound on a
non-emergent basis for further characterization.
4. Biapical pleural scarring, if clinically indicated, would be
better
evaluated with a dedicated chest CT.
Brief Hospital Course:
Ms [**Known lastname 26812**] is a 66yo W with a history of longstanding tobacco
abuse, EtOH Abuse (3 drinks/night per family), lower back pain
s/p placement of thecal morphine pump, recent history of
recurrent pneumonia/bronchitis, HTN, HLD, GERD, anemia who was
brought to the [**Hospital1 18**] ED for complaints of altered mental status
and urinary incontinence. Her history started two weeks ago
approximately when she developed her third pneumonia of the year
and she was hospitalized at [**Hospital **] Hospital for the same,
treated with IV antibiotics and discharged to rehab. During her
short rehab stint, she developed an episode of "shakiness", high
blood pressures to the 200s systolic, and visual disturbances
characterized as flashes of light in the peripheral visual
fields, odd shadows/contours around objects in her field as well
as patchy areas of blindness. During this episode, she was
confused. They improved her blood pressure and 12 hours after
the onset of symptoms her visual disturbance improved. She
received CT imaging (which "ruled out" stroke), as well as
carotid US imaging which showed the presence of a right sided
70% stenosis of the carotid artery. She was once again
discharged to rehab.
Over the past two days prior to her ED presentation this time,
she was noted to be once again shaky, confused, lethargic and
displaying urinary incontinence. She was noted to be quite
perseverative and repeating herself, but was comprehending well
and the language that she used ultimately made sense. In the ED,
her examination was significant for inattention, inability to
follow commands, diffuse paratonia and a possible right lower
extremity drift. On her statnet EEG, she was noted to have
multifocal epileptiform discharges (L>R) and loaded with keppra.
She received 1mg of ativan she became more obtunded, bradycardic
to the 30's and hypotensive, SBP to the 90's. Admitted to the
ICU for further care. EKG was reviewed, sinus with no block,
rapid repolarization but no significant ST changes and no TWI.
Overnight, there were no acute events. She remained
hemodynamically stable and her AM labs were all within normal
limits. On her second hospital morning, she had difficulty
producing words. On exam, she was afebrile and hemodynamically
stable with BPs overnight between 90-100 SBP, and satting 93-95%
on 2L/nC. There
were no remarkable abnormalities on her general physical
examination. Her neurologic examination was significant for a
transcortical motor aphasia with preserved repetition,
comprehension, [**Location (un) 1131**] but not writing. She also displayed
bilateral asterixis with brisk reflexes and downgoing toes.
Formal strength testing was symmetric and full and there was no
drift.
Given her known morphine pump for lower back pain, an MRI could
not be performed. The pain service was consulted, and they
recommended that an MRI not be performed and that her morphine
pump not be changed in settings. To evaluate the cause for her
expressive aphasia, she received a NCHCT and CTA head/neck which
showed no evidence of an acute stroke, hemorrhage or mass, but
did reveal atherosclerotic disease in both carotid arteries
(R>L). Given her continued hemodynamic stability, the patient
was transferred to the floor EMU service for continued EEG
monitoring.
On the floor, her exam slowly improved with increased
attentiveness but still some decreased fluency of speech. Her
EEG did not show any further seizures. To further evaluate the
cause of seizures, she received a contrast-enhanced Head CT on
[**2159-1-20**]
which did not reveal any abnormal enhancement. Her Levetiracetam
was decreased with the hopes of reducing her dose to a less
sedating standing dose; she was given 500mg on [**2159-1-20**] PM.
Overnight, she had a cluster of short seizures around 0215 with
motor manifestations which resolved with lorazepam 1 mg. Around
0630 on [**2159-1-21**], she start to have clinical seizure activity
again with left head turn, left eye deviation, and left arm
myoclonic jerks which lessened but was followed by left foot
myoclonic jerks. She was given another LZP x 2mg without
resolution. Her
seizure started involving right hip/knee flexion, and right arm
raise to the nose. Levetiracetam 1500 mg was bolused, followed
by another LZP x 1mg and Fosphenytoin 1000 mg. She was
transferred back to the ICU for further monitoring and care for
status epilepticus.
The patient's seizures were able to be controlled on two agents.
Her fosphenytoin was switched for Vimpat/lacosamide. She was
transferred out of the ICU in stable condition and gradually
improved with regards to her mental status. She was continued on
Keppra 1500mg [**Hospital1 **] and Vimpat 150mg [**Hospital1 **] with no further seizure
activity. She continued to improve clinically, and became more
awake and alert with fluent speech. She remained somewhat
inattentive and perseverative, and was oriented to place but not
date. She continued to have difficulty swallowing as well, and
failed several subsequent swallow evaluations. She was
maintained on tube feeds via an NG tube until a PEG tube could
be placed on [**2159-2-1**]. She tolerated this well and was restarted
on tube feeds on [**2-2**].
She seen by PT and OT who recommended acute rehab placement upon
discharge. She was discharged to [**Hospital1 **] in good condition on
[**2159-2-2**].
TRANSITIONAL CARE ISSUES:
Patient will need to remain on Keppra 1500mg [**Hospital1 **] and Vimpat
150mg [**Hospital1 **] for seizure control. She has a follow-up appointment
in epilepsy clinic with Dr. [**First Name (STitle) 437**] on [**2159-2-26**]. She will need
continued PT/OT as well as speech therapy.
Medications on Admission:
hydrochlorothiazide 12.5 mg Capsule [**Date Range **]: One (1) Capsule PO
DAILY (Daily).
baclofen 10 mg Tablet [**Date Range **]: Two (2) Tablet PO TID (3 times a
day).
rosuvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
amlodipine 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
lisinopril 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB, wheeze.
2. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or T > 99.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
5. hydrochlorothiazide 12.5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO
DAILY (Daily).
6. baclofen 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a
day).
7. rosuvastatin 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. amlodipine 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. insulin regular human 100 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection ASDIR (AS DIRECTED): Please give ACHS per insulin
sliding scale.
11. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection TID (3 times a day).
15. Keppra 500 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO twice a day.
16. lacosamide 150 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 26812**],
It was a pleasure taking care of you during this
hospitalization. You were admitted for altered mental status and
were found to have seizure activity on your EEG. We have treated
this with two medications called Keppra and Vimpat, which you
will need to continue as prescribed. Your other laboratory
studies and imaging studies were normal. You do have stenosis of
your right internal carotid artery which means you should
control your high blood pressure and cholesterol well and follow
closely with your primary care physician.
A feeding tube was placed in your stomach in order to give you
nutrition as you are still having difficulty swallowing. Your
swallowing function will continue to be followed by the speech
therapists at [**Hospital1 **], and hopefully at some point the tube
will be able to be removed if you are able to eat on your own.
The following changes were made to your medications:
Started Keppra 1500mg twice a day
Started Vimpat 150mg twice a day
You should continue the rest of your medications as prescribed.
Please keep your follow-up appointments as listed below.
Please seek immediate medical attention should you experience
any of the below listed danger signs.
Followup Instructions:
You have the following appointment scheduled with Dr. [**First Name (STitle) 437**]:
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Last Name (un) 68187**] [**Last Name (un) 68188**] Phone:[**Telephone/Fax (1) 2928**]
Date/Time:[**2159-2-26**] 11:30
You should also make an appointment to see your primary care
doctor Dr. [**Last Name (STitle) 4454**] within 1-2 weeks.
|
[
"4019",
"2724",
"53081",
"496"
] |
Admission Date: [**2182-8-22**] Discharge Date: [**2182-9-12**]
Date of Birth: [**2121-3-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Vancomycin Analogues / Histamine / Ciprofloxacin / Penicillins /
Cephalosporins / Atorvastatin / Rosuvastatin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea, weakness
Major Surgical or Invasive Procedure:
OPERATION PERFORMED:
1. Coronary artery bypass grafting x3, with a left internal
mammary artery graft to the left anterior descending and
reversed saphenous vein graft to the marginal graft and
the right coronary artery.
2. Mitral valve repair with a 30-mm Physio II annuloplasty
ring.
History of Present Illness:
61M complicated hx including Diabetes,Dyslipidemia,Hypertension
Afib s/p failed cardioversion on coumadin and amiodarone,
Dilated cardiomyopathy, sCHF with EF of 25-30%, severe 3+ MR,
PFO, CAD, severe pulmonary hypertension on sidafenil, and CKD
p/w complaints of worsening dyspnea over the past 4-5 days. Per
the patient, has been doing well with rehabilitation, walking up
to [**1-6**] mile per day and "getting stronger everyday". Woke up
around Sunday morning, stating his legs were extremely week. In
addition, he felt he was more SOB and having worsening chest
pain. On the day of presentation,
his VNA saw him and noted increased work of breathing. He denied
fever, cough, nausea, vomiting, diaphoresis, abdominal pain,
although did attest to right LE swelling with B/L LE pain
(aching). He does have 4 pillow orthopnea which has been stable
since he was discharged one month ago (was admitted here and
found to have pulmonary hypertension) as well as PND, though no
lower extremity swelling at baseline. Denies any recent trips.
Has been compliant with low sodium/low fluid diet. Called Dr.
[**First Name (STitle) 437**] today and spoke with [**Doctor First Name **] Nestory, who recommended the
patient present to the hospital. Of note, was scheduled for
surgery [**2182-8-28**] for MV replacement as well as PFO correction and
CABG.
.
In the ED, initial vitals were T99 HR89 BP136/86 RR18 98% RA.
EKG showed sr 88, lad, 1st deg avb, ivcd, STD V4/5 [**Doctor Last Name **] to prior,
no stemi with scattered pvcs. Labs were significant for WBC of
10.6 (baseline), HCT of 33 with microcytosis of 80 for MCV
(baseline since [**2182-7-5**]), Creatinine of 1.7 (baseline), proBNP
of 3699 (last value of 8480 in [**4-/2182**]), troponin of 0.08
(baseline since [**4-/2182**]), INR of 2.4. CXR showed mild engorgement
of central pulmonary vasculature as well as scattered lines
denoting intralobular thickening with an impression of pulmonary
edema likely cardiogenic in etiology. Vitals prior to transfer
were 99.1 91 124/83 22 100%2l.
.
On the floor the patient is c/o chest pain (at baseline).
Otherwise NAD, but feels generally unwell.
Past Medical History:
1. CARDIAC RISK FACTORS:
(+)Diabetes, (+)Dyslipidemia, (+)Hypertension
2. CARDIAC HISTORY:
- Afib s/p failed cardioversion on coumadin
- Dilated cardiomyopathy, non-ischemic
- CAD
- CHF (EF 25-35%)
- PFO
3. OTHER PAST MEDICAL HISTORY:
- severe pulmonary hypertension on sidafenil
- CKD with baseline Cr
- CVA in [**2175**]--L sided facial droop
- Osteoarthritis.
- Depression.
- Hx of Hodgkin's disease s/p surgical excision and CTX at age
18
.
PAST SURGICAL HISTORY:
1. Appendectomy.
2. Hernia repair.
3. Back surgery after falling from 36 feet.
4. Multiple operations on his left knee and his right knee.
5. Multiple abdominal surgeries, first to remove small bowel
polyps and then followed by surgeries to fix complications of
previous surgeries.
6. Lymph node removal from the groin that was infected
Social History:
He lives with his sister and her family. States there is always
someone home. He has 3 children, including a 6 yr old son who
live in [**Name (NI) **]. He used to be an avid athlete, running > 12
miles daily but due to progressive heart failure, develops
symptoms of fatigue/ dyspnea with minimal exertion
denies current tobacco, ETOH, IVDA
Family History:
Father had 1st heart attack at 35 then died of MI at 45. Mom
with DM2, died of AAA rupture.
Physical Exam:
Physical Exam
Pulse:73 Resp:20 O2 sat: 98% on 2Lpm nc
B/P 108/76
Height:5'[**81**]" Weight:187.4
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] __1+(B)LE
Varicosities: None [x]
Neuro: Grossly intact [x](L) sided facial droop resolved
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit-none, pulse Right:2+ Left:2+
Pertinent Results:
CAROTID DUPLEX ([**8-23**]):
1. There is no evidence of significant carotid artery stenosis
bilaterally.
2. Atherosclerotic plaques in the carotid bulbs and internal
carotid arteries bilaterally.
.
PANOREX TEETH AND MANDIBLE ([**8-23**]; handwritten note): 4x6mm
asymmetric nodule under angle of left mandible. Would recommend
repeat read by radiologist. Otherwise unremarkable
.
CHEST X-RAY ([**2182-8-23**])
FINDINGS: Mild engorgement of the central pulmonary vasculature
is
identified. There is minimal prominence of the interstitial
markings. Few
scattered lines are denoting interlobular septal thickening
identified at the bases. The mediastinum is otherwise
unremarkable. The cardiac silhouette is enlarged but stable. No
definite effusion or pneumothorax is noted. Degenerative
changes are seen throughout the mid and lower thoracic spine and
in the included left acromioclavicular joint.
IMPRESSION: Mild prominence of the interstitial markings may
indicate mild
early edema, likely cardiogenic in etiology.
.
RIGHT HEART CATHETERIZATION ([**2182-8-29**]):
1. Severe pulmonary hypertension.
2. Moderately elevated left sided filling pressures.
3. Minimally elevated RA pressure.
4. Preserved cardiac output.
5. Slight response to nitric oxide in addition to 100% O2,
sildenafil,
and nifedipine (last dose given evening prior to AM test). PVR
decreased from 6.5 to 5.7.
.
ECHOCARDIOGRAM ([**8-29**]):
IMPRESSION: Moderately dilated left ventricle with mild
symmetric left ventricular hypertrophy and severely depressed
left ventricular systolic function with regional wall motion
abnormalities as described above. Mildly dilated aortic root and
ascending aorta. Mild aortic regurgitation. Moderate to severe
mitral regurgitation. Severe pulmonary artery systolic
hypertension. Compared with the prior study (images reviewed) of
[**2182-8-12**], the previously noted noncoronary sinus of Valsalva
aneurysm is not clearly visualized. The peak pulmonary artery
systolic pressure has increased from 70 mmHg to 80 mmHg.
.
[**2182-9-10**] 05:09AM BLOOD WBC-11.4* RBC-3.39* Hgb-9.5* Hct-28.5*
MCV-84 MCH-28.1 MCHC-33.4 RDW-16.2* Plt Ct-308
[**2182-9-9**] 05:12AM BLOOD WBC-12.0* RBC-3.38* Hgb-9.6* Hct-28.5*
MCV-84 MCH-28.4 MCHC-33.7 RDW-16.0* Plt Ct-264
[**2182-9-10**] 05:09AM BLOOD Neuts-80.1* Lymphs-12.2* Monos-5.0
Eos-2.6 Baso-0.2
[**2182-9-10**] 05:09AM BLOOD Plt Ct-308
[**2182-9-10**] 05:09AM BLOOD PT-17.0* PTT-29.3 INR(PT)-1.5*
[**2182-9-9**] 05:12AM BLOOD Plt Ct-264
[**2182-9-9**] 05:12AM BLOOD PT-16.4* PTT-26.7 INR(PT)-1.5*
[**2182-9-10**] 05:09AM BLOOD Glucose-108* UreaN-49* Creat-1.7* Na-138
K-4.1 Cl-97 HCO3-30 AnGap-15
[**2182-9-9**] 07:00AM BLOOD Glucose-121* UreaN-45* Creat-1.7* Na-137
K-4.1 Cl-96 HCO3-32 AnGap-13
[**2182-9-10**] 05:09AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.6
[**2182-9-9**] 07:00AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.3
Brief Hospital Course:
The patient was brought to the operating room on [**9-2**] where he
underwent coronary artery bypass grafting x3, with a left
internal mammary artery graft to the left anterior descending
and reversed saphenous vein graft to the marginal graft and the
right coronary artery and mitral valve repair with a 30-mm
Physio II annuloplasty
ring as well as a closure of a patent foramen ovale. The
patient tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. The patient was electivly kept intubated
overnight due to elevated pulmonary artery pressures, but
eventually extubated on post operative day #1. The patient was
neurologically intact and hemodynamically stable, but remained
on milrinone until post operative day number 2 and dobutamine
was weaned to 2.5 on day 4 and eventually stopped on post
operative day 6. Coreg was started and titrated up for chronic
systolic heart failure. Lisinopril to be started when
creatinine stabilizes per cardiologist Dr. [**First Name (STitle) 437**]. The patient
was gently diuresed toward his preoperative weight. The patient
was transferred to the telemetry floor for further recovery on
post operative day 8 ([**2182-9-10**]). Chest tubes and pacing wires
were discontinued without complication. He was placed on
macrodantin for a urinary tract infection. His coumadin was
restarted for chronic atrial fibrillation. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD ten the
patient was ready for discharge to rehab. The patient was
discharged in good condition with appropriate follow up
instructions to [**Hospital3 4103**] on the [**Hospital **] Rehab.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 HFA(s)
inhaled
every 4-6 hours
AMIODARONE - 200 mg Tablet - 1 Tablet(s) by mouth once a day
Take
2 tablets twice daily for 2 days only, then decrease to one
tablet daily
DIGOXIN - 125 mcg Tablet - one Tablet(s) by mouth every other
day
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 20
Solution(s)
at bedtime
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) -
Dosage uncertain
METOPROLOL SUCCINATE - 25 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth DAILY (Daily)
OXYCODONE-ACETAMINOPHEN - (Prescribed by Other Provider: [**Name Initial (NameIs) **])
-
5 mg-325 mg Tablet - 1 Tablet(s) by mouth every six (6) hours as
needed for pain has narcotics contract
POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - 1
Tablet(s) by mouth once a day
SILDENAFIL [REVATIO] - 20 mg Tablet - 2 Tablet(s) by mouth three
times a day
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
TORSEMIDE - 20 mg Tablet - 4 Tablet(s) by mouth DAILY (Daily)
WARFARIN - 5 mg Tablet - daily [**Name8 (MD) **] MD***Last dose=[**2182-8-22**] 5mg
ZOLPIDEM - 5 mg Tablet - 1 Tablet(s) by mouth at bedtime - No
Substitution
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day - No Substitution
CAMPHOR-MENTHOL [SARNA ANTI-ITCH] - (Prescribed by Other
Provider) - 0.5 %-0.5 % Lotion - 1 Lotion(s) four times a day as
needed for pruritis
Plavix - last dose:Coumadin last dose 8/18/11-5mg
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
6. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. nitrofurantoin macrocrystal 50 mg Capsule Sig: One (1)
Capsule PO Q6H (every 6 hours) for 1 days: for UTI.
9. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO ONCE (Once)
for 1 doses: titrate dose for goal INR of [**2-7**] for atrial
fibrillation. next INR check on [**9-13**]. Tablet(s)
10. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
tbd
Discharge Diagnosis:
Diabetes, Dyslipidemia,Hypertension, Afib s/p failed
cardioversion (coumadin), Dilated cardiomyopathy, non-ischemic-
CAD
CHF (EF 25-35%), PFO, severe PHTN on sidafenil, CKD (Cr 1.7),
CVA/ [**2175**](L sided facial droop-resolved), Osteoarthritis,
Depression, Hodgkin's disease s/p surgical excision and CTX at
age 18.
Appendectomy/Hernia repair/Back surgery after 36 foot fall,
Multiple operations to bilateral knees, Multiple abdominal
surgeries (removal of small bowel polyps followed by surgeries
to fix complications of previous surgeries), Lymph node removal
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:
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**10-9**] at 2:15 in the [**Hospital **]
medical office building [**Hospital Unit Name **]
Cardiologist: Dr. [**First Name (STitle) 437**] on [**9-17**] at 1pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 8598**] in [**4-9**] 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:[**2182-9-12**]
|
[
"5990",
"4168",
"42731",
"4280",
"41401",
"4240",
"25000",
"V5867",
"V5861",
"5859",
"311",
"32723"
] |
Admission Date: [**2147-10-9**] Discharge Date: [**2147-10-24**]
Date of Birth: [**2095-2-7**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
Flexible sigmoidoscopy
History of Present Illness:
52 yo woman with Type 1 DM and HTN who presents in DKA in the
setting of a recent C.diff infection and worsening N/V/D over
the past 1 week. She states that her symptoms initally started
at the end of [**Month (only) 205**] with N/V/D (non-bloody) and crampy abdominal
pain. She was admitted to [**Hospital1 18**] from [**Date range (1) 16998**], was treated for
c. diff with Flagyl but experienced excessive nausea so she was
switched to oral Vancomycin. Her BSs were well controlled during
this admission. She is currently employed in a nursing home
facility and feels that she may have contracted c. diff at work.
.
After being discharged from [**Hospital1 18**] she felt better for several
weeks but continued to have [**7-6**] loose BMs but was better than
before. She was seen by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1586**] [**Doctor Last Name 2161**] in the [**Hospital **] clinic on
[**2147-9-25**], referred to him by her PCP. [**Name10 (NameIs) **] was thought that she may
have had recurrent c. diff or a post-infectious IBS like
syndrome at the time. On [**10-3**] she underwent a flexible
sigmoidoscopy with biopsy, which was unremarkable.
.
For the past week she has had non-bloody diarrhea, abdominal
discomfort, weakness, nausea, and vomiting which have all
progressively gotten worse. She was initally having 10+ loose
BMs each day but has not had any in the past day since she has
not eaten anything. She states that her appetite has been very
poor since last Monday. Whenever she tries to eat something she
feels nauseous and vomits what she eats. She localizes her
abdominal discomfort to the RLQ.
.
She states that her sugars have been extremely high on the day
of admission in the 400's and denies stopping or missing any of
her insulin she takes at home. She denies any recent fevers,
chills, cough, SOB, or chest pain. Denies any recent travel or
sick contacts. [**Name (NI) **] had some polydipsia but denies polyuria.
.
In the ED her vitals were T 95.1 BP 127/74 AR 140-150's RR 24 O2
sat 98% RA. Her BS>500 and she had an anion gap of 29. She was
started on continuous IVFs and was started on insulin drip
Past Medical History:
1. Diabetes mellitus type I x38 years, followed by [**Doctor Last Name 14116**] @
[**Hospital1 **]. mild peripheral neuropathy
2. Hypertension.
3. Hypercholesterolemia.
4. Mild COPD.
Social History:
Social History: The patient recently quit tobacco use
approximately 2 years ago. She has a 25-pack year history.
She denies alcohol use. She works as a secretory in the physical
therapy rehab center. She is married with two children. Her
daughter has fibromyalgia syndrome and irritable bowel syndrome.
Family History:
Family History: Sister has juvenile rheumatoid arthritis. Aunt
has rheumatoid arthritis. There is no known psoriasis,
osteoarthritis, thyroid disease or inflammatory bowel disease
known in the family. No family hx of bowel problems, IBD.
Physical Exam:
On admission -
VITALS: T 97.3 BP 152/67 AR 106 RR 22 O2 sat 96% RA
GEN: Pt awake but extremely tired and lethargic
HEENT: Dry mucous membranes
NECK: No lymphadenopathy, thyromegaly
HEART: nl s1/s2, no s3/s4, no m,r,g
LUNGS: CTAB, no crackles
ABDOMEN: soft, nt/nd, +BS
EXTREMITIES: 2+ DP/PT pulses, no edema
RECTAL: Heme negative
Pertinent Results:
[**2147-10-24**] 06:30AM BLOOD WBC-3.8* RBC-3.20* Hgb-8.9* Hct-27.5*
MCV-86 MCH-27.8 MCHC-32.3 RDW-16.4* Plt Ct-569*
[**2147-10-9**] 01:30PM BLOOD WBC-15.8*# RBC-4.39 Hgb-12.7 Hct-38.2
MCV-87 MCH-29.0 MCHC-33.4 RDW-14.4 Plt Ct-656*
[**2147-10-12**] 03:53AM BLOOD Neuts-79* Bands-1 Lymphs-10* Monos-7
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-2*
[**2147-10-9**] 01:30PM BLOOD Neuts-71* Bands-6* Lymphs-13* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-2* Promyel-1*
[**2147-10-17**] 04:10PM BLOOD PT-12.5 PTT-50.4* INR(PT)-1.1
[**2147-10-24**] 06:30AM BLOOD UreaN-4* Creat-0.4 K-3.7
[**2147-10-21**] 06:52AM BLOOD UreaN-5* Creat-0.4 Na-139 K-3.3 Cl-103
HCO3-26 AnGap-13
[**2147-10-9**] 01:30PM BLOOD Glucose-521* UreaN-18 Creat-1.3* Na-138
K-4.1 Cl-93* HCO3-16* AnGap-33*
[**2147-10-16**] 06:10AM BLOOD ALT-10 AST-15 AlkPhos-81 TotBili-0.3
[**2147-10-13**] 05:45AM BLOOD calTIBC-144* VitB12-779 Ferritn-284*
TRF-111*
[**2147-10-9**] 01:30PM BLOOD Acetone-LARGE
[**2147-10-17**] 04:10PM BLOOD TSH-3.9
Pleural fluid:
[**2147-10-18**] 02:12PM PLEURAL WBC-396* RBC-194* Polys-10* Lymphs-44*
Monos-36* Eos-1* Meso-2* Other-7*
[**2147-10-18**] 02:12PM PLEURAL TotProt-1.9 Glucose-137 LD(LDH)-70
Amylase-21 Albumin-1.2 Cholest-32
Cytology - NEGATIVE FOR MALIGNANT CELLS
CXR [**2147-10-18**]
COMPARISON: PA and lateral radiograph [**2147-10-16**].
Most of right pleural effusion has been removed. Minimal
parenchymal changes are identified within the right lung base,
presumably related to residual atelectasis. No pneumothorax
identified. Cardiomediastinal silhouette is normal in
appearance.
ECHO
The left atrium is elongated. 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) appear
structurally normal with good leaflet excursion and no aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation
is seen. The estimated pulmonary artery systolic pressure is
normal. There is
a trivial/physiologic pericardial effusion.
CT chest -
IMPRESSION:
1. No evidence of pulmonary embolus.
2. Moderate-sized right pleural effusion
FINDINGS: Grayscale and color Doppler son[**Name (NI) 1417**] of the bilateral
lower extremities including the common femoral veins,
superficial femoral veins, and popliteal veins was performed.
Normal flow, augmentation, compressibility, and waveforms was
demonstrated bilaterally. Intraluminal thrombus was not
identified.
IMPRESSION: No DVT.
CXR [**2147-10-17**]
IMPRESSION:
1. A new moderately sized right pleural effusion.
2. New lingular atelectasis vs. early pneumonia.
US abdomen -
IMPRESSION: No evidence of megacolon. Cecum measures
approximately 7 cm in diameter.
[**2147-10-11**] 07:31AM STOOL NA-49 K-63
Brief Hospital Course:
# DKA: Treated in the ICU with insulin drip with eventual
closure of anion gap and transfer to the medical floor. [**Last Name (un) **]
was consulted and sugars were controlled with an insulin sliding
scale and glargine.
.
# C. Difficile colitis diarrhea: Positive stool c.diff. The
patient had a very protracted course while in the hospital. GI
followed her while in house. High doses of oral vancomycin was
started with some improvement initially. A combination of IV
flagyl and oral vanc was tried as well, with no improvement.
Rifaximin was started. The patient was advised a low-lactose
diet. A flexible sigmoidoscopy was done by GI after 2 weeks of
unremitting diarrhea - which revealed pseudomembranes. Biopsies
were done to r/o other processes the results of which are
pending at this time and should be followed up in clinic. The
overall appearance at flex. sig was more suggestive of a C. diff
colitis than an IBD.
After about a week of high dose vancomycin and rifaximin - the
patient started having decreasing stools at night and more
semi-formed stools. Her appetite improved. All along, she was
placed on contact precautions. She was observed for a few days
after the stools had decreased to ensure resolution and then
discharged home.
The plan is to continue vancomycin 500 PO Q6h for atleast a 3
week course. Then after a repeat stool c diff x 3, and if the
patient's symptoms are consistantly improving - a very slow
taper may be tried. The patient may need vancomycin for the next
many months to a year. This plan was communicated to PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **]
[**Last Name (STitle) **] and GI physician who will be following her - Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 437**].
The patient was also advised to take potassium tablets till
diarrhea persists. She is advised not to return to work for the
next few weeks and also strictly follow C diff precautions at
home.
.
# Hypoalbuminemia - likely from protein loss from diarrhea. This
caused LE edema. ECHO showed no significant findings and LFT's
were normal. Small doses of lasix were tried with resolution of
the edema. Pleural effusion was noted on CXr which was tapped -
was transudate and cytology was negative for Cancer cells. The
effusion could be due to hypoalbuminemia.
# Skin - The patient developed transient LE erythematous lesions
when getting diureses - derm was consulted who recommend f/u in
clinic. Their differential diagnosis for these lesions include
resolving vesicles secondary to edema and mild stasis
dermatitis. Their recommendations include - Topical moisturizer
with aveeno [**Hospital1 **] and topical triamcinolone [**Hospital1 **] as needed for
pruritus. However, there was spontaneous resolution of the rash
# HTN: Metoprolol and Lisinopril continued.
.
# Hyperlipidemia: statin continued.
# Mild leucopenia was noted. They should be followed in primary
care clinic.
Medications on Admission:
1. Atenolol 100mg PO daily
2. Lisinopril 40mg daily
3. Pravastatin 20 mg daily
4.Insulin regimen:
a. Levemir 6U [**Hospital1 **]
b. Humalog sliding scale
5.Lorazepam 0.5 mg 1-2 Tablets PO every 4-6 hours
Discharge Medications:
1. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
Disp:*60 Tablet, Chewable(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. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 4 weeks.
Disp:*224 Capsule(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO DAILY (Daily): Continuue
to take as long as you have diarrhea.
Disp:*90 Capsule, Sustained Release(s)* Refills:*0*
10. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
11. Insulin Glargine 100 unit/mL Solution Sig: One (1) 15
Subcutaneous Q Am before breakfast.
Disp:*30 15* Refills:*0*
12. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1) as
instructed Subcutaneous as instructed.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Recurrent C. Difficile Colitis
2. DKA, resolved
3. Hypoalbuminemia/ pleural effusion
4. Anemia of Chronic Disease
5. Mild leucopenia
Secondary Diagnoses
1. Hypertension
2. Type I diabetes mellitus uncontrolled with complications
3. Hyperlipidemia
4. Mild COPD
Discharge Condition:
Stable
Discharge Instructions:
Please return to the emergency room if you notice worsening
diarrhea, abdominal pain or distension, fever, nausea, vomiting
or any other unusual symptoms.
Please keep yur appointments. You should also have to get blood
work done for potassium and magnesium levels at that time.
Discuss with your doctor about the continuing need for lasix and
potassium. Also discuss with her about anemia and low white
blood cell counts as we had discussed.
Your anemia is likely due to loosing blood in stool bacause of
C. diff infection. You will likely need iron tablets for the
anemia.
Make an appointment at the [**Hospital **] clinic as well. Your insulin
doses have been changed for better control of sugars during this
hospitalization. Please continue monitoring the blood sugar
levels at home 1-2 times a day before meals till you are seen at
[**Hospital **] clinic.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2147-10-25**] 2:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2147-11-2**] 10:20 ( Dr[**Name (NI) 16999**] office)
GI Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12427**], MD Phone:[**Telephone/Fax (1) 1954**]
Date/Time:[**2147-10-30**] 10:00
[**Last Name (un) 387**] - Make an appointment with your doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] in the
next 10 days
|
[
"5119",
"496",
"4019"
] |
Admission Date: [**2139-8-12**] Discharge Date: [**2139-8-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
CC: Fever
Reason for MICU admission: Line sepsis
Major Surgical or Invasive Procedure:
R femoral line insertion
Hemodialysis
Removal of left portacath
Placement of right PICC
History of Present Illness:
This [**Age over 90 **] year old genleman with hx of ESRD on HD, CAD s/p CABG,
CHF, HTN, A-fib, ventricular brady-paced, RCC s/p L nephrectomy
presented to ED after dialysis as he experienced fever to 103,
rigors approximately 30 minutes into start of dialysis.
Of note, he is s/p new AV fistula placement on LUE with
temporary right fem line and placement of L permacath at recent
hospitalization ([**2139-7-26**]). Today he reports he hasn't felt quite
right since last hospitalization but today finally felt "back to
his usual self". Denies any history of nausea, vomiting, or
diarrhea since his last hospitalization.
Patient initally afebrile with systolic blood pressure initially
in 130 range, other VS stable. Through the course of his stay
his blood pressure trended downward to the 90's range (which
reportedly is his baseline) One hour later the patient's blood
pressure fell to 76/44, HR 70s, RR 20, 97% RA. Laboratories
revealed WBC 7.6 with bandemia of 8 and a lactate of 3.8.
Received fluid bolus with brief rise to systolic blood pressure
to 80's range. Pt began to act more confused and SBP to 70's.
Dopamine started. Given concern for line sepsis, perm-a-cath was
removed by transplant surgery team. R femoral line placed. SBP
returned to 100-110 range. Pt transferred to MICU.
Past Medical History:
1) CAD s/p CABG
-Cardiac catheterization [**5-4**] w/L main and 3 vessel dz w/
patent LIMA to LAD w/ 70% stenosis in distal LAD, patent SVG to
diagnoal ramus w/ 50% stenosis in native diagonal branch, patent
SVG to OM1/OM2 but occluded OM1 at touchdown. s/p unsuccessful
PTCA of LM, Moderate right and left ventricular diastolic
dysfunction
-5-vessel CABG [**2124**] (LIMA-LAD, SVG-D1, SVG-RI,
SVG-OM1, SVG-OM2)
2) CHF: Echo ([**6-4**]) EF 30-35%, [**12-1**]+ MR, 2+ TR, moderate
pulmonary artery systolic HTN. Reportedly small ASD on a TEE
3) S/p pacemaker placement Tachy-Brady syndrome [**3-/2128**],
w/replacement
[**11-2**]
4) HTN
5) Hypercholesterolemia
6) ESRD, on HD (since [**2134**]) MWF evenings via left arm AV graft
(evening shift at [**Location (un) 4265**], [**Location (un) **])
7) Chronic anemia associated w/ renal failure
8) Renal cell carcinoma, s/p left nephrectomy
9) Gout w/flairs 1-2x/mo
10) s/p TURP for BPH
11) Bilateral cataracts
12) Left hydrocele w/ hydrocelectomy [**12/2130**]
#. Multiple episodes of SOB
.
PSHx:
#. Right common femoral artery thrombus s/p cath in [**5-4**]
#. Left CEA [**2127**] (s/p TIA)
#. Thrombectomy and revision of LUE AV graft [**2-1**] w/multiple
interventions to graft in the past.
Social History:
He lives alone in [**Location (un) 745**]. Recently retired fully from selling
furniture, pt had reduced from full time work to part time work
over the past year.
+ tob: cigar/pipe smoking, daily x20-25 years w/cessation 20yrs
prior
- EtOH
- Illicit/Recreational drug use
Family History:
Daughter with MI in mid-40s, had Type 1 DM, deceased 56y/o
Brother w/heart disease, ?MI. + hypertension, + diabetes
mellitus, Brother w/lymphoma, ? question liver ca
Physical Exam:
(on presentation to MICU):
Vital Signs: T=99.7; HR=73; BP=100-110/30-40 on 7.5 of dopamine;
RR=20; O2Sat=98% on 2L
General: Elderly gentleman in NAD, sleepy but fully arousable.
HEENT: NC/AT, MM slightly dry, scar c/w previous CEA
Neck: Old permcath site c/d/i
CV: RR S1S2, S3 gallop audbile, no murmur, no rub
Pulm: CTA bilaterally, no rhonchi, wheezes or crackles
Abd: Soft, NT/ND with normoactive BS.
Ext: No cyanosis, 2+ radial and 2+ DP bilat, AV graft in L arm
Pertinent Results:
Admission laboratories notable for:
WBC 7.8 with 8 bands, lactate 3.8 K 4.4 BUN 25 Cr 4.5
HCT 33.5 with MCV 111
.
CXR: There is a small amount of pleural fluid at the left
costophrenic angle. No evidence of pneumonia.
EKG: V paced with rate 60, ST depressions I and aVL, unchanged
from [**2139-7-22**]
U/S L AV graft- no fluid around the graft, flow appropriate
.
Trends:
INR 2.9 on admission then down to 1.5 on discharge (after
coumadin was held briefly).
.
Starting [**8-14**]:
Trop 0.54 - 0.55 - 0.62 - 0.65 - 0.74 - 0.81 - 0.69
CK: 95 - 52 - 39 - 32 - 23 - 30 - 27 - 35 - 21
.
TSH 4.6, FT4 4.8
Vit B12 1658
Folate: "greater than normal range"
.
Echo:
Conclusions:
The left atrium is moderately dilated. The left ventricular
cavity size is normal. Resting regional wall motion
abnormalities include inferolateral
akinesis. Right ventricular chamber size is normal. Right
ventricular systolic function is normal. The aortic root is
moderately dilated. The ascending aorta is moderately dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-1**]+) mitral regurgitation
is seen. The tricuspid valve leaflets are mildly thickened.
There is severe pulmonary artery systolic hypertension.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2139-2-11**],
estimated
pulmonary artery systolic pressure is now higher and left
ventricular systolic function is similar (prior ejection
fraction may have been underestimated).
Brief Hospital Course:
HOSPITAL COURSE BY PROBLEM:
# Coag neg staph sepsis: The patient had [**1-3**] blood cultures
positive with coag neg staph sepsis. He was treated with
vancomycin and gentamicin starting on [**2139-8-12**]. Initially the
patient was hypotensive and required dopamine/levo for blood
pressure support briefly. His recently placed left port-a-cah
was removed given evidence that suggested that the sepsis was
likely [**1-1**] the line. He remained afebrile thereafter and his
blood pressure improved. We monitored survelliance cultures and
continued with vancomycin (stopped the gentamicin). We would
like him to complete a two week course of antibiotics. We had
been dosing by level (goal >15) and were giving the vancomycin
with hemodialysis.
.
# ESRD on HD: There was a concern that the patient had some
swelling of his LUE fistula. This was seen by the transplant
surgery team and an ultrasound was negative for any fluid
collection. His graft was mature and usable for hemodialysis.
The patient continued on his routine schedule of HD once his
blood pressure had stabilized. He has HD on Mondays,
Wednesdays, and Fridays.
.
# CAD: The patient has a known history of coronary disease. He
had a brief episode of chest pain, shortness of breath, and
troponin elevation on [**8-14**]. His CKMB did not rise and his EKG
was difficult to interpret due to a paced rhythm. The pain
lasted 30 seconds and was pleuritic in nature. He was seen by
the cardiologists who initially recommended medical management
with isosorbide mononitrate, statin, aspirin, and the beta
blocker. They did not request further intervention at that
time. We subsequently obtained an echocardiogram which showed
inferolateral akinesis. When compared to the previous echo done
on [**2139-6-9**], the degree of inferior akinesis was unchanged.
.
# Atrial Fibrillation: The patient's coumadin was held initially
since he had the port-a-cath removed and also had a femoral line
placed briefly. However, in the setting of his chest pain, the
patient was started on a heparin drip. We started coumadin at
3mg qhs and bridged the patient with heparin to obtain an INR of
[**1-2**]. He will leave the hospital on hep gtt until he becomes
therapeutic.
.
# CHF: The patient had his AceI, digoxin, and BB held on
admission. The beta blocker was restarted and the patient also
was started on isosorbide mononitrate. His fluid was regulated
also by hemodialysis.
.
# Anemia: It was stable throughout his hospitalization. We
continued the patient on his B12 and Folate. A free T4 level
was normal.
.
# Hypertension: Initially the patient's antihypertensives were
held on admission due to his hypotension. The patient was
started on isosorbide mononitrate 15mg [**Hospital1 **] in addition to his
atenolol 50mg qd once his blood pressure could tolerate it.
.
# Code status: The patient's code status was confirmed to be DNR
DNI with both the patient and his daughter.
Medications on Admission:
1) Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY
2) Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
3) Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet PO DAILY
4) Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO BID
5) Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
6) Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
7) B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY
8) Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
9) Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO WITH
BREAKFAST AND LUNCH
10) Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO WITH
DINNER
11) Warfarin 3 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
12) Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO every other day.
13) Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
14) Digoxin 50 mcg/mL Solution Sig: One (1) mL PO every other
day.
15) Colchicine prn gout flair
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pyridoxine 100 mg Tablet Sig: One (1) Tablet PO twice a day.
5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B Complex Plus Vitamin C Tablet Sig: One (1) Tablet PO
once a day.
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO once a day.
9. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO twice
a day: please take with breakfast and with lunch.
10. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO once
a day: please take with dinner.
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
12. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: variable Intravenous ASDIR (AS DIRECTED): goal PTT is
60-80. please continue until INR [**1-2**].
13. Isosorbide Mononitrate 10 mg Tablet Sig: 1.5 Tablets PO BID
(2 times a day).
14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
15. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous QHD (each hemodialysis) for 6 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
- Coag negative staph sepsis
- Chest Pain
- ESRD on HD
- HTN
- Atrial Fibrillation
Secondary:
- CAD s/p CABG in [**2124**].
- Systolic and diastolic CHF with EF 30-35%
- s/p pacemaker placement for Tachy-Brady syndrome [**3-/2128**], with
replacement [**11-2**].
- Hypercholesterolemia
- Chronic anemia associated with renal failure
- RCC s/p left nephrectomy
- Gout
- s/p TURP for BPH
- Bilateral cataracts
- remote hx of TIA
- s/p right common femoral artery thrombus
- Left CEA in [**2127**]
- Thrombectomy and revision of LUE AV graft [**2-1**] with mx
revisions
- Left hydrocele with hydrocelectomy
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with a fever and chills. You
had bacteria growing in your blood and we treated you with
antibiotics. You tolerated this very well and recovered
rapidly. If you experience chest pain, shortness of breath,
recurrent fever or chills, please call your doctor or return to
the emergency department.
.
Please take your medications as directed. Notably you will need
a total of two weeks of vancomycin. Your vanco course started
on [**2139-8-12**]. You will get your doses based on the level detected
in your blood. After you receive your last dose, you should
have the PICC line removed.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
.
Please take your medications as directed. Please contact your
physician to make [**Name Initial (PRE) **] followup appointment.
Followup Instructions:
Please followup with your cardiologist Dr. [**Last Name (STitle) **].
Please followup with your nephrologist, Dr. [**Last Name (STitle) 1366**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"40391",
"42731",
"4280",
"41401",
"V4581",
"V1582"
] |
Admission Date: [**2143-3-1**] Discharge Date: [**2143-3-9**]
Date of Birth: [**2068-8-5**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
RUQ pain, hypoxia, fever
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Central line (femoral and then subclavian)
ERCP
History of Present Illness:
74F w/ h/o COPD, on 3L home O2, admitted to [**Hospital Unit Name 153**] w/ RUQ pain,
fever to 101, and SOB. Pat initially presented to OSH ([**Hospital1 9487**]) w/ SOB for a few days, found by daughter to be
acutely worse today, fever to 101, and intermittent RUQ pain w/
nausea and dry heaves. Pat had apparently similar pain a week
ago. In OSH ED, she was noted to be febrile to 101 and hypoxic.
She was given solumedrol, nebs, and was started on NIPPV. CXR
showed per report RLL PNA. Pt was transferred to [**Hospital1 18**].
Here, she had a sodt abdomen, was hemodynamically stable, but
required NIPPV. Labs were notable for elevated WBC (31.8K w/ 11%
bands), chem 7 w/ low K (2.9) and high BS (301). LFTs showed
cholestatis (Tbili 5.8-direct 4.5, AP 468, ALT/AST in 600s.
Lipase and CE were wnl. She had a negative UA. Her ABG on NIPPV
was 7.44/47/114.
CXR here confirmed RLL opacity, RUQ U/S showed dilated CBD w/o
wall thickening or fluid around gall bladder. ERCP service was
called- they wanted to send pat to ICU for NIPPV w/ plan to ERCP
in AM.
ROS: as above
Past Medical History:
COPD on home O2 3L, never intubated
HTN
h/o breast CA s/p L mastectomy
hyperlipidemia
ALL: NKDA
Social History:
quit smoking >30 years ago, no EtOH, no drugs; lives in house w/
daughter
Family History:
Non-contributory
Physical Exam:
VS 97.3, 100, 119/50, 21, 100% NIPPV
Gen AOX3, NAD, obese
HEENT: dry MM, mask on, mild scleral icterus
Chest: decreased BS throughout, no wheezing/rales
CV: very distant HS, regular, slightly tachy, no murmurs
appreciated
Abd: obese, soft, nontender, +BS, mildly distended (baseline)
Ext: dry, no edema
Neuro: AOX3, non-focal
Skin: no jaundice
Pertinent Results:
[**2143-3-1**] 12:51AM BLOOD WBC-31.8* RBC-4.20 Hgb-12.9 Hct-38.2
MCV-91 MCH-30.7 MCHC-33.8 RDW-12.9 Plt Ct-379
[**2143-3-2**] 04:48AM BLOOD WBC-36.7* RBC-3.50* Hgb-10.9* Hct-32.8*
MCV-94 MCH-31.2 MCHC-33.4 RDW-13.1 Plt Ct-341
[**2143-3-3**] 03:54AM BLOOD WBC-26.9* RBC-3.50* Hgb-10.8* Hct-32.1*
MCV-92 MCH-31.0 MCHC-33.8 RDW-12.6 Plt Ct-300
[**2143-3-1**] 12:51AM BLOOD Neuts-86* Bands-11* Lymphs-1* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2143-3-2**] 04:48AM BLOOD Neuts-92.8* Bands-0 Lymphs-4.9* Monos-2.3
Eos-0 Baso-0
[**2143-3-1**] 05:45AM BLOOD PT-13.1 PTT-25.1 INR(PT)-1.1
[**2143-3-1**] 12:51AM BLOOD Glucose-301* UreaN-20 Creat-1.1 Na-139
K-2.9* Cl-91* HCO3-31 AnGap-20
[**2143-3-3**] 03:54AM BLOOD Glucose-123* UreaN-14 Creat-0.6 Na-139
K-3.4 Cl-100 HCO3-32 AnGap-10
[**2143-3-1**] 12:51AM BLOOD ALT-681* AST-635* CK(CPK)-148*
AlkPhos-468* TotBili-5.8* DirBili-4.5* IndBili-1.3
[**2143-3-1**] 05:45AM BLOOD ALT-603* AST-513* LD(LDH)-467*
CK(CPK)-202* AlkPhos-424* TotBili-6.1*
[**2143-3-2**] 04:48AM BLOOD ALT-455* AST-279* AlkPhos-324*
TotBili-3.7*
[**2143-3-3**] 03:54AM BLOOD ALT-371* AST-169* LD(LDH)-226
AlkPhos-279* TotBili-1.9*
[**2143-3-1**] 12:51AM BLOOD cTropnT-0.02*
[**2143-3-1**] 05:45AM BLOOD CK-MB-6 cTropnT-<0.01
[**2143-3-1**] 12:51AM BLOOD Lipase-42
[**2143-3-1**] 05:45AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.8
[**2143-3-3**] 03:54AM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.2*
Mg-2.2
[**2143-3-1**] 01:15AM BLOOD Type-ART pO2-114* pCO2-47* pH-7.44
calTCO2-33* Base XS-7
[**2143-3-1**] 06:12AM BLOOD Type-ART O2 Flow-4 pO2-60* pCO2-51*
pH-7.43 calTCO2-35* Base XS-7
[**2143-3-2**] 08:45PM BLOOD Type-ART pO2-49* pCO2-49* pH-7.42
calTCO2-33* Base XS-5
[**2143-3-1**] 05:16AM BLOOD Lactate-2.1*
[**2143-3-2**] 08:45PM BLOOD Lactate-1.1
CXR [**3-1**]:
Tip of the new right subclavian line ends in the mid SVC. No
pneumothorax, pleural effusion or mediastinal widening is seen.
Moderately severe bibasilar atelectasis has worsened. Lateral
aspect of left lower chest is excluded from the examination.
There may be a small left pleural effusion, but there is no
indication of right pleural fluid or any pleural air. Heart size
top normal. Upper lungs clear. Endotracheal tube tip at the
lower margin of the clavicles is in standard placement.
ERCP report pending
RUQ US [**3-1**]:
Multiple shadowing stones seen within the gallbladder, without
definite evidence of acute cholecystitis.
CXR [**3-3**]:
Bibasilar atelectasis persists. Upper lungs clear. Pleural
effusion if any is minimal. No pneumothorax. Heart size is
partially obscured by overlying soft tissue but not appreciably
enlarged.
Brief Hospital Course:
A/P 74F w/ h/o COPD on home 3L O2 p/w SOB, fever, RUQ pain.
SEPSIS, SEVERE (WITH ORGAN DYSFUNCTION)
Patient was supported with levophed but quickly became
hemodynamically stable and pressors were weaned off. Her urine
output, which was initially poor, improved and her Cr remained
stable. She was dicharged with planned course of completion of
vancomycin and zosyn to cover both pneumonia and cholangitis.
RESPIRATORY FAILURE, ACUTE (NOT ARDS/[**Doctor Last Name **]) due to COPD
exacerbation and Pneumonia
Patient has underlying COPD on 3L of oxygen at home. She was
intubated for her ERCP, but was able to be extubated one day
later. She was started on steroids, and required frequent
nebulizer treatments for COPD exacerbation. Pna treated as
above, and plan slow taper from steroids. At time of d/c was at
baseline (requiring 3-5 litres of nasal cannula oxygen for sats
in the low 90's.). Follow up with pulmonary here at [**Hospital1 18**]
arranged.
CHOLANGITIS
Patient had gallstones and dilation of her bile duct on RUQ US.
ERCP was done with placement of plastic stent, which needs to be
removed in 6 weeks (appointment arranged). Imaging reveals
[**Last Name (LF) 77292**], [**First Name3 (LF) **] f/u with surgery for evaluation for CCY
arranged with Dr. [**Last Name (STitle) **] of surgery.
HYPERTENSION, BENIGN
Patient is on HCTZ and verapamil at home for BP control. These
were initially held. HCTZ was restarted on the last day of her
ICU stay; did not require verapamil this admission.
CANCER (MALIGNANT NEOPLASM), BREAST
Continued home arimidex
Hyperlipidemia
Statin held in setting of elevated LFTs. Will need to be
restarted as outpatient.
Medications on Admission:
atenolol 25 qd -- patient not taking
HCTZ 12.5 qd
verapamil 240 qd
lipitor 10
singulair 10
advair 250/50
nebulizer
arimidex 1mg daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q2H (every 2 hours) as needed.
7. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) inhallation Inhalation [**Hospital1 **] (2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 5 days: start [**2143-3-10**].
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days: start [**2143-3-15**].
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days: Start [**2143-3-20**].
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q6H (every 6 hours).
13. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 5 days.
14. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 grams Intravenous Q8H (every 8 hours) for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 38**]
Discharge Diagnosis:
Respiratory failure due to copd exacerbation and pneumonia
sepsis due to cholangitis
Discharge Condition:
Stable, at baseline level of home o2: 3-5 litres nasal cannula.
Discharge Instructions:
Take all medications as prescribed.
Return to the [**Hospital1 18**] Emergency Department for:
Fever
Shortness of breath
Abdominal pain
Nausea and vomiting
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2143-4-1**] 10:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2143-4-1**] 11:00
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2143-4-1**] 11:00
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**Doctor Last Name 39752**] on [**4-5**]@11:20am
ERCP procedure with Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for removal of stent on
[**4-16**] @8am arrival time: ([**Telephone/Fax (1) 2306**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Surgery) for evaluation for cholecystectomy
(removal of gall bladder) on [**4-23**] @10am: ([**Telephone/Fax (1) 2363**]
|
[
"0389",
"486",
"78552",
"99592",
"2724"
] |
Admission Date: [**2190-9-2**] Discharge Date: [**2190-9-20**]
Date of Birth: [**2117-7-15**] Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Codeine / Bactrim DS / IV Dye, Iodine
Containing / Levofloxacin / Lipitor / Shellfish / Sulfa
(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
"altered mental status."
Major Surgical or Invasive Procedure:
PICC placement
History of Present Illness:
This is a 73 yo WF with a PMHx of breast cancer originally
diagnosed in [**2160**] with recurrence 6 months ago, s/p recent
bilateral mastectomy c/b infection and removal of expanders, now
with pseudomonas osteomyelitis who now p/f home with subacute
changes in MS and increased problems ambulating.
.
The patient was discharged for the plastic surgery service about
2 months ago for surgical treatment for complications related to
her bilateral mastetomy. She was re-admitted several weeks ago
for a delayed closure of her wounds. Her most recent tissues
culture from her chest grew pan-sensitive pseudomonas. She is
on vancomycin and cefipme therpay, end date is [**2190-9-29**]. The
patient had been at home for the last several weeks and the
family notes a slow decline in mental functioning. They report
she is slower to answer questions and has a poor attention span.
They thinks her metal function started to decline noticably as
she was diagnosed with her second breast cancer in 2/[**2190**]. They
did note that she has some level of forgetfulness at baseline.
The day of admission, the patietn had decreased ability to
ambulate with a walked like she had been able to previously, so
they presented to the hospital. They denied falls and the
patietn denies dysequilibrium or vertigo. The patient has had
problems taking in po [**3-17**] to increased nausea and vomiting of
clear liquid. The patient family notes she is on many
medications and that her pain medications and reglan may have
been changed recently. Per the ED notes, reglan was added
recently.
.
In the ED they got a HCT which was negative for acute processes
and a CXR that was negative except for her picc was in her RIJ.
The patients labs were signifcant for acidosis with a bicarb of
14, a normal lactate and a creatinine of 1.8. There the patient
was AAOX2.
When the patient arrived to the floor she had no complaints.
She denied pain, cp, sob, f/c. The plastic surgery team
evalauted the patietn and probed her wound and got pus like
drainage from the patient right chest. She had minimal pain
during the procedure.
Past Medical History:
PMH:
1) Left breast cancer [**2160**]
-carcinoma of the left breast diagnosed in [**2160**]
-At that time, she was treated with breast conserving surgery
including an axillary dissection, chemotherapy, and adjuvant
radiation therapy.
-She has had no further problems with her breast until [**2-/2190**]
when Ms. [**Known lastname **] [**Last Name (Titles) 1834**] a wire localized right breast
biopsy for a mammographic abnormality, which demonstrated
microcalcifications associated with benign breast lobules. An
initial core biopsy had demonstrated calcifications associated
with a sclerosed fibroadenoma and lobular carcinoma in situ
-new left breast ca, the pathology of which was the same as her
initial breast ca over 20 yrs ago
-there was 1 positive sebtinel node, Her-2 neg
-In [**Month (only) 956**] she [**Month (only) 1834**] a bilateral mastectomy
with expanders placed
-her post op course was complicated by a significant cellulitis
of both surgical sights, requiring surgical intervention and
removal of expanders
2) L squamous cell carcinoma
3) Hypertension
4) Hyperlipidemia
5) Hypothyroidism
6) Arthritis
7) Diverticulitis s/p sigmoidectomy
Past Surgical History:
1) [**2190-4-15**] Bilateral breast debridement
2) [**2190-3-30**] Bilateral total simple mastectomies
3) [**2183**] Sigmoidectomy for diverticulitis
4) [**2180-7-11**] arthroscopy with major synovectomy and thermal
chondroplasty of right knee
5) [**2180-1-25**] operative arthroscopy with partial medial
meniscectomy and debridement
6) [**2179-8-18**] Wire localized right breast biopsy
7) [**2178-4-13**] Excision of cyst on buttocks
8) [**2175-9-15**] Removal of distal radius pin
9) [**2175-7-24**] Closed reduction of the right distal radius
fracture,
external fixator application of right wrist, percutaneous K-wire
placement of right distal radius
10) [**2165**] Left breast lumpectomy and chemoradiation
11) [**2153**] C-section
12) [**2135**] Appendectomy
13) [**2123**] Tonsillectomy
Social History:
Cigarettes-denied, EtOH rare social.
Family History:
negative for breast and ovarian cancer.
Physical Exam:
Admission Physical Exam:
.
VS 98.6, 138/62, 67, 16, 97 RA
General: patient is easily arousable, AAOX3-knows she is in the
hospital, knows the month, unsure of the year, throughts are
somewhat tangential and sometiems does not answer questions
appropirately
HEENT: CN 2-12 grossly intact, mmm, no lad
Endo: no obvious thyroid masses
CV: 3/6 systolic murmur
Lungs: CTAB no wrr
Abdomen: positive bs, obese but not TTP, liver and spleen not
palpable, no rebound
Extremities:
UE:5/5 strength, pulses 2+ and equal, sensation grossly intact
LE:4+/5 strength, pulses 2+ and equal, sensation grossly intact,
2+ pitting ble edema
Neuro:
-strength equal, slightly decreased per above
-reflexes 1+ and equal
-sensation grossly intact
-unable to participate in cerebellar exam
-mental status per above, able to answer some simple questions
but is tangential
ICU Admission Exam:
Vitals: T 98.9, BP 168/61, HR 92, RR 27, SpO2 97% on 8L
Ventimask
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Chest wall: Dressing in place, non-tender, bilateral mastectomy
sutures clean.
Lungs: Increased work of breathing, tachypnea. Bibasilar
crackles. Wheezing audible without stethoscope, upper airway.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Warm, well perfused. Distal pulses 2+. Lower extremity
edema 1+ bilaterally at ankles.
DERM: Sacral decub ulcer, healing incision on right mid-back.
.
Discharge Physical Exam:
.
VS 97.8, 132/78, 72, 18, 97 RA
General: AOx3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Chest wall: Dressing in place, non-tender, bilateral mastectomy
sutures clean.
Lungs: Increased work of breathing, tachypnea. Bibasilar
crackles. Wheezing audible without stethoscope, upper airway.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Warm, well perfused. Distal pulses 2+. Lower extremity
edema 1+ bilaterally at ankles.
Neuro: non-focal
.
Pertinent Results:
Admission Labs:
.
[**2190-9-2**] 12:15PM URINE HOURS-RANDOM
[**2190-9-2**] 12:15PM URINE GR HOLD-HOLD
[**2190-9-2**] 12:15PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.008
[**2190-9-2**] 12:15PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM
[**2190-9-2**] 12:15PM URINE RBC-1 WBC-21* BACTERIA-FEW YEAST-NONE
EPI-<1
[**2190-9-2**] 12:15PM URINE AMORPH-FEW
[**2190-9-2**] 12:15PM URINE MUCOUS-RARE
[**2190-9-2**] 10:12AM LACTATE-1.0 K+-4.1
[**2190-9-2**] 10:05AM GLUCOSE-84 UREA N-34* CREAT-1.8* SODIUM-133
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-14* ANION GAP-19
[**2190-9-2**] 10:05AM estGFR-Using this
[**2190-9-2**] 10:05AM ALT(SGPT)-3 AST(SGOT)-12 LD(LDH)-226 ALK
PHOS-93 TOT BILI-0.2
[**2190-9-2**] 10:05AM LIPASE-10
[**2190-9-2**] 10:05AM CALCIUM-9.6 PHOSPHATE-3.3 MAGNESIUM-1.4*
[**2190-9-2**] 10:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2190-9-2**] 10:05AM WBC-8.4 RBC-3.54* HGB-10.4* HCT-33.2* MCV-94
MCH-29.4 MCHC-31.3 RDW-16.2*
[**2190-9-2**] 10:05AM NEUTS-83.3* LYMPHS-6.3* MONOS-3.7 EOS-5.7*
BASOS-1.0
[**2190-9-2**] 10:05AM PLT COUNT-353
.
Pertinent Labs:
.
[**2190-9-3**] 07:05AM BLOOD freeCa-1.25
[**2190-9-3**] 11:17AM BLOOD Type-ART pO2-273* pCO2-26* pH-7.28*
calTCO2-13* Base XS--12
[**2190-9-14**] 03:47AM BLOOD Type-ART pO2-43* pCO2-38 pH-7.51*
calTCO2-31* Base XS-6
[**2190-9-2**] 10:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2190-9-18**] 05:47AM BLOOD CRP-31.1*
[**2190-9-5**] 06:00AM BLOOD T4-3.4*
[**2190-9-4**] 05:45AM BLOOD TSH-8.0*
[**2190-9-3**] 06:00AM BLOOD Ammonia-34
[**2190-9-7**] 06:00AM BLOOD Triglyc-151*
[**2190-9-3**] 06:00AM BLOOD VitB12-272 Folate-5.3
.
Discharge Labs:
.
[**2190-9-20**] 06:00AM BLOOD WBC-6.5 RBC-3.23* Hgb-9.8* Hct-28.7*
MCV-89 MCH-30.2 MCHC-34.0 RDW-15.2 Plt Ct-375
[**2190-9-20**] 06:00AM BLOOD Plt Ct-375
[**2190-9-20**] 02:00PM BLOOD Glucose-121* UreaN-49* Creat-1.3* Na-135
K-5.3* Cl-99 HCO3-26 AnGap-15
[**2190-9-20**] 02:00PM BLOOD Calcium-10.1 Phos-4.2 Mg-2.2
.
MICRO/PATH:
.
Blood culture [**9-2**]: No growth
Abscess Culture [**9-2**]: Pseudomonas Aeruginosa pan-sensitive
Blood culture x 2 [**9-4**]: No growth
Urine Culture [**9-4**]: Yeast 10k-100k orgs/ml
Stool Cdiff [**9-6**]: Negative
Stool Cdiff [**9-7**]: Negative
MRSA Screen [**9-8**]: Negative
Urine Culture [**9-10**]: No growth
Urine Culture [**9-14**]: No growth
Urine Legionella Antigen [**9-14**]: Negative
Stool Cdiff [**9-14**]: Negative
.
IMAGING:
.
Chest Portable [**9-14**]
IMPRESSION:
1.Mild interval progression of pulmonary edema
2.New left upper lung opacity which could potentially represent
a focus of
consolidation or may be from the summation shadows of the ribs
and scapula. Lateral radiograph is suggested for further
evaluation.
3. Unchanged bilateral minimal pleural effusions
.
CXR PA/LAT [**9-2**]
IMPRESSION:
1. Right PICC terminates in the right neck - likely within the
internal
jugular vein and should be repositioned.
2. Mild congestive heart failure. No pneumonia.
.
CT Head [**9-2**]
1. No acute intracranial hemorrhage. Note that MRI is more
sensitive for
detection of metastases and mass lesions.
2. Bifrontal prominence of CSF space could reflect bifrontal
atrophy, chronic small subdural hematomas, or CSF hygromas.
.
MR [**Name13 (STitle) 430**] [**9-4**]
1. No acute intracranial abnormality; specifically, there is no
evidence of an acute ischemic event.
2. No secondary finding to specifically suggest intracranial
metastatic
disease on this non-enhanced examination.
3. Relatively marked symmetric prominence of the bifrontal
extra-axial CSF
spaces, most likely representing severe bifrontal cortical
atrophy.
.
CT Chest [**9-3**]
1. Extensive irregularity and sclerosis of the sternum since the
prior study, concerning for progression of osteomyelitis with
soft tissue stranding anterior to the sternum.
2. No focal fluid collections or tracking soft tissue air with
soft tissue
inflammatory changes in the left greater than right chest wall
possibly
reflecting associated soft tissue infection.
3. Right greater than left pleural effusions.
4. Right middle lobe nodules similar in size, although perhaps
slightly
[**Hospital1 2824**] than on the prior study, can be followed in three to six
months with a followup chest CTA.
5. Mild pulmonary edema with small bilateral effusions.
6. Lucent lesion in the left glenoid could reflect degenerative
subchondral cystic change. However, metastasis cannot be fully
excluded.
.
CXR [**9-7**]
Pulmonary edema, if present, is mild. There is substantial
opacification of the right lower lung, probably collapsed. On
the left, there may be a moderate pleural effusion and basal
consolidation is not excluded. Heart is mildly-to-moderately
enlarged, and there is mild mediastinal venous engorgement.
Right PICC line ends in the upper right atrium.
.
CXR [**9-9**]
Mild left lower lobe atelectasis or pneumonia. Vascular
congestion has improved.
.
ECHO [**9-3**]
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. 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 grossly normal with
trivial mitral regurgitation. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal study. No valvular
pathology or pathologic flow identified.
.
RENAL US [**9-3**]
No hydroureteronephrosis or renal stone.
.
LUB [**9-3**]
Unremarkable abdominal x-ray. No evidence of free air.
.
Brief Hospital Course:
This is a 73 yo WF with a PMHx of breast cancer with new primary
diagnosed [**2-/2190**] s/p bialteral mastecomy c/b sternal and rib
osteomyelitis who was on IV abx at home who now p/w altered
mental status and decreased ability to abulate with a walker and
persistent n/v, found to have 3/6 systolic murmur, ARF (Cr 1.8),
metabolic acidosis (bicarb 14), and only able to answer simple
questions with tangential thoughts.
.
Active Diagnoses:
.
#Altered mental status: The etiology of Mrs.[**Known lastname 69032**] altered
mental status was likely multifactorial but predominately a
result of delirium given her serious medical illnesses. We
tested for reversible causes of AMS including B12 and folate
levels which were wnl's, CT head which was negative for
intracranial processes, UA and urine cultures which were
negative for UTI, and reduced her doses of CNS-depressing
medications including her fentanyl patch, gabapentin, and
benadryl. We continued to treat her underlying skin/wound
infection of IV vanc and cefepime and her mental status
gradually improved until she became alert, oriented, conversant,
and demanding for discharge home.
.
#Pseudomonas osteomyelitis of chest: She remained afebrile
during the admission but had immunosuppression from
chemotherapy, metastatic disease, and malnutrition. She was
treated with IV vanc and cefepime and was followed closely by
plastics for evlauation of her wounds and removal of her wound
drains. Her urine and blood cultures remained negative
throughout admission but her wound abscess grew pan-sensitive
pseudomonas. Her TTE was negative for vegetations as well. Stool
Cdiff antigen test was negative x 2. Her infection was monitored
with weekly CRP/ESR levels which remained severely elevated.
During her admission she was switched to daptomycin and
meropenem per ID recs. She was followed closely by ID and
continued on IV antibiotics on discharge with follow-up
established in the [**Hospital **] clinic for final antibiotic course
determination to be made as an outpatient. Per the plastics
team, she will need further severe surgical debridement if she
is able to become healthy enough to tolerate such an operation
in the future.
.
#[**Last Name (un) **]: Pt with [**Last Name (un) **] that was assessed to be pre-renal or as a
result of interstitial nephritis from her IV cefepime. She had
an elevated BUN/Cr ratio and trace urine Eos. Her ACEI and home
diuretics were held and she was given good amounts of continuous
IV fluids and her Cr level fell towards baseline down to 1.3
from 2.3 earlier in her hospital course.
.
#Metabolic Acidosis, Anion Gap +: She had a widened anion gap
metabolic acidosis early in her hospital course but with a
normal lactate level thought to be related to her smoldering
pseudomonas osteomyelitis. We continued treatment of her
underlying infection and this resolved.
.
#Malnutrition: This patient was found to have low-low normal
albumin levels with a pre-albumin wnl's. She however, had
significant nausea and occasional vomiting and had difficulty
tolerating food by mouth. She was treated with TPN for much of
her admission yet as her mental status improved her nausea began
to fade and she was able to tolerate a better diet. She was
discharged home without TPN as it was determined that her risk
of developing further infection given her widespread pseudomonal
osteomyelitis was quite high and her appetite and PO intake was
rapidly improving.
.
ICU Course:
Mrs. [**Known lastname **], a 73 year old lady with Pseumonal osteomyelitis and
soft tissue infection s/p breast resections, was transferred to
the East ICU on [**9-8**] after developing respiratory distress on
the floor with a concern for anaphylaxis. Her ICU course was
also complicated by hypertension, acute kidney injury, altered
mental status and anemia.
.
# Respiratory Distress: Floor team was concerned that the
patient had developed anaphylaxis to meropenem, as she had
recently begun that antibiotic for treatment of her Pseudomonal
osteomyelitis and soft tissue infection. On arrival to the ICU
however, her history, exam, labs (elevated BNP [**Numeric Identifier **]) and chest
x-ray (vascular congestion) seemed most consistent with
pulmonary edema in the setting of uncontrolled hypertension.
For her suspected allergic reaction, her meropenem was
discontinued, and she was treated with ranitidine and
albuterol/iprotropium nebulizers. For her pulmonary edema, she
was diuresed with furosemide IV. She responded with good UOP
and improved exam. Her blood pressure was also controlled.
Prior to transitioning back to the floor, the patient was
challenged with meropenem and carefully monitored for signs of
anaphylaxis. She tolerated the meropenem challenge, and was
continued on meropenem along with daptomycin for treatment of
her sternal osteomyelitis. Patient acutely developed anxiety,
but [**3-17**] AMS patient was unable to explain symptoms. CE cycled
and negative; EKG without acute ST/T wave changes. CXR done at
the time consistent with pulmonary edema. She was diuresed and
given 10mg IV hydralazine and her symptoms seemed to improve.
.
# Pseudomonal Wound Infection: Infectious Disease and Plastic
Surgery continued to follow the patient in the ICU. She was
continued on vancomycin and cefepime for treatment of her wound
infection, until she passed the meropenem challenge. Wound care
and dry dressings were done per the advice of the Plastic
Surgery team. On discharge from the ICU, the patient's
antibiotic regimen was meropenem and daptomycin.
.
# Hypertension: The patient's blood pressures remained elevated
in the ICU; however, some elevation was attributed to the fact
that there was significant external pressure on her leg blood
pressure cuff. This pressure was likely falsely elevating her
readings. Home lisinopril was held [**3-17**] elevated sCr. She was
treated with amlodipine 10mg qDay and hydralazine 10mg TID, as
well as IV furosemide for diuresis. We tolerated leg blood
pressures of SBP 150-170, so that her kidneys would remain
well-perfused.
.
# [**Last Name (un) **]: Elevated creatinine persisted while in the ICU. Renal
team continued to follow and believed that her urine sediment
was consistent with ATN. Volume status, urine output, and
electrolytes were monitored, and her medications were
renally-dosed.
.
# Altered Mental Status: The patient reportedly had subacute
mental status changes at home with confusion and impaired gait
which prompted her presentation. Several deliriogenic meds,
including Fentanyl patch, were stopped on admission to the
hospital or shortly after. In the ICU, she continued to have
waxing and [**Doctor Last Name 688**] confusion and impaired attention consistent
with delirium. She seemed to have a better mental status with
her family present in the room. Her Ativan was changed from qHS
to [**Hospital1 **], and other delirogenic medications were avoided.
.
# Anemia: The patient's Hct was low, but stable at her recent
baseline prior to hospitalization. Her CBC was trended and
stools Guaiac'd to monitor.
Transitional/Follow-up Issues:
-F/u w/ primary breast surgeon: will need more surgery to remove
osteomyelitis of sternum but not until she is more stable, ~6
weeks. Follow-up was set up with the ID team to tailor and
determine her final antibiotic course as an outpatient.
Medications on Admission:
1. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily)-will hold
2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily).
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for burning pain, anterior right chest.
Disp:*63 Capsule(s)* Refills:*1*
8. fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Transdermal
Q72H (every 72 hours) as needed for cancer pain.
Disp:*10 patches* Refills:*1*
9. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal
every seventy-two (72) hours as needed for cancer pain.
Disp:*10 patches* Refills:*1*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
11. vancomycin in D5W 1 gram/200 mL Piggyback Sig: 1000 (1000)
mgs Intravenous Q 24H (Every 24 Hours): Last dose to be given on
[**2190-9-29**].
Disp:*7 IV bags* Refills:*6*
12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
13. cefepime 2 gram Recon Soln Sig: Two (2) gms Injection Q8H
(every 8 hours): Last dose to be given on [**2190-9-29**].
Disp:*21 IV bags* Refills:*6*
Discharge Medications:
1. meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 15 days.
Disp:*30 Recon Soln(s)* Refills:*0*
2. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H (every 48 hours) for 15 days.
Disp:*8 Recon Soln* Refills:*0*
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*1 Tablet(s)* Refills:*0*
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
Disp:*1 * Refills:*0*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO three
times a day.
Disp:*30 Capsule(s)* Refills:*0*
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
10. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day) as needed for nausea.
Disp:*120 Tablet(s)* Refills:*0*
11. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*14 Tablet, Rapid Dissolve(s)* Refills:*0*
12. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety: hold for sedation.
Disp:*7 Tablet(s)* Refills:*0*
13. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*24 Tablet(s)* Refills:*0*
14. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
15. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
16. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours.
Disp:*240 Tablet(s)* Refills:*0*
17. Outpatient Lab Work
Please obtain blood and check CBC and Chem 10 (including
magnesium, calcium, and phosphate)
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Pseudomonal osteomyelitis
pulmonary edema
hypertension
acute kidney injury
delirium
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure caring for you. You were admitted with altered
mental status and were found to have an infection in the site of
your prior mastectomies, and kidney damage. We are treating your
infection with antibiotics and your kidney function is
improving.
.
We made the following changes to your medications:
-START Meropenem 1g IV every 12 hours
-START Daptomycin 400mg IV every 48 hours
-START Hydralazine 10mg, 2 tablets, by mouth every 6 hours
-START Amlodipine 10mg by mouth daily
-START Hydrochlorothiazide 25mg by mouth daily
-START Omeprazole 20mg by mouth daily
-START Metoclopramide 10mg by mouth four times daily as needed
for nausea
-START Zofran 8mg by mouth every eight hours as needed for
nausea
-START Compazine 10mg by mouth every six hours as needed for
nausea
-START Ativan 0.5mg by mouth every four hours as needed for
anxiety
-START Dilaudid 2mg by mouth every four hours as needed for pain
-STOP Triamterene
-STOP Lisinopril
-STOP Gabapentin
-STOP Fentanyl patches
-STOP Cefepime
-STOP Vancomycin
Please make sure to eat as much as you can by mouth to keep up
your nutritional status. Also, please make sure to follow up
with your primary care doctor sometime this week for repeated
lab work and follow-up. You will have to discuss with him the
possibility of returning to your original blood pressure
medications once your kidney function improves. Please also
continue your IV antibitoics until your appointment with Dr.
[**Last Name (STitle) **] on [**10-5**]. We wish you a speedy recovery.
Followup Instructions:
Department: INFECTIOUS DISEASE
When: TUESDAY [**2190-10-5**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
Name:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 97917**],MD
[**Last Name (Titles) 90499**]: Primary CAre
Location: PERSONAL MDS, LLC
Address: [**Location (un) **] [**Apartment Address(1) 97918**], [**Location (un) **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 95663**]
When: [**Last Name (LF) 766**], [**9-27**] at 10:30am
Completed by:[**2190-10-12**]
|
[
"5845",
"2762",
"4019",
"2724",
"2449"
] |
Admission Date: [**2132-4-1**] Discharge Date: [**2132-4-2**]
Date of Birth: [**2052-5-1**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Morphine Sulfate / Latex
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
This is a 79 yo F with a hx of breast ca, asthma, and HTN who
originally presented to the ED for evaluation of a HA. She
states that the HA started approximately at noon on the day of
admission, and was localized to the left posterior region and
throbbing, initially an [**7-28**]. She denies photophobia,
phonophobia or visual changes. She likens it to her previous SDH
but not as severe. She did not note any focal weakness,
numbness, tingling, confusion, neck pain, or difficulty with her
speech. It got initially better with tylenol but the returned so
she presented to the emergency room. She has been having HA
since returning from [**State 108**] 2 weeks ago which she associates
with her seasonal allergies.
.
In ED, vitals were 98.9, 78, 147/81, 99% RA. She had a negative
CT Head and LP. She received 2mg IV morphine, 1mg IV lorazepam,
4mg IV Zofran prior to the LP. She was about to be discharged
when she developed a fever to 100.9. She received tylenol and
benadryl. A U/A and CXR were negative. She then became
transiently hypotensive to the systolic 80s. Her blood pressures
responded well to IVF(1L), returning to the systolic 94/77 Of
note she did take her BP meds today. She also received 1g IV
Ceftriaxone.
.
On presentation to the ICU, patient still had a mild HA, [**4-27**],
but no other complaints. She does note some increased nasal
congestion. Denies f/c at home, sore throat, cough, SOB, CP,
abd. pain, N/V/D, dysuria, or rash.
Past Medical History:
1. Right breast cancer, status post lumpectomy in [**2105**] with
radiation therapy and chemotherapy. Right breast mass
recurrence in [**2115**], status post mastectomy with
reconstruction and chemotherapy.
2. History of asthma.
3. History of cataracts.
4. History of polio.
5. Tonsillectomy.
6. Bilateral shoulder replacement
7. HTN
8. GERD
9. IBS
10. Hyperlipidemia
11. Traumatic SDH s/p evacuation 2 years ago
Social History:
Married, drinks 6-7 oz of alcohol a week and exercises by using
a treadmill three times a week. Previously smoked, approximately
20 pack years, but quit 45 years ago. No illicit drugs. Lives at
home with her husband.
Family History:
Noncontributory
Physical Exam:
VS - Temp 98.4 F, BP 128/57 , HR 73 ,14 R , O2-sat 100% RA
GENERAL - well-appearing female in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, dry MM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-22**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait deferred.
Pertinent Results:
[**3-31**] CT head
1. No intracranial hemorrhage or edema.
2. Complete opacification of the sphenoid sinus, perhaps with
inspissated
secretions
CT chest [**4-1**]
Final read pending, but prelim no PE. Incidental pancreatic tail
lesion and right upper lung nodule, needs f/u CT abdomen for
evaluation.
[**2132-3-31**] 11:30PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-2
Lymphs-88 Monos-10
[**2132-3-31**] 11:30PM CEREBROSPINAL FLUID (CSF) TotProt-28 Glucose-64
[**2132-4-1**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2132-4-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-4-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-3-31**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-PRELIMINARY EMERGENCY [**Hospital1 **]
[**2132-3-31**] 07:15PM BLOOD WBC-13.2*# RBC-3.96* Hgb-11.8* Hct-35.8*
MCV-90 MCH-29.7 MCHC-32.9 RDW-13.0 Plt Ct-388
[**2132-4-2**] 05:39AM BLOOD WBC-7.7 RBC-3.32* Hgb-10.2* Hct-30.5*
MCV-92 MCH-30.5 MCHC-33.3 RDW-13.0 Plt Ct-254
[**2132-3-31**] 07:15PM BLOOD Neuts-87.8* Lymphs-8.2* Monos-2.7 Eos-1.0
Baso-0.2
[**2132-4-2**] 05:39AM BLOOD Neuts-77.7* Lymphs-17.3* Monos-2.9
Eos-1.8 Baso-0.3
[**2132-3-31**] 07:15PM BLOOD PT-12.4 PTT-24.2 INR(PT)-1.0
[**2132-4-1**] 03:52PM BLOOD PT-13.2 PTT-26.0 INR(PT)-1.1
[**2132-3-31**] 07:15PM BLOOD Glucose-105 UreaN-20 Creat-0.8 Na-134
K-4.4 Cl-101 HCO3-24 AnGap-13
[**2132-4-2**] 05:39AM BLOOD Glucose-86 UreaN-6 Creat-0.5 Na-138
K-3.2* Cl-107 HCO3-23 AnGap-11
[**2132-4-1**] 03:52PM BLOOD Calcium-7.7* Phos-3.5 Mg-1.8
[**2132-4-2**] 05:39AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8
[**2132-4-1**] 03:52PM BLOOD Cortsol-6.6
[**2132-4-1**] 05:32PM BLOOD Cortsol-26.5*
[**2132-4-1**] 03:30AM BLOOD Lactate-0.8
Brief Hospital Course:
This is a 79 yo F with a hx of breast ca and HTN who presents
for evaluation of HA, fever, and hypotension.
#. Hypotension: [**Last Name (un) **] stim test was normal. She had no localizing
signs/symptoms of infection other than headache and LP was
negative. Her blood pressure responded to IVF. Her lactate was
normal. Manual recheck of her BP failed to demonstrate absolute
hypotension, only relative hypotension to SBP 100, her usual is
about 130. [**Month (only) 116**] have represented relative hypovolemia after not
feeling well and having poor PO intake. She was d/c'd w/
instructions not to restart her BP meds HCTZ and prindil until
instructed to do so by her PCP.
.
#. Fever: LP was negative. Blood cultures and CSF cultures were
no growth to date at time of d/c. Unclear source but she did
have opacification of her L sphenoid sinus on CT head. Also some
possible infectious changes on CT chest. She was discharged w/
instructions to use afrin nasal spray, saline nasal spray and a
prescription for azithromycin for 5 days.
.
#. HA: Negative CT and negative LP both showing no signs of
bleed or infection. Likely either tension HA, slight migraine,
or sinus HA. Improved significantly with ibuprofen and tylenol,
but tended to wax and wane.
.
#. HTN: Held home regimen
.
#. GERD: Con't PPI
.
#. Hyperlipidemia: Con't Wellchol
.
#. Asthma: Con't advair and prn albuterol
.
#. FEN - cardiac diet
.
Follow up
.
CT chest with some incidental finding -- apical scarring c/w
prior radiation, pancreatic tail enhancement (needs CT abd for
clinical correllation).
d/c'ed abx
Medications on Admission:
COLESEVELAM 625 mg - 3 Tablet(s) by mouth twice a day
FEXOFENADINE 60mg PO daily
FLUTICASONE-SALMETEROL 100/50 INH daily
HCTZ - 25mg PO daily
NASONEX - 50 mcg Spray, 1 once a day
OMEPRAZOLE - 20mg PO daily
PLENDIL - 2.5mg PO daily
ASA 81mg PO daily
Celebrex 100mg PO BID
Calcium+Vit. D
CRANACATIN - (OTC) - - 2 capsules once a day
MVI
Albuterol Inh PRN
Discharge Medications:
1. Colesevelam 625 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Celebrex 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
9. cranactin Sig: Two (2) capsules once a day.
10. Multivitamin Capsule Sig: One (1) Capsule PO once a day.
11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed.
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-21**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*3 bottles* Refills:*0*
13. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal
[**Hospital1 **] (2 times a day) for 3 days.
14. Azithromycin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
15. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days: Start the day after taking the 500mg tablet.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Sinusitis
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the intensive care unit with headache and
fever. All of the tests that we did were negative. A CT of your
head did not show any recurrent bleeding and a lumbar puncture
did not show any signs of infection. Your blood pressure was
slightly low and this came up with IV fluids. We did see a
nodule in you upper lung and a lesion in the pancreas on a CT
scan. You will need to make sure that your doctor checks this
with another CT scan in [**5-26**] weeks.
We started you on Afrin nasal spray, you should only use this
for 3 days, your nose may get more congested after stopping this
medication, this will not last and you should not restart this
medication.
We started you on azithromycin for your sinus infection, you
will take this for the next 5 days.
We started you on saline nasal spray, you should continue to use
this while you have nasal congestion.
We did not give you your blood pressure medications:
hydrochlorothiazide, plendil. You should talk to your doctor
before restarting these.
We did not change any of your other medications
If you have any worsening of your headache, changes in vision,
numbness, tingling, weakness, bleeding, fevers or chills, chest
pain or any other concerning symptoms please call your doctor
immediately or go to the emergency department.
Followup Instructions:
[**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern1) 21**], M.D. Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2132-5-20**] 9:00
[**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] [**Telephone/Fax (1) 1408**] [**2132-4-3**] 10:00 am
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2132-4-2**]
|
[
"4019",
"2724",
"53081"
] |
Admission Date: [**2180-1-14**] Discharge Date: [**2180-2-1**]
Service: MICU
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
African-American female with a history of congestive heart
failure and chronic obstructive pulmonary disease who
presented with one week of shortness of breath.
The patient was an extremely poor historian largely secondary
to her shortness of breath. The patient denies any fevers,
chills, nausea, vomiting, diarrhea, or chest pain. The
patient has had coughing attacks that leave her out of
breath. At baseline, the patient uses three liters of oxygen
at home and can only walk around the house but cannot walk up
stairs. The patient denies any sick contacts or loss of
consciousness.
Over the past two days, she has experienced increasing
worsening night sweats (waking up at 3 a.m. to 4 a.m.) in
addition to a decreased appetite. The patient also has sleep
apnea and uses a continuous positive airway pressure machine
at night.
Her last admission at [**Hospital1 69**]
was in [**2177-10-8**] when she was given Lasix for mild
bilateral pulmonary edema and azithromycin for pneumonia.
PAST MEDICAL HISTORY:
1. Congestive heart failure (last echocardiogram on [**2179-9-28**] revealed an ejection fraction of greater than 60%
with moderate aortic stenosis).
2. Chronic obstructive pulmonary disease (last pulmonary
function tests in [**2176-5-7**] revealed an FVC of 68%, FEV1
of 74%, and an FEV1:FVC ratio of 109%).
3. Hypertension.
4. Diabetes.
5. Hyperlipidemia.
6. Gout.
7. Osteoarthritis.
8. Coronary artery disease; last cardiac catheterization in
[**2178-1-8**] showed patent right coronary artery stent
with mild disease and mild atrial fibrillation.
9. Sleep apnea; the patient uses a continuous positive
airway pressure at night.
10. Status post bilateral cataract surgery.
MEDICATIONS ON ADMISSION: (Medications as an outpatient
included)
1. Lasix 120 mg p.o. once per day.
2. Norvasc 10 mg p.o. once per day.
3. Hydralazine 10 mg p.o. three times per day.
4. Isordil 10 mg p.o. three times per day.
5. Allopurinol 100 mg p.o. once per day.
6. Aspirin 81 mg p.o. once per day.
7. Insulin with insulin sliding-scale.
8. Albuterol nebulizers three times per day.
9. Prednisone taper.
ALLERGIES: BETA BLOCKER MEDICATIONS (lead to bradycardia)
and MEVACOR (leads to numerous side effects).
SOCIAL HISTORY: The patient denies any tobacco or alcohol
use. She lives [**Location (un) 6409**] with her daughter.
CODE STATUS: At the time of admission the patient was full
code.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed heart rate was 81, blood pressure was 150/81,
respiratory rate was 22, and oxygen saturation was 91% on
three liters via nasal cannula. In general, the patient was
an elderly and moderately obese female in respiratory
distress. Head, eyes, ears, nose, and throat examination
revealed cloudy sclerae. Pupils were equal, round, and
reactive to light and accommodation. Cardiovascular
examination revealed distant heart sounds. A 2/6 systolic
ejection murmur heard best at the best. Lung examination
revealed diffuse coarse wet sounds with rhonchi and crackles
bilaterally. The abdomen was soft, mildly distended, and
nontender. Normal active bowel sounds. Extremity
examination revealed bilateral 2+ pitting edema in the lower
legs. Bilateral radial pulses were 2+.
PERTINENT LABORATORY VALUES ON PRESENTATION: White blood
cell count was 12.4 (with differential of 87% neutrophils and
8% lymphocytes), hematocrit was 38.9, and platelets were 243.
Chemistry-7 revealed sodium was 138, potassium was 5,
chloride was 102, bicarbonate was 23, blood urea nitrogen was
33, creatinine was 1.4, and blood glucose was 147. Creatine
kinase number one was 100. Creatine kinase number two was
70.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a
sinus rhythm with left axis deviation. A left bundle-branch
block. No major change from [**2179-10-8**]
electrocardiogram.
A chest x-ray showed left lower lobe collapse/consolidation
and mild congestive heart failure.
HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was started on
a prednisone taper for her chronic obstructive pulmonary
disease. She was also prescribed levofloxacin for a presumed
pneumonia.
While on the floor, the patient was also treated for
congestive heart failure exacerbation with 60 mg of Lasix
intravenously twice per day. She was noted to be tachycardic
up to the 160s, but then bottomed out in response to
Lopressor. The patient was felt to have a tachy-brady
syndrome.
Electrophysiology was consulted at this time. A repeat
echocardiogram was also performed, and this showed an
ejection fraction of less than 20% with mild symmetric left
ventricular hypertrophy and severe global left ventricular
hypokinesis. This was a marked decrease in function from the
echocardiogram in [**2178**].
Because of the tachy-brady syndrome, the patient received a
DDI pacemaker. During the pacemaker placement the patient
developed atrial flutter and was shocked with 200 joules
which resulted in a normal sinus rhythm. She then became
disoriented. She was started on Coumadin, digoxin, and
quinidine. She then developed episodes of desaturations to
80% while off [**Hospital1 **]-level positive airway pressure.
At this point, she was transferred to the Medical Intensive
Care Unit. In the Medical Intensive Care Unit, the patient
was hypoxic without clear reason. She was intubated for
continued hypoxia. Overall, the patient was thought to be
hypoxic either from ongoing congestive heart failure or
atelectasis. The patient was also aggressively diuresed with
Lasix and then Natrecor. She did develop acute renal failure
with a bump in her creatinine to 2.9.
The patient's hypoxia was further worked up with a chest
computed tomography which showed excessive collapse of the
bronchus intermedius consistent with bronchomalacia in
addition to left lower lobe with bronchus collapse. She was
also noted to have multifocal patchy consolidation and ground
glass in both upper lobes. A flexible bronchoscopy revealed
marked collapse.
The differential diagnosis at that point included neoplasm,
infection, and chronic fibrosis which would have been
consistent with her previously restrictive pulmonary function
tests patterns.
The rest of the Medical Intensive Care Unit course was most
significant for an inability to wean the patient off the
ventilator. The patient failed a pressure support trial. A
family meeting was held, and the family was informed that the
patient would not tolerate weaning and that further options
included an tracheostomy versus comfort measures only with
extubation. The overall family consensus was to make the
patient comfort measures only and extubate her. This was
done, and the patient expired 12 minutes after extubation.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36
D: [**2180-6-12**] 11:56
T: [**2180-6-15**] 11:12
JOB#: [**Job Number 108996**]
|
[
"4280",
"51881",
"496",
"42731",
"4241",
"5849",
"25000"
] |
Admission Date: [**2160-2-18**] Discharge Date: [**2160-3-1**]
Service: VSU
CHIEF COMPLAINT: Abdominal aortic aneurysm.
HISTORY OF PRESENT ILLNESS: The patient was referred to Dr.
[**Last Name (STitle) 1391**] for evaluation of abdominal aortic aneurysm. She now
is admitted for elective open abdominal aortic repair with
ventral herniorrhaphy. Initial findings of the aneurysm was
on a x-ray for workup for a UTI.
PAST MEDICAL HISTORY: Includes rheumatoid arthritis,
prednisone dependent and on methotrexate; ischemic heart
disease with a myocardial infarction in [**2155**], stress test
done on [**2159-11-18**] was without ischemic changes, no
perfusion deficits, ejection fraction was 72% with no wall
motion abnormalities; also history of GERD; history of
urinary tract infections, treated; history of skin cancer;
history of MRSA infections; history of UTI sepsis with
hypotension.
PAST SURGICAL HISTORY: Includes coronary artery angioplasty
with stenting to the right coronary artery, proximal mid RCA
and distal RCA in [**2156-3-29**]; knee replacements; closed
reduction of a olecranon process fracture; open
reduction/internal fixation in [**2157**]; hernia repair; a gastric
repair; a pelvic fracture in [**2158-8-30**]; hysterectomy.
ALLERGIES: A history of multiple drug allergies; which
include DEMEROL causing nausea and vomiting; LOPRESSOR
causing hypotension; PENICILLIN manifestation no documented;
all "[**Last Name (un) **] DRUGS like i.e., NOVOCAINE/LIDOCAINE."
MEDICATIONS ON ADMISSION: Aspirin 81 mg daily, atenolol 50
mg daily, Atrovent puffer 2 daily, Colace 100 mg daily, folic
acid 1 mg daily, Lipitor 20 mg daily, lorazepam 0.5 mg [**12-31**]
tablet daily, prednisone 5 mg in the morning and 2 mg in the
evening, Protonix 40 mg daily. Other medications include
Actonel 35 mg daily, methotrexate 2.5 mg 6 tablets q. Friday,
multivitamins, vitamin D and oyster calcium.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure was
174/84, heart rate was 88, O2 saturation 96% on room air. The
patient is 58 inches in height and is 161 pounds (or 73.818
kilograms). GENERAL APPEARANCE: A white female in no acute
distress. Pupils are equal, round and reactive to light and
accommodation. There are no tremors. HEART: A regular rate
and rhythm. Normal S1 and S2 without any extra heart sounds.
There are no carotid bruits. LUNGS: With rales/crackles at
the bases bilaterally. ABDOMEN: Protuberant, soft, nontender;
without bruits. Abdominal aortic prominence could not be
felt. EXTREMITIES: Show some pedal edema with dopplerable
pedal pulses bilaterally.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area on [**2160-2-18**]. She underwent
abdominal aortic repair on a infrarenal aortic aneurysm with
a tube graft and a ventral hernia repair secondary to
compartment separation. The patient tolerated the procedure
well and was transferred to the PACU intubated in stable
condition. She did have some episodes of hypotension
requiring fluid boluses. The patient failed to be extubated
and was transferred to the surgical intensive care for
ventilatory support. The patient required aggressive diuresis
for volume overload and transfusion for blood loss anemia.
The patient remained in the ICU. The patient was extubated on
postoperative day #5. She continued to do well. Her blood gas
was 7.37/46/86/28/0. WBC was 10.6, hematocrit 28.2, BUN 23,
creatinine 0.8. The patient continued to remain with JP
drains in place. She was transferred to the VICU for
continued monitoring and care. She was transfused 1 unit of
packed red blood cells for her hematocrit of 23.9 and
diuresed. She did have some episodes of SVT which responded
to beta blockade. The patient's NG was removed, and sips of
clear liquids were begun on [**2160-2-26**]. The patient
tolerated these. She did have active bowel sounds, but denied
passing flatus. She did require continued diuresis for her
postoperative volume overload. The patient was evaluated by
physical therapy, and felt that she was a good candidate for
rehab at the time of discharge prior to being discharged to
home. Ambulation was begun on [**2160-2-26**] to a chair;
and on [**2160-2-27**] ambulation in the [**Doctor Last Name **] was begun. JP
drainage was monitored and if less than 100 cc for 24 hours
would consider discontinuing the JP's.
DISCHARGE DISPOSITION: The patient will be transferred to
rehab when medically ready.
DISCHARGE DIAGNOSES:
1. Abdominal aortic aneurysm; status post open abdominal
aortic repair with a tube graft.
2. A ventral hernia with compartment separation; status post
repair on [**2160-2-18**].
3. History of methicillin-resistant Staphylococcus aureus.
4. History of intraoperative and postoperative blood loss
anemia; transfused, corrected.
5. Postoperative hypovolemia with hypotension requiring
vasopressors; corrected.
6. Postoperative pulmonary edema; diuresed, resolved.
7. Postoperative atelectasis with a the left lower lobe and
right middle lobe; improved.
8. Postoperative supraventricular tachycardia; controlled
with beta blockade.
9. History of rheumatoid arthritis; prednisone and
methotrexate dependent.
10. History of hyperlipidemia; on a statin.
11. History of hypertension; controlled.
12. History of chronic obstructive pulmonary disease; on
Atrovent inhalers.
13. History of ischemic heart disease, status post myocardial
infarction in [**2155**] with a negative stress test on
[**2159-11-18**].
14. History of diverticulosis; asymptomatic.
15. History of skin cancer.
16. History of a urinary tract infection with sepsis and
hypotension; resolved.
17. Status post cardiac stent to the proximal, mid and distal
right coronary artery in [**2154-3-30**].
18. On [**2158-5-31**] knee replacement, open reduction and
internal fixation of an olecranon process fracture.
19. Status post hernia repair.
20. Status post gastric repair.
21. Pelvic fracture repair in [**2158-8-30**].
22. Status post hysterectomy.
DISCHARGE MEDICATIONS: Acetaminophen 325-mg tablets 1 to 2
q.4-6h. p.r.n. for pain; folic acid 1 mg daily; methotrexate
2.5-mg tablets 6 q. Friday; aspirin 81 mg daily; miconazole
nitrate powder to affected areas b.i.d.; Nystatin suspension
5 cc q. odd day swish-and-swallow; albuterol sulfate
inhalations q.4h. p.r.n.; ipratropium bromide inhalation
q.4h. as needed; Lopressor 50 mg q.i.d.; prednisone 5 mg
q.a.m. and 2 mg in the evening; atorvastatin 20 mg daily.
DISCHARGE INSTRUCTIONS: The patient may take showers; no tub
baths. She should call us if develops a fever of greater than
101.5. No heavy lifting for a total of 6 weeks. No driving
until seen in followup. She should call if there are any
changes in her incisional areas, when they become red or
drain. She should follow up with both Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) 1391**] 2 weeks post discharge, and she should call for an
appointment at (617) 632-_______ and Dr.[**Name (NI) 6433**] office at
([**Telephone/Fax (1) 6449**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2160-2-27**] 15:02:51
T: [**2160-2-27**] 17:06:12
Job#: [**Job Number 64729**]
|
[
"4280",
"2851",
"5990",
"496",
"42789",
"V4582"
] |
Admission Date: [**2179-9-27**] Discharge Date:[**2179-10-3**]
Date of Birth: [**2179-9-27**] Sex: M
Service: NB
DATE OF DISCHARGE FROM NICU: [**2179-10-1**].
DATE OF DISCHARGE FROM [**Hospital1 18**]: [**2179-10-3**].
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Name2 (NI) 57669**] is the 1810
gram product of a 35-3/7 week twin gestation born to a 40
year old Gravida 4, Para 0 now 2 mother by cesarean section
for unstoppable preterm labor with breach presentation.
Prenatal screens were blood pressure O positive, antibody
negative, Hepatitis B surface antigen negative, RPR
nonreactive, rubella immune. GBS is unknown. Mother is from
[**Country 2559**]. She has had three first trimester losses. She has a
prothrombin gene mutation, thalassemia minor, and
hypothyroidism. She is treated with Lovenox and baby aspirin
during this pregnancy. This IUI pregnancy was triplets which
was reduced to twins. The pregnancy was additionally
complicated by preterm labor at 24-5/7 weeks. She was made
beta complete at that time. Delivery was uncomplicated and
Apgar scores were eight at one minute and nine at five
minutes of life.
ADMISSION PHYSICAL EXAMINATION: Birth weight was 1810 grams
which was the tenth percentile. Length was 45 centimeters
which was the 50th percentile and head circumference was 31
centimeters which was the 25th percentile. In general, Baby
[**Name (NI) **] [**Known lastname 57666**] was a male with preemie habitus in mild
respiratory distress. HEENT examination revealed an anterior
fontanel that was open and flat. Red reflex was present
bilaterally and palate was intact. Pulmonary
examination showed very shallow respirations with audible
grunting and mild intercostal retractions. Heart was regular
rate and rhythm with no murmur; femoral pulses were two plus
bilaterally and capillary refill was brisk. The abdomen was
soft with active bowel sounds and no masses. Genitourinary
examination revealed a normal preterm male with testes
palpable in the inguinal canals bilaterally. The anus was
patent. The spine was without clefts, [**Hospital1 **] or dimples.
Hips were stable. Neurologic examination was appropriate for
gestational age.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: Initially Baby [**Name (NI) **] [**Name2 (NI) 57669**] number 2 had
some respiratory distress and was placed on CPAP of 5
centimeters in room air. He was able to wean off CPAP
to room air at about eight hours of life and remained
stable in room air thereafter. He did have one
desaturation to 53 percent at about 12 hours of life, so
he remained in the NICU for further monitoring. At the
time of transfer to the Newborn Nursery he has had no
desaturations in greater than 72 hours. In the Newborn
Nursery, there were no further respiratory events.
2. Cardiovascular: Baby [**Name (NI) **] [**Name2 (NI) 57669**] has been
hemodynamically stable throughout his stay with normal
perfusion and blood pressures.
3. Fluids, Electrolytes and Nutrition: Initially Baby [**Name (NI) **]
[**Name2 (NI) 57669**] was held NPO on D10W at 80 cc per kilo per day.
After his respiratory status stabilized he was allowed to
breast feed and has since been advancing on breast and
bottle feedings. He was initially fed with Similac 20 but
this was switched on the day of transfer to NeoSure 24
calorie per ounce secondary to his low birth weight. At
the time of discharge home his weight is 1695 grams and he has
excellent breastfeeding intake in addition to approxiamtely 30-40
ml (unrestricted) supplementation with each feed. He has
voided and stooled normally throughout his stay.
4. Hematology: Initial hematocrit was 58.1 percent with
normal platelets of 264,000. Bilirubin at 24 hours of
life was 6.2 with a direct component of 0.2. By 48 hours
of life, it had peaked at 9.5, so he was begun on single
phototherapy. Repeat the following morning was 9.2.
Phototherapy was discontinued on the day of transfer,
[**10-1**], but restarted the next morning for a rebound
bilirubin that had increased to 13.6. Phototherapy was again
discontinued on [**10-3**], with a discharge bilirubin of 11.0.
The parents will return to the [**Hospital1 18**] NICU 24 hours after
discharge for a repeat bilirubin level.
5. Infectious Disease: Secondary to risk factors of preterm
delivery and unknown GBS status, Baby [**Name (NI) **] [**Known lastname 57666**] had a
CBC and blood culture sent and was begun on ampicillin and
Gentamicin. CBC revealed a white blood cell count of
10,000 with 42 polys, no bands, and 52 lymphs. Cultures
were negative at 48 hours so antibiotics were
discontinued.
6. Sensory: Hearing screen was negative at discharge from the
Newborn Nursery.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To Newborn Nursery at [**Hospital1 346**].
Name of primary pediatrician: Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **]. Fax
number [**Telephone/Fax (1) 47151**].
CARE / RECOMMENDATIONS:
1. At the time of transfer feedings are with NeoSure 24 p.o.
ad lib plus breast feeding frequently (q2h).
2. Baby [**Name (NI) **] [**Known lastname 57666**] is on no medications.
3. Car seat position screening was normal, showing no
desaturations of other cardiorespriatory events in 90 minutes.
4. State Newborn Screen has been sent.
5. Baby [**Name (NI) **] [**Known lastname 57666**] has not yet had his Hepatitis B
vaccination but will need this prior to discharge.
6. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 547**] for any of the following three
criteria: 1) Born at less than 32 weeks; 2) born between
32 and 35 weeks with two of the following: Daycare during
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 six months of age. Before
this age (and for the first 24 months of the child's life),
immunization against influenza is recommended for household
contacts and for out of home caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity at 35-3/7 weeks gestation.
2. Mild respiratory distress, resolved.
3. Immature feeding.
4. Hyperbilirubinemia.
5. Suspected sepsis, resolved.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Doctor Last Name 56593**]
MEDQUIST36
D: [**2179-10-1**] 18:00:33
T: [**2179-10-1**] 18:41:12
Job#: [**Job Number 57670**]
|
[
"7742",
"V290"
] |
Admission Date: [**2192-10-11**] Discharge Date: [**2192-10-19**]
Date of Birth: [**2128-12-23**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 22591**] is a 63-year-old
gentleman, with a history of rheumatic heart disease, who has
had moderate known mitral stenosis which had become
progressively worse with symptoms over the past several
months. He had a cardiac echo done on [**2192-6-13**] which
showed a markedly dilated left atrium, ejection fraction of
55%, moderately dilated aortic root, and severely thickened
and deformed aortic valve leaflets. There was noted to be
severe aortic valve stenosis with mild aortic regurgitation.
The mitral valve leaflets were moderately thickened with
severe mitral annular calcification. Also, in comparison to
a previous study in [**2191-8-15**], there was noted to be worsened
aortic stenosis with a peak aortic valve gradient of 79 mmHg,
with a mean aortic valve gradient of 54 mmHg, and an aortic
valve area of 0.7.
The patient noted that his dyspnea on exertion over the past
6-8 months had been getting worse, and he denies any episodes
of syncope, presyncope, or chest pain. He had recently prior
to admission had a work-up for anemia, including a bone
marrow biopsy, which revealed an anemia consistent with his
HIV infection, and iron deficiency due to hemolysis from
damaged cells across the aortic valve.
PAST MEDICAL HISTORY:
1. HIV infection.
2. Aortic stenosis.
3. Mitral stenosis.
4. Mitral regurgitation.
5. Anemia.
6. Reflux.
ALLERGIES: He has No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg po qd.
2. Actos 45 mg po qd.
3. Epivir 150 mg po bid.
4. Lipitor 40 mg po qd.
5. Prilosec 20 mg po qd.
6. Sotalol 120 mg po bid.
7. Sustiva 600 mg po q hs.
8. Tenofovir 300 mg po qd.
9. Zerit 40 mg po bid.
10.Lisinopril 5 mg po qd.
SOCIAL HISTORY: He lives alone and is retired. He used to
work at [**Hospital6 2910**]. He is a nonsmoker.
PHYSICAL EXAM: Heart rate 72, blood pressure 108/60. He is
an alert, pleasant male in no apparent distress.
HEENT: PERRL, EOMI. His pharynx is clear.
NECK: Supple with mild JVD and no bruits.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm with a [**Known lastname 1105**]/VI systolic
ejection murmur.
ABDOMEN: Soft, nontender, nondistended, no
hepatosplenomegaly, and positive bowel sounds.
EXTREMITIES: Show no varicosities, and he has weak pulses
bilaterally.
NEURO EXAM: Shows him to be alert and oriented x 3 and
grossly intact.
SKIN: Shows no signs of rash, nor any signs of infection.
LABS ON ADMISSION: White count 7.4, hematocrit 37%, platelet
count 250,000, sodium 136, potassium 4.0, chloride 98, CO2
29, BUN 18, creatinine 0.8, INR 1.0.
HOSPITAL COURSE: On [**2192-10-11**], the patient underwent
coronary angiography which showed elevated right and left
heart filling pressures with severe pulmonary hypertension,
severe aortic stenosis with an aortic valve area of 0.7 cm2,
and mitral stenosis with a mitral valve area of 1 cm2. He
had 1+ mitral regurgitation, and ejection fraction of
approximately 50%. His coronary arteries showed his left
main to have mild disease, his left anterior descending
artery with a 50% stenosis after the second diagonal, and the
second diagonal had an ulcerated 70% stenosis. His left
circumflex had 90% stenosis in large OM1, and the right
coronary has 70% stenosis at the ostial PDA. Following the
results of this catheterization, a consult was called to
cardiothoracic surgery service for possible coronary artery
bypass grafting with replacement of aortic and mitral valves.
As part of the patient's preoperative work-up, he was seen by
the dental service who cleared him for surgery. The
remainder of his preoperative work-up was within normal
limits, and on [**2192-10-12**] he underwent coronary artery
bypass grafting x 2 with endoscopically harvested saphenous
vein graft to the OM and endoscopically harvested saphenous
vein graft to the PDA. He also had aortic valve replacement
with a #19 mm bovine pericardial valve, and a mitral valve
replacement with a #27 [**Company 1543**] mosaic porcine valve. The
surgery was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] [**Name (STitle) 14968**]
with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], PA-C and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP as assistants.
The surgery was performed under general endotracheal
anesthesia with a total cardiopulmonary bypass time of 225
minutes, with a crossclamp time of 203 minutes. The patient
tolerated the procedure well and was transferred to the
Cardiac Recovery Unit in normal sinus rhythm and on
dobutamine, Levophed and propofol drips.
Upon arrival in the Intensive Care Unit, the patient was
noted to be hypoxic with respiratory acidosis requiring Ambu
and 100% FIO2 in order to achieve an SPO2 of greater than
90%. Consequently, he underwent a bedside bronchoscopy, for
which he had minimal secretions, but a thick white plug was
suctioned. Following this, his respiratory acidosis did
improve. Throughout the operative night, he had his
dobutamine weaned, and the Levophed was weaned as tolerated.
By the morning of postoperative day #1, he was weaned to
extubate. After extubation, his Levophed was able to be
weaned off, although he did require atrial pacing to keep the
systolic blood pressure greater than 90. The patient
continued to progress and eventually was able to maintain a
blood pressure greater than 90 without pacing, and a heart
rate in the mid to upper 50s to low 60s. He did remain in
the Intensive Care Unit through postoperative day #3
secondary to unavailability of a bed on the surgical floor.
He was out-of-bed to the chair each day and began work with
cardiac rehab and physical therapy. He continued with
physical therapy while on the floor, and on postoperative day
#5 his pacing wires were DC'd without incident. The plan was
for him to be discharged to home on postoperative day #6.
On the evening of postoperative day #5, he went into a rapid
atrial fibrillation with a rapid ventricular response rate in
the 150s. He was given boluses of IV Lopressor up to a total
of 40 mg, and was started on a diltiazem drip to achieve rate
control. He also was being given sotalol which was a
preoperative medication and this was increased to 120 mg [**Hospital1 **]
which was his preoperative dose. He did remain with a heart
rate in the 130s-150s throughout the overnight period despite
increasing the diltiazem drip up to a maximum of 20 mg.
On postoperative day #6, the EP service was consulted, and it
was planned that he would go for cardioversion on that day.
Prior to being taken to the EP Lab for cardioversion, he
spontaneously converted to normal sinus rhythm with a rate in
the low-60s, and this was following approximately a [**5-19**]
second pause. He has since maintained normal sinus rhythm at
a rate of 66, and continues on his sotalol 120 mg [**Hospital1 **]. He
has passed to level 5 with physical therapy, having climbed
the stairs, and is ready to be discharged to home today.
DISCHARGE EXAM: Lungs clear to auscultation bilaterally.
Heart - regular rate and rhythm. Abdomen is soft, nontender,
nondistended, positive bowel sounds. His extremities show no
clubbing, cyanosis or edema. His wounds are clean, dry and
intact, and the sternum is stable.
DISCHARGE LABS: White count 10.1, hematocrit 29.8%,
potassium 4.4, blood glucose 150. His previous electrolytes
were all within normal limits. His discharge chest x-ray
shows a very small sliver of a right apical pneumothorax
which has been stable for several days. Otherwise, his chest
x-ray is clear with no signs of effusion.
DISCHARGE STATUS: To home. He will be discharged in good
condition.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, mitral stenosis, aortic stenosis,
status post aortic valve replacement, mitral valve
replacement, and coronary artery bypass grafting x 2.
2. Postoperative atrial fibrillation.
3. Human immunodeficiency virus infection.
4. Anemia.
5. Reflux.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg po qd.
2. Actos 45 mg po qd.
3. Lamivudine 150 mg po bid.
4. Lipitor 40 mg po qd.
5. Protonix 40 mg po qd.
6. Efavirenz 600 mg po q hs.
7. Tenofovir 300 mg po qd.
8. Stavudine 40 mg po bid.
9. Lisinopril 5 mg po qd.
10.Sotalol 120 mg po bid.
11.Lasix 20 mg po qd x 7 days.
12.Potassium chloride 20 mEq po qd x 7 days.
FOLLOW-UP: He should follow-up with Dr. [**Last Name (STitle) **] in [**2-16**] weeks,
with Dr. [**Last Name (STitle) 1911**] in 1 week, and with Dr. [**Last Name (STitle) **] in 4
weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 22592**]
MEDQUIST36
D: [**2192-10-19**] 11:57
T: [**2192-10-19**] 11:02
JOB#: [**Job Number 22593**]
|
[
"42731",
"41401",
"4168"
] |
Admission Date: [**2206-6-13**] Discharge Date: [**2206-6-17**]
Date of Birth: [**2152-7-13**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Valium / Allopurinol
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
respiratory distress
.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
53 year old woman with hypertension, end-stage renal disease on
hemodialysis, atrial fibrillation, diasolic CHF (preserved EF),
pulmunary HTN, and COPD, with recent admission for SVC syndrome
during which she received catheter based tPA, who was brought to
the ED from rehab after her hemodialysis catheter had fallen
out. She was was brought to the angio suite where she had a
right IJ hemodialysis catheter advanced into the right atrium.
She subsequently complained of dyspnea, became profoundly
hypoxic (O2 sat 50s), and had a respiratory code initiated.
.
The patient was admitted from [**5-30**] through [**6-10**] with facial
swelling. She was found to have an SVC clot and received
catheter based tPA overnight. The following day ([**6-3**]) she
underwent thrombectomy and dilatation of the SVC.
Post-thrombectomy she had good flow in her SVC. On [**6-7**] she had
acute dyspnea, at which time she had a CTA which did not
demonstrate any PE, and demonstrated decreased collaterals,
indicative of resolution of SVC clot. It did, however,
demonstrate a new right upper lobe infiltrate. She was started
on ciprofloxacin and discharged to rehab to complete a 7 day
course.
.
At rehab her dialysis catheter apparently fell out on the day of
admission. She was brought to the ED, from which she went to the
angio suite after getting 2 units of FFP. In the angio suite
they reintroduced a hemodialysis line through the old tunneled
site in the right IJ. The wire advanced with ease, as did the
catheter. While suturing in the catheter after the procedure the
patient acutely complained of inability to breath, after which
point her O2 saturation dropped to the 50s on room air. She
received nebulizer treatment several times without effect. A
code blue was called. Hemodynamically she was stable throughout,
with systolic BP 150-220, HR 120-140. She had a right femoral
central line placed. She was difficult to bag, and after
intubation her peak inspiratory pressures were noted to be in
the 50s and she was therefore given bag mask ventilation until
she arrived in the CCU. Post-intubation CXR demonstrates
placement of the HD line relatively low, almost RV, with dense
infiltrate throughout the right lung.
.
She was admitted to the MICU and remained intubated until
[**2206-6-14**] when she was extubated. It was felt her respiratory
decompensation was due to pneumonia, and her antibiotics
coverage was expanded to Meropenem/Vancomycin. She also had a
chest CT angiogram of the chest which showed RUL/RLL pneumonia
without evidence of PE. On presentation now she is sating 100%on
2L NC. Afebrile for 24 hours and w/o complaints.
.
Past Medical History:
1. HTN
2. ESRD ([**3-7**] HTN), on HD since [**5-/2205**]
3. Atrial fibrillation s/p DCCV (dx 2 years ago)
4. Diastolic CHF with preserved EF, PCWP 32 on cath [**2201**]
(followed by Dr. [**First Name (STitle) 437**]
5. PVD s/p B/L fem-[**Doctor Last Name **]
6. Pulmunary HTN
7. Small secundum type atrial septal defect
8. COPD
9. Gout
10. Complicated left parapneumonic effusion s/p VATS drainage
[**2205**]
11. h/o Right-sided ovarian teratoma (s/p resection)
12. h/o Splenic Infarct
13. s/p BTL [**2179**]
14. h/o PPD+ (per old discharge summary)
15. h/o MRSA line infection
16. s/p fibroid resection
Line history:
s/p RSC X 3
s/p LSC X 2
s/p resection of infected graft in L arm
s/p fistula placement in L arm (still maturing)
Social History:
Works as a school bus monitor, lives with her husband in [**Name (NI) **],
has 5 kids. 75 pack yr smoking hx, quit 7 yrs ago. [**2-4**] glasses
of wine/day, no injection drugs. H/o cocaine use in the 80s.
Family History:
Mother had MI at age 25, died at 26. Father died of renal
disease [**3-7**] HTN. Mother of 5. One son was murdered. Another
son in jail. Her daughter (36) has depression. Her son (32)
and daughter (30) are healthy.
Physical Exam:
99.4, 114/59, 93, on AC 450 x 14, 100%, PEEP 5. Pip 44 pplat 27.
GENERAL: Obese african american female appearing comfortable,
awake on the vent, nodding yes and no to questions.
HEENT: Pupils equal, moist mucous membranes.
COR: RR, normal rate, no murmurs.
LUNGS: Bilateral coarse breath sounds.
ABDOMEN: Obese, normoactive bowel sounds, soft.
EXTR: no CCE
.
Pertinent Results:
IMAGING:
CTA 5/11/07:1. Status post endotracheal intubation.
2. Findings suggest mild upper tracheal stenosis, which could be
related to prior intubation.
3. Evidence of pneumonia in the right upper and lower lobes.
4. Findings suggest left subclavian artery stenosis near its
origin
.
SVC venogram [**6-3**]: IMPRESSION:
1. SVC venogram post TPA check demonstrated persistent clot and
stenosis in the brachiocephalic vein/ SVC.
2. Mechanical thrombectomy performed with AngioJet and
angioplasty with 10 mm balloon with good angiographic results.
3. A final venogram demonstrates free flow of contrast through
the SVC, with small residual clot.
.
CTA [**6-7**]: IMPRESSION: Since [**2206-5-30**],
1. No evidence of pulmonary embolus.
2. New ground-glass opacities in the right upper lobe that could
represent a combination of asymmetric pulmonary edema and
infection.
3. New small bilateral pleural effusions.
4. Interval resolution of multiple collaterals in the right
upper chest and neck suggesting that the previous SVC
obstruction has resolved.
[**2206-6-13**] 07:43PM TYPE-ART PO2-93 PCO2-48* PH-7.40 TOTAL
CO2-31* BASE XS-3 INTUBATED-INTUBATED
[**2206-6-13**] 07:43PM O2 SAT-97
[**2206-6-13**] 04:20PM LACTATE-0.9
[**2206-6-13**] 02:53PM GLUCOSE-111* UREA N-33* CREAT-5.5* SODIUM-141
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-29 ANION GAP-18
[**2206-6-13**] 02:53PM ALT(SGPT)-15 AST(SGOT)-23 LD(LDH)-226
CK(CPK)-62 ALK PHOS-92 TOT BILI-0.5
[**2206-6-13**] 02:53PM CK-MB-NotDone cTropnT-0.07*
[**2206-6-13**] 02:53PM CALCIUM-9.9 PHOSPHATE-5.7*# MAGNESIUM-2.5
[**2206-6-13**] 02:53PM WBC-13.0* RBC-2.85* HGB-8.4* HCT-25.4* MCV-89
MCH-29.6 MCHC-33.3 RDW-16.6*
[**2206-6-13**] 02:53PM PLT COUNT-227
[**2206-6-13**] 02:53PM PT-20.5* PTT-37.3* INR(PT)-2.0*
[**2206-6-13**] 01:10PM PO2-25* PCO2-90* PH-7.13* TOTAL CO2-32* BASE
XS--3
[**2206-6-13**] 01:10PM LACTATE-4.0* K+-4.1
[**2206-6-13**] 01:10PM O2 SAT-23
[**2206-6-13**] 05:50AM GLUCOSE-94 UREA N-28* CREAT-4.9*# SODIUM-138
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-30 ANION GAP-15
[**2206-6-13**] 05:50AM CK(CPK)-56
[**2206-6-13**] 05:50AM CK-MB-2 cTropnT-0.02*
[**2206-6-13**] 05:50AM WBC-8.7 RBC-3.11* HGB-9.0* HCT-27.7* MCV-89
MCH-29.1 MCHC-32.6 RDW-17.0*
[**2206-6-13**] 05:50AM NEUTS-64.6 LYMPHS-16.6* MONOS-5.1 EOS-12.6*
BASOS-1.2
[**2206-6-13**] 05:50AM PT-25.2* PTT-33.1 INR(PT)-2.5*
[**2206-6-12**] 06:30AM PT-23.8* INR(PT)-2.4*
Brief Hospital Course:
53 year old female with hypertension, end-stage renal disease on
hemodialysis, atrial fibrillation, diasolic CHF (preserved EF),
pulmunary HTN, and COPD with recent admission for SVC syndrome
during which she received catheter based tPA, who comes to the
MICU after hypoxic respiratory failure shortly after a
replacement of a right IJ tunneled dialysis line, found to have
increased/new infiltrates in the right lung but no PE on
admission CTA of chest. Pt was initally intubated and in ICU.
She was started on broad spectrum ABX HD1 and was dialysed via
new catheter. After fluid removal via HD per the renal service,
she was able to be extubated evening of HD1. Bronchoscopy
[**2206-6-13**] demonstrated mucous plugging and rare blood. Her
antibiotic regimen was changed to IV Vanomycin and Meropenam
renally dosed for a 8 day course- complete on [**2206-6-20**]. She was
maintained on Albuterol/Iprtrapium NEBs and inhalers and on HD 2
was sating 100%on 2L NC. She was transferred to a regular
medical floor in stable condition. She had repeat Hemodialysis
on HD 4 and was sating well on RA.
Medications on Admission:
Fluticasone-Salmeterol 100-50 mcg/Dose One Inhalation [**Hospital1 **]
Oxycodone-Acetaminophen 5-325 mg PO Q6H PRN
Pantoprazole 40 mg PO Q24H
Sevelamer 1200 mg PO W/ BREAKFAST, 1600 mg W/ EACH SNACK, 2400mg
W/ LUNCH AND DINNER
Aspirin 81 mg PO DAILY
Albuterol Sulfate NEB Q6H PRN
Ipratropium Bromide NEB Q6H PRN
Warfarin 5 mg PO HS
Atorvastatin 20 mg PO DAILY
Oxycodone-Acetaminophen 5-325 mg PO Q4-6H PRN
Propafenone 225 mg PO TID
B Complex-Vitamin C-Folic Acid 1 mg PO DAILY
Zolpidem 5 mg PO QHS PRN
Carvedilol 6.25 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Aspiration Pneumonia.
2. Respiratory Failure.
3. HD Catheter Dislodged.
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: 2000cc
Please present to the hospital or call your primary care
physician if you have fever/chills, chest pain/shortness of
breath, headache/dizzness.
Followup Instructions:
You have the following appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2206-6-19**] 1:40
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2206-6-21**] 3:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2206-7-10**] 10:30
|
[
"51881",
"5070",
"40391",
"4280"
] |
Admission Date: [**2125-6-20**] Discharge Date: [**2125-6-26**]
Date of Birth: [**2080-12-19**] Sex: F
Service: MEDICINE
Allergies:
Lortab
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Tylenol overdose
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
44F w/ PMH of depression with psychotic features & PTSD s/p
multiple suicide attempts who presented to Southern [**Hospital 1727**]
Medical Center after ingesting 200 extra-strength Tylenol
tablets. Around noon [**2125-6-18**] she drank 60mL of isopropyl
alcohol, 4 handfuls of Aspirin, "a couple handfuls" of women's
MV's and approximately 200 extra-strength Tylenol. Her intent
was to kill herself because she apparently cheated on her
fiance. After ingesting the above products, she went to work
but came home with an upset stomach. That evening she began
having nausea and vomiting. She refused to come to the hospital,
but eventually consented.
.
On arrival to Southern [**Hospital 1727**] Medical Center, she was somewhat
sleepy but oreiented x3. Initial AST 129, ALT 132, Tylenol level
142, INR 1.3, Tbili 1.0, salicylate <5, alcohol <10, serum
aceton negative and lipase 17. Urine drug screen was negative,
and ABG [**Last Name (un) **] dpH 7.45 PCO2 30, PO2 80. She was immediately
started on IV N-acetylcysteine at 100mg/kg in 1 L D5W. At the
end of 20 hours AST and ALT noted to be 2669 and 2597
respectively with APAP level of 11. INR increased to 2.2. NAC
infusion was continued at the same rate for 16 hour infusion
(unclear how much of 16 hour infusion was provided) and
transferred to [**Hospital1 18**] for further care. Other labs at time of
transfer include Total bili 1.5, alk phos 9.4, album in 3.7.
.
On the floor, pt is in NAD.
Past Medical History:
- depression, s/p hospitalization in [**3-/2121**] with psychotic
feautres and SI. Readmitted [**8-/2122**] for depression. Previous
suicide attempt in [**2120**].
- PTSD
- OSA w/ poor compliance of CPAP
- IBS
- hyperlipidemia
Social History:
Social History: Works at [**Company **]. Engaged.
- Tobacco: None
- Alcohol: Very rare
- Illicits: None
Family History:
Brother suicide at 16. Other brother with depression.
Physical Exam:
ON ADMISSION:
Vitals: T: BP:144/100 P:109 R:18 O2:96
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic. Regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: obese. soft, non-distended, bowel sounds present, no
rebound tenderness or guarding. Mild TTP in RUQ and LLQ. Liver
edge palpable and slightly nodular about 2 cm below costal
margin. Fungal rash under pannus.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOX3. CNII-XII focally in tact. 5/5 strength throughout.
2+ DTR in patellar and BR regions B/L. No dysdiachokinesia. No
asterixis.
ON DISCHARGE:
Vitals: Tm 98.8, Tc98.3, BP 138/62 (138-160/62-101), HR 80s-90s,
18, 98/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese. soft, non-distended, bowel sounds present, non
tender, no rebound tenderness or guarding.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: grossly intact
Pertinent Results:
STUDIES:
[**2125-6-20**] CXR: The lung volumes are normal. Borderline size of the
cardiac
silhouette without pulmonary edema. No pneumonia. No pleural
effusions. No
pneumothorax.
[**2125-6-25**] CXR: There are no focal pulmonary abnormalities to
suggest pneumonia. Mild cardiomegaly is chronic and upper lobe
pulmonary vascular engorgement is persistent, but there is no
pulmonary edema or pleural effusion.
[**2125-6-26**] 07:15AM BLOOD WBC-11.1* RBC-3.99* Hgb-12.2 Hct-35.3*
MCV-88 MCH-30.6 MCHC-34.6 RDW-14.8 Plt Ct-322
[**2125-6-25**] 07:30AM BLOOD WBC-15.0* RBC-3.97* Hgb-12.3 Hct-35.8*
MCV-90 MCH-30.9 MCHC-34.3 RDW-14.8 Plt Ct-371
[**2125-6-24**] 07:30AM BLOOD WBC-13.1* RBC-4.02* Hgb-12.6 Hct-36.6
MCV-91 MCH-31.3 MCHC-34.5 RDW-14.8 Plt Ct-384
[**2125-6-23**] 07:35AM BLOOD WBC-11.1* RBC-4.06* Hgb-12.1 Hct-36.4
MCV-90 MCH-29.8 MCHC-33.2 RDW-14.7 Plt Ct-318
[**2125-6-22**] 07:45AM BLOOD WBC-10.4 RBC-4.10* Hgb-12.2 Hct-36.9
MCV-90 MCH-29.8 MCHC-33.1 RDW-14.6 Plt Ct-284
[**2125-6-21**] 03:07AM BLOOD WBC-11.6* RBC-4.27 Hgb-13.3 Hct-37.9
MCV-89 MCH-31.1 MCHC-35.0 RDW-14.3 Plt Ct-258
[**2125-6-20**] 08:15PM BLOOD WBC-15.7* RBC-4.62 Hgb-14.3 Hct-40.4
MCV-88 MCH-31.0 MCHC-35.4* RDW-14.3 Plt Ct-333
[**2125-6-25**] 07:30AM BLOOD Neuts-73* Bands-0 Lymphs-13* Monos-6
Eos-8* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2125-6-20**] 08:15PM BLOOD Neuts-92.5* Lymphs-4.7* Monos-1.8*
Eos-1.0 Baso-0.1
[**2125-6-25**] 07:30AM BLOOD PT-12.5 PTT-25.9 INR(PT)-1.1
[**2125-6-24**] 07:30AM BLOOD PT-12.4 PTT-26.2 INR(PT)-1.0
[**2125-6-22**] 07:45AM BLOOD PT-15.8* PTT-28.1 INR(PT)-1.4*
[**2125-6-21**] 06:35PM BLOOD PT-20.6* PTT-29.4 INR(PT)-1.9*
[**2125-6-21**] 03:15PM BLOOD PT-21.0* PTT-28.9 INR(PT)-1.9*
[**2125-6-21**] 11:40AM BLOOD PT-22.7* PTT-30.3 INR(PT)-2.1*
[**2125-6-21**] 03:07AM BLOOD PT-25.6* PTT-32.5 INR(PT)-2.4*
[**2125-6-20**] 08:15PM BLOOD PT-29.4* PTT-35.0 INR(PT)-2.9*
[**2125-6-26**] 07:15AM BLOOD Glucose-115* UreaN-12 Creat-0.6 Na-139
K-4.6 Cl-102 HCO3-30 AnGap-12
[**2125-6-23**] 07:35AM BLOOD Glucose-112* UreaN-10 Creat-0.5 Na-138
K-3.9 Cl-103 HCO3-26 AnGap-13
[**2125-6-21**] 11:40AM BLOOD Glucose-129* UreaN-8 Creat-0.3* Na-138
K-3.2* Cl-103 HCO3-25 AnGap-13
[**2125-6-20**] 08:15PM BLOOD Glucose-225* UreaN-11 Creat-0.4 Na-140
K-3.6 Cl-105 HCO3-24 AnGap-15
[**2125-6-26**] 07:15AM BLOOD ALT-656* AST-46* LD(LDH)-198 AlkPhos-83
TotBili-0.4
[**2125-6-25**] 07:30AM BLOOD ALT-987* AST-58* LD(LDH)-221 AlkPhos-92
TotBili-0.5
[**2125-6-24**] 07:30AM BLOOD ALT-1588* AST-85* LD(LDH)-222 AlkPhos-95
TotBili-0.5
[**2125-6-23**] 07:35AM BLOOD ALT-2167* AST-177* LD(LDH)-235 AlkPhos-99
TotBili-0.7
[**2125-6-22**] 07:45AM BLOOD ALT-3430* AST-511* LD(LDH)-310*
AlkPhos-107* TotBili-1.2
[**2125-6-21**] 06:35PM BLOOD ALT-4440* AST-1339* LD(LDH)-521*
AlkPhos-107* TotBili-1.3
[**2125-6-21**] 11:40AM BLOOD ALT-5302* AST-2353* LD(LDH)-980*
AlkPhos-109* TotBili-1.4
[**2125-6-21**] 03:07AM BLOOD ALT-6500* AST-4171* LD(LDH)-2750*
AlkPhos-102 TotBili-0.8
[**2125-6-20**] 08:15PM BLOOD ALT-8720* AST-7982* LD(LDH)-[**Numeric Identifier **]*
AlkPhos-114* TotBili-0.7
[**2125-6-26**] 07:15AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.0
[**2125-6-24**] 07:30AM BLOOD Calcium-9.2 Phos-4.6*# Mg-1.9
[**2125-6-22**] 07:45AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.2
[**2125-6-21**] 11:40AM BLOOD Calcium-7.7* Phos-1.1* Mg-1.8
[**2125-6-20**] 08:15PM BLOOD Albumin-4.1 Calcium-8.8 Phos-1.1* Mg-2.1
Iron-170*
[**2125-6-20**] 08:15PM BLOOD calTIBC-280 Ferritn-[**Numeric Identifier 88737**]* TRF-215
[**2125-6-23**] 07:35AM BLOOD TSH-1.0
[**2125-6-20**] 08:15PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2125-6-20**] 08:15PM BLOOD Acetmnp-NEG
[**2125-6-20**] 08:15PM BLOOD HCV Ab-NEGATIVE
[**2125-6-20**] 10:03PM BLOOD Type-ART pO2-89 pCO2-35 pH-7.46*
calTCO2-26 Base XS-1
[**2125-6-20**] 10:03PM BLOOD Lactate-1.7
[**2125-6-21**] 03:07AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2125-6-21**] 03:07AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2125-6-20**] 8:01 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2125-6-23**]**
MRSA SCREEN (Final [**2125-6-23**]): No MRSA isolated.
Brief Hospital Course:
44 y/o F with history of severe depression with psychotic
features s/p multiple suicide attempts who presented after
suicide attempt via ingestion of multiple agents including MVI,
APAP, and isopropyl alcohol.
1. Tylenol Overdose with ASA/Multivitamin/isopropyl alcohol
ingestion:
- Presenting levels of APAP 24 hours after ingestion (142)
placed patient at extremely high risk of hepatotoxicity, with
markedly elevated enzymes. She was continued on NAC and her LFTs
trended down. Her INR peaked at 2.6 and subsequently trended
down. During her hosptialization she had no evidence of
encephelopathy or renal failure. By the time of discharge her
INR had normalized to 1.1 and transaminases had trended down
below 1000. The consulting hepatology team did not feel that
further trending of LFTs or hepatology follow up was necessary
and patient was discharged to an inpatient psychiatric facility.
# Depression with psychotic features, Suicidal Ideation,
Suicidal Ingestion:
Patient had a history of serious depression with multiple
suicide attempts. Given this most recent attempt she was kept on
a 1:1 sitter. She denied active SI during hospitalization. Her
antidepressants were held in the setting of her acute liver and
potential renal toxicity. Psych evaluated the patient, and
agreed to admit her to the psychiatry unit once medically
stable. She was discharged to inpatient psychiatry back on her
home regimen of thiothixene, prozac, and trazodone.
# Hyperlipidemia:
Patient's home statin was held given hepatotoxicity. This should
be restarted as an outpatient once LFTs have fully normalized.
# Leukocytosis:
Patient had a mild leukocytosis towards the end of her
hospitalization. She remained afebrile and culture data showed
no growth. She did have a runny nose and mild non-productive
cough so a CXR was done which was negative for pneumonia. Her
leukocytosis and symptoms were attributed to a URI. Leukocytosis
was downtrending on discharge. The thought was that most likely
these were due to the resolving hepatonecrosis.
# Benign Hypertension:
Patient was started on amlodipine for hypertension with blood
pressures in the 150s-160s. She was asymptomatic while in house.
Her blood pressures should be monitored as an outpatient.
Full Code
Medications on Admission:
- Thiothixene 5mg PO QHS
- Prozac 60mg daily
- oxybutynin ER 10mg QHS
- trazodone 150mg QHS
- simvastatin 20mg QHS
- ASA 81mg daily
Discharge Medications:
1. trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. oxybutynin chloride 10 mg Tablet Extended Rel 24 hr Sig: One
(1) Tablet Extended Rel 24 hr PO at bedtime.
3. thiothixene 5 mg Capsule Sig: One (1) Capsule PO at bedtime.
4. Prozac 20 mg Capsule Sig: Three (3) Capsule PO once a day.
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day. Tablet, Chewable(s)
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Primary:
Acetaminophen overdose
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 1968**],
You were admitted to the [**Hospital1 18**] with a tylenol overdose. You were
treated with a medication called NAC and your liver and kidney
function was closely monitored. Your condition improved. You
were seen by the psychiatry team who recommended an inpatient
hospitalization to treat your depression particularly given your
suicide attempt with the overdose.
We have made the following changes to your medications:
- STOP taking simvastatin until you follow up with your primary
care doctor
- START taking amlodipine for your high blood pressures
It was a pleasure taking care of you. We wish you a speedy
recovery.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 88738**], your primary care doctor, at [**Telephone/Fax (1) 88739**] to schedule an appointment for follow one week after you
are discharged from your psychiatric rehabilitation.
Completed by:[**2125-6-27**]
|
[
"2724",
"4019"
] |
Admission Date: [**2127-4-23**] Discharge Date: [**2127-4-28**]
Date of Birth: [**2077-9-13**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 49 year old male with
known Hepatitis C virus cirrhosis, complicated by known
esophageal and gastric varices, who presents after vomiting
one cup of blood at 7 a.m. the morning of admission. He had
near syncope and melena but denied abdominal pain. He
initially presented to [**Hospital3 3765**] where he was found to
be orthostatic. His hematocrit there was 32 and he was
started on Octreotide drip and then transferred to our
hospital.
On arrival here, his heart rate was 92; his blood pressure
was 105/75; no orthostatics were measured. He was
immediately brought to the gastrointestinal suite, where an
initial esophagogastroduodenoscopy revealed a massive amount
of blood in the stomach. An NG tube was dropped and lavaged
to clear after two liters of normal saline. A repeat
esophagogastroduodenoscopy showed non-bleeding esophageal
varices and a large clot overlying the stomach varices. It
was decided to admit the patient directly to the Medical
Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Hepatitis C cirrhosis diagnosed in [**2120**], status post
esophagogastroduodenoscopy in [**2126-9-21**], which showed
Grade I esophageal and gastric varices. He is listed at the
[**Hospital 9940**] Clinic for a transplant. He has failed ribavirin and
Interferon therapy. He has a history of hyperkalemia.
MEDICATIONS:
1. Nadolol 60 mg p.o. q. day.
2. Colchicine 0.6 mg p.o. twice a day.
3. Ursodiol 600 mg p.o. twice a day.
4. Aldactone 100 mg p.o. q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He denies alcohol. He lives with his wife
and three children. He works in computers.
PHYSICAL EXAMINATION: Vital signs on admission were not
recorded. On physical examination, HEENT: Extraocular
motions intact. Pupils equally round and reactive to light.
Anicteric sclerae. Oropharynx dry. No blood in the mouth.
Neck: No jugular venous distention. Lungs are clear to
auscultation bilaterally. Cardiovascular: Normal S1, S2,
regular rate and rhythm; II/VI systolic murmur. Abdomen
mildly tender diffusely. The hepatic edge is palpated three
fingerbreadths below the costal margin. There were present
bowel sounds. Extremities were without edema. No asterixis.
Alert and oriented times three.
LABORATORY: At the outside hospital, the hematocrit was
33.7, white blood cell count was 8.4 and platelets were 126.
Chem-7 at the outside hospital was sodium 135, potassium 5.7,
chloride 102, bicarbonate 27, BUN 30, creatinine 1.1, glucose
95.
Calcium was 8.9, albumin 2.4, ALT 68, AST 84, alkaline
phosphatase 115, total bilirubin 2.2, INR 1.25, PTT 32.5.
EKG showed sinus rhythm at 70 beats per minute, no peaked T
waves.
Upon arrival to our hospital, hematocrit was 31.0, the
potassium was 5.9 and the INR was 1.4. Total bilirubin was
2.6. Albumin was 2.9.
IMPRESSION: This is a 49 year old male with Hepatitis C
cirrhosis who is admitted with upper GI bleed secondary to
gastric variceal bleeding.
HOSPITAL COURSE: On arrival to the Intensive Care Unit, the
Octreotide drip was continued. Vitamin K and fresh frozen
plasma were given to correct his coagulopathy. Intravenous
Ciprofloxacin was given for SBP prophylaxis. The initial
plan had been to go for a TIPS placement the next day, but
that evening, the patient developed nausea and dropped his
blood pressure to 50/palpable. His hematocrit dropped to 28
and ultrasound of the abdomen revealed a stomach filled with
fluid.
The patient therefore went emergently to Interventional
Radiology for TIPS placement, which was performed without
complications. He received two units of packed red blood
cells which bumped his hematocrit up to 38; there was no
further bleeding. Urine output remained adequate. Protonix,
Ciprofloxacin and Octreotide were continued, and changed to
p.o. once he was started on a p.o. diet. Ultimately,
Octreotide was discontinued and Lactulose was started.
He was transferred to the General Medical Floor where he did
well. His hematocrit was stable. Nadolol, Aldactone,
Ursodiol and Colchicine were re-instated. He was discharged
home on the following medications.
DISCHARGE MEDICATIONS:
1. Ursodiol 600 mg p.o. twice a day.
2. Colchicine 0.6 mg p.o. twice a day.
3. Aldactone 100 mg p.o. q. day.
4. Nadolol 60 mg p.o. q. day.
5. Ciprofloxacin 500 mg p.o. twice a day for five days.
DISCHARGE INSTRUCTIONS:
1. He is to maintain a low salt diet.
2. He is to follow-up in one week with the Liver Center.
3. It was recommended that he have a repeat upper endoscopy
and echocardiogram as an outpatient shortly.
DISCHARGE STATUS: To home.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Upper gastrointestinal bleed secondary to gastric
varices.
2. Anemia, requiring transfusion.
3. Thrombocytopenia.
4. End-stage liver disease secondary to Hepatitis C.
5. Hyperkalemia.
6. Intubation for airway protection.
[**Doctor Last Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 5708**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2127-6-25**] 17:50
T: [**2127-6-26**] 12:20
JOB#: [**Job Number 33254**]
|
[
"4019"
] |
Admission Date: [**2186-5-30**] Discharge Date: [**2186-7-14**]
Date of Birth: [**2123-11-1**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Pt fell, struck head and siezed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PT was s/p fall and after fall had a siezure,
Past Medical History:
Afib/Aflutter, HTN, CVA with subsequent siezures
Social History:
+EtOH
Physical Exam:
On discharge:
HEENT: Atraumatic, PERRL, EOMI
Neck: Cervical collar in place
Chest: CTAB
Cardiac: irregular rhythm, rate of approx. 90
Abd: soft, NT/ND +BS
Ext: no edema
Pertinent Results:
[**2186-7-11**] 10:10AM BLOOD WBC-7.3 RBC-4.32* Hgb-14.9 Hct-40.9
MCV-95 MCH-34.4* MCHC-36.4* RDW-13.5 Plt Ct-258
[**2186-7-12**] 04:54AM BLOOD Glucose-92 UreaN-10 Creat-0.8 Na-140
K-4.3 Cl-101 HCO3-30* AnGap-13
[**2186-7-12**] 04:54AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.0
[**2186-5-30**] 10:27PM BLOOD PT-14.1* PTT-20.7* INR(PT)-1.3
[**2186-5-30**] 10:27PM BLOOD Glucose-144* UreaN-11 Creat-0.9 Na-137
K-4.3 Cl-99 HCO3-18* AnGap-24*
[**2186-5-30**] 10:27PM BLOOD CK(CPK)-387* Amylase-52
[**2186-5-31**] 12:40AM BLOOD Albumin-3.8 Calcium-8.2* Phos-2.3* Mg-1.6
[**2186-5-30**] 10:27PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2186-5-31**] 01:23AM BLOOD Type-ART pO2-129* pCO2-33* pH-7.47*
calHCO3-25 Base XS-1
Brief Hospital Course:
After his fall and siezure, pt was admitted to Trauma surgery,
was found to have a question of widening of atlantooccipital
joint so was put in a cervical collar, during his stay the
patient was also noted to have an irregular heart rate that
would occasionally increase to the 150-160 but then decrease to
90-100, the patient remained completely assymptomatic during
these episodes, Cardiology was consulted and lopressor was
increased up to a dose of 50 TID with his pressures tolerating
this dose at 100-110/70-80 on d/c. Pt continued to have
transient episodes of tachycardia, but was always asymptomatic
during these episodes and these episodes always subsided within
minutes. These findings were discussed with in house cardiology
and his primary care physician who were all comfortable with his
discharge and close follow up with his primary care physician.
[**Name10 (NameIs) **] note the Patient had a mild level of underlying dementia
which precluded him from going home alone and was discharged
with a friend.
Radiology positive findings:
CT neck:
IMPRESSION: No fractures. Apparent malalignment of C1 ring and
dens is
probably due to patient positioning, although rotatory
subluxation cannot be
excluded on the basis of this study.
Medications on Admission:
Pt non-compliant on Coumadin
atenolol
lisinopril
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO Q 8H (Every 8 Hours).
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
fall resulting in cervical ligamentous injury
A fib
Discharge Condition:
Stable
Discharge Instructions:
Follow up with you primary care physician, [**Name10 (NameIs) 61874**] collar at all
times, take medications as perscribed
Followup Instructions:
Follow up with your Dr. [**First Name (STitle) **] on Thursday [**7-20**] at 4:15pm,
they will call to move up appointment if there are
cancellations. Wear cervical collar for a total of 8wks, discuss
setting up an orthopaedics appointment with primary care
physician for collar removal.
|
[
"42731",
"4019",
"2720"
] |
Admission Date: [**2188-3-14**] Discharge Date: [**2188-5-10**]
Date of Birth: [**2105-3-31**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Acute R knee pain; R knee infection
Major Surgical or Invasive Procedure:
[**2188-3-14**]: ortho - I&D of R knee and polyethylene exchange
[**2188-3-27**]: ortho - I&D of R knee wound and manipulation under
anesthesia
[**2188-4-4**]: plastics - R knee gastrocnemius flap
[**2188-4-24**]: thoracics - PEG placement
[**2188-4-24**]: thoracics - tracheostomy
[**2188-4-29**]: PICC placement
[**2188-5-6**]: interventional radiology - post-pyloric dobhoff
History of Present Illness:
Mr. [**Known lastname 79747**] had a total knee arthroplasty performed on [**2188-3-4**]
and did very well postoperatively until the day before admission
when he had acute onset of R knee pain. He had a temperature of
101 at home and was taken to an OSH ED where he was transferred
to [**Hospital1 18**].
Past Medical History:
HTN, Peripheral neuropathy, elevated cholesterol, and
osteoarthritis, carotid bruit, right carotid has between 16 and
49% ICA stenosis, same on the left, both with antegrade flow on
this [**8-/2187**] study. R TKA [**2188-3-4**]
Social History:
He is a retired executive from the Emhart Corporation. He is a
widower. He lives in [**State 3914**], a former smoker, smoked up to two
packs per day, but quit after smoking for about 45 years. He
drinks two glasses of alcohol per day.
Family History:
Positive for cancer in his brother and in-laws. Mother had
cardiomyopathy and cardiac hypertrophy, father had a CVA, lung
disease in a brother, COPD. [**Name2 (NI) **] disease in a brother.
Daughter has skin cancer.
Physical Exam:
At the time of discharge:
Satting 96% on trach mask
VS: Tm 99.6, Tc 99, HR 78, BP 118/44, RR 32
GEN: awake and alert, responds to simple commands, no acute
distress
HEART: RRR, distant S1/S2
LUNGS: coarse diffuse breath sounds
[**Last Name (un) **]: soft, nontender, PEG tube clamped off with trace amount of
yellow output
EXTREM: non-edematous, no rashes. Dressing in place over right
knee.
Pertinent Results:
[**2188-3-14**] 01:40AM BLOOD WBC-19.7*# RBC-3.15* Hgb-10.0* Hct-30.1*
MCV-96 MCH-31.9 MCHC-33.3 RDW-14.1 Plt Ct-388#
[**2188-3-15**] 06:20AM BLOOD WBC-15.7* RBC-2.36*# Hgb-7.6* Hct-23.3*
MCV-99* MCH-32.2* MCHC-32.7 RDW-13.9 Plt Ct-261
[**2188-3-16**] 05:50AM BLOOD WBC-11.5* RBC-2.72* Hgb-8.6* Hct-25.6*
MCV-94 MCH-31.7 MCHC-33.7 RDW-14.9 Plt Ct-250
[**2188-3-17**] 04:30AM BLOOD WBC-10.2 RBC-2.80* Hgb-8.8* Hct-26.6*
MCV-95 MCH-31.5 MCHC-33.1 RDW-14.5 Plt Ct-298
[**2188-3-18**] 04:47AM BLOOD WBC-7.7 RBC-2.69* Hgb-8.5* Hct-25.1*
MCV-93 MCH-31.6 MCHC-33.8 RDW-15.1 Plt Ct-337
[**2188-3-19**] 11:00AM BLOOD WBC-7.9 RBC-2.69* Hgb-8.4* Hct-25.5*
MCV-95 MCH-31.1 MCHC-32.8 RDW-15.2 Plt Ct-365
[**2188-3-20**] 06:33AM BLOOD WBC-9.2 RBC-2.77* Hgb-8.6* Hct-26.3*
MCV-95 MCH-31.0 MCHC-32.6 RDW-14.9 Plt Ct-401
[**2188-3-14**] 01:40AM BLOOD Plt Smr-NORMAL Plt Ct-388#
[**2188-3-15**] 06:20AM BLOOD PT-19.4* PTT-38.1* INR(PT)-1.8*
[**2188-3-14**] 01:40AM BLOOD Glucose-125* UreaN-24* Creat-0.9 Na-135
K-4.2 Cl-101 HCO3-22 AnGap-16
[**2188-3-15**] 06:20AM BLOOD Glucose-117* UreaN-33* Creat-1.8* Na-132*
K-4.5 Cl-103 HCO3-20* AnGap-14
[**2188-3-16**] 05:50AM BLOOD UreaN-42* Creat-2.2* Na-132* K-4.1 Cl-104
[**2188-3-17**] 04:30AM BLOOD Glucose-103 UreaN-39* Creat-2.0* Na-137
K-3.9 Cl-110* HCO3-19* AnGap-12
[**2188-3-18**] 04:47AM BLOOD Glucose-114* UreaN-37* Creat-2.1* Na-139
K-4.0 Cl-109* HCO3-23 AnGap-11
[**2188-3-19**] 11:00AM BLOOD Glucose-147* UreaN-31* Creat-1.8* Na-138
K-3.7 Cl-107 HCO3-21* AnGap-14
[**2188-3-20**] 06:33AM BLOOD Glucose-100 UreaN-28* Creat-1.8* Na-138
K-4.0 Cl-107 HCO3-22 AnGap-13
[**2188-3-17**] 04:30AM BLOOD ALT-54* AST-103* LD(LDH)-291* AlkPhos-73
TotBili-2.4*
[**2188-3-19**] 11:00AM BLOOD ALT-37 AST-47* AlkPhos-69 TotBili-2.2*
[**2188-3-15**] 06:20AM BLOOD Calcium-7.4* Phos-3.7 Mg-2.2
[**2188-3-20**] 06:33AM BLOOD Calcium-7.8* Phos-3.0 Mg-2.3
Micro: culture and sensitivities from 4 OR specimens and from ED
aspiration all grew pan sensitive MSSA.
Tissue [**3-14**]: Staph aureus
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Abdomenal ultrasound ([**4-17**]):
1. Normal appearance of the gallbladder and liver
2. Bilateral renal cysts.
3. Single septation and equivocal nodularity in a cyst arising
from the lower pole of the right kidney. No vascular flow seen,
but suggested MRI of the kidney suggested for more definitive
assessment.
Chest x-ray ([**5-4**])
When compared to the prior studies, there has been no
appreciable change. Tracheostomy is appropriately placed and
unchanged. There is again noted areas of confluent opacities
within the left lower and left upper lobes as well as within the
right perihilar and peripheral areas in the right lung. These
are all relatively stable and can be consistent with sequela of
ARDS or more chronic fibrotic changes as described on multiple
previous examinations.
ABG prior to discharge ([**4-10**]): 7.45/35/108
Brief Hospital Course:
The patient was admitted on [**2188-3-14**] after being evaluated in the
ED and having his knee aspirated. Later that day, he was taken
to the operating room by Dr. [**Last Name (STitle) **] for R knee I&D and liner
exchange without complication. Please see operative report for
details. Postoperatively the patient did well. The patient was
initially treated with a PCA followed by PO pain medications on
POD#1. Infectious disease was consulted.
The patient was started preoperatively on vancomycin and this
was continued until culture results returned. His cultures from
the ED joint aspiration and from the OR grew back pan sensitive
MSSA. ID recommended changing antibiotics to Nafcillin, which we
did. They were to start rifampin once LFTs normalized. A PICC
line was placed for long term antibiotics.
He was started on lovenox for DVT prophylaxis starting on the
morning of POD#1. The patient had two drains that were
maintained until POD 2. He was kept in a knee immobilizer for 2
days and then worked with physical therapy. The Foley catheter
was removed without incident. The surgical dressing was removed
on POD#2 and the surgical incision was found to be clean and dry
but with a 4x4 cm area of congested skin overlying the patella
and straddling the incision. This area eventually desquamated
and a beefy red dermal layer was seen below. Plastics was
consulted and we discussed whether a gastroc flap would be
appropriate, ultimately it was decided that we should treat the
wound conservatively and see where the line of demarcation would
be and if there was any viable tissue. Regranex was started to
help with skin growth. The patient returned to the OR on [**3-27**]
for a wound debridment and R knee manipulation under anesthesia.
After the procedure, the regranex was changed to [**Hospital1 **] bacitracin.
During the procedure and through the following days, the wound
began to develop an eschar. As conservative treatment was
failing, plastics was reconsulted. He was taken to the OR on
[**4-4**] with plastic surgery for a gastroc flap; he was sent to the
[**Hospital Unit Name 153**] postop for a transient pressor requirement. He was weaned
from pressors within the first hour in the [**Hospital Unit Name 153**] and was
transferred back to the floor by POD1.
His routine labs showed an elevated creatinine of 2.2.
Nephrology was consulted and it was felt that he had some ATN.
He was hydrated aggressively and creatinine trended back down to
normal.
Additionally he was found to have elevated LFTs with an elevated
Tbili. An ultrasound was done which showed a normal gallbladder
without evidence of obstruction. He did not have any abdominal
pain.
He was transferred to [**Hospital Unit Name 153**] after hypoxia on the floor.
MEDICAL INTENSIVE CARE UNIT HOSPITAL COURSE BELOW:
1. Acute Respiratory Distress:
He was initially placed on 4L nasal cannula and then required
NRB. He was given 40 mg IV lasix on the floor and put out 900 cc
urine prior to transfer with symptomatic relief. On arrival to
the MICU he was speaking in full sentences, comfortable, and
subjectively improved. A CXR was consistent with worsening
pulmonary edema/CHF vs infection. CHF was supported by increased
BNP. He was given additional IV Lasix. Because of concern for
aspiration PNA, he underwent speech and swallow evaluation which
was normal. CE and EKG in the unit were negative for MI. Over
the course of several days, his respiratory distress worsened
requiring BiPAP. His CXR showed interval worsening of
infiltrates and raised concern for ARDS. He was also
intermittantly febrile. He was therefore intubated on [**4-12**] and
treated with Vancomycin and Meropenem for hospital acquired
pneumonia, although no organism was ever isolated. His condition
did not improve for over 12 days and in the interim he was
started on Azithromycin and Flagyl to cover for anerobes and
atypicals. Patient had also been trialed on five day course of
steroids. He ultimately underwent tracheostomy placement, and
over the ensuing days was weaned off the vent and placed on
trach mask. Unfortunately, he had an aspiration event after
coming off the vent and his respiratory status worsened. He was
started back on vanco and Zosyn for HAP/aspiration pna and
should complete an 8-day course of vanco/Zosyn to end on [**5-14**]. At time of discharge, he is maintaining good oxygenation on
trach mask, with high flow oxygen at FiO2 of 50%. Patient had
also been diursed during his hospital course using a lasix drip
to euvolemic state.
2. Septic Knee / Infection:
He had an increasing WBC count while in the unit. He was
continued on meropenem and rifampin while in the unit as per ID
recs. Antibiotics were then changed to levofloxacin and rifampin
for treatment of septic knee. While he was treated for HAP as
above, the Levo and Rifampin were temporarily stopped. However,
these SHOULD BE RESTARTED when he finishes the eight-day course
of vanc/Zosyn as above for HAP. He was seen routinely by
physical therapy. The operative extremity was neurovascularly
intact. After the gastroc flap procedure, he was followed by
plastics. They have recommended that he continue 45 degree
flexion until [**5-9**], at which time he can progress to 90 degree
flexion until [**5-16**], then full range-of-motion as tolerated.
Antibiotics for septic knee should resume with levo 500mg daily
and Rifampin 300mg [**Hospital1 **] on [**5-14**].
3. Hypotension:
Patient had intermittent periods of hypotension requiring use of
levophed. It was unclear if patient's hypotension was related
to sepsis (likely not). At time of discharge, he has been stable
off pressors for over one week with good blood pressures.
4. Gastric Dysmotility / Food and Nutrition:
While in the unit, a PEG tube was placed due to prolonged
intubation and altered mental status. He was started on tube
feeds through the PEG but was noted to have high residuals, in
addition to which he aspirated resulting in pneumonia as
outlined above. There was concern about ileus versus
obstruction, the PEG was placed to suction and he was started on
TPN. CT abdomen with PO contrast showed no obstruction. A
post-pyloric tube was placed and tube feeds started without
complication. The TPN was weaned off. At time of discharge, he
continues on tube feeds. In 4 to 6 weeks, he should follow-up
with thoracics to discuss removal of the post-pyloric tube and
repositioning of the PEG tube into the small bowel. This
procedure must wait until the PEG tube tract has had a chance to
mature, which generally takes 4 to 6 weeks. Note that both the
tracheostomy and PEG tube were placed by the thoracics service
(Dr. [**Last Name (STitle) **].
5. Anemia:
His hematocrit was generally stable in the mid 20s. The cause
for his anemia was thought to be multifactorial in setting of
chronic disease, frequent phlebotomy, and blood loss from
procedures. On the day of discharge, he was transfused one unit
PRBCs for hematocrit of 22.
6. Disposition and Follow-up Plans:
He should follow-up in plastics clinic one week after discharge:
[**Telephone/Fax (1) 4652**]. He should follow-up with Dr. [**Last Name (STitle) **] in orthopedics
clinic in 2 weeks: [**Telephone/Fax (1) 79748**], and should continue Lovenox
until that follow-up. He should follow-up in [**Hospital **] clinic
with Dr. [**Last Name (STitle) 11482**] Pe??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: [**Telephone/Fax (1) 170**]. He should
follow-up in infectious diseases clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
An appointment has been made for [**2188-5-27**] at 10am in the [**Hospital **]
Medical Office Bldg at [**Doctor First Name **] on the ground floor.
Dr. [**Last Name (STitle) **] has requested that all laboratory results be faxed
to infectious disease R.Ns. at [**Telephone/Fax (1) 432**]. All questions
regarding outpatient antibiotics should be directed to the
when clinic is closed.
6. Code Status:
His code status is DNR/DNI, as confirmed with his daughter and
health-care proxy, [**Name (NI) **].
Medications on Admission:
amlodipine 10 mg daily, lisinopril 10 mg daily, simvastatin 40
mg one-half
tablet daily, ascorbic acid 500 mg daily, aspirin 81 mg daily,
cyanocobalamin 500 mcg daily, glucosamine chondroitin daily,
ibuprofen 600 mg daily, multivitamin with [**Last Name (LF) **], [**First Name3 (LF) 14595**] lipoic
acid, and vitamin E.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: do not take more than 4
grams of tylenol per day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
6. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily) for 3 weeks.
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): Start on [**5-15**] and continue until follow-up in
infectious diseases clinic.
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed.
12. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-11**]
Drops Ophthalmic PRN (as needed).
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
15. Ferrous Sulfate 300 mg (60 mg [**Month/Day (2) **])/5 mL Liquid Sig: One (1)
PO DAILY (Daily).
16. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): Continue for eight days
until [**5-14**].
17. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: One (1) Intravenous Q8H (every 8 hours): Continue for
eight days until [**5-14**].
18. Insulin Regular Human 100 unit/mL Solution Sig: ASDIR
Injection ASDIR (AS DIRECTED): per sliding scale.
19. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H
(every 6 hours).
20. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
21. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 1-2 Puffs
Inhalation Q4H (every 4 hours).
22. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
23. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
24. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
25. Levofloxacin 25 mg/mL Solution Sig: Three (3) Intravenous
once a day: Start on [**5-15**] after vanco/Zosyn finished. Continue
until follow-up in infectious diseases clinic.
26. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
27. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Infected right total knee arthroplasty
Acute respiratory distress syndrome
Aspiration pneumonia
Gastric dysmotility
Discharge Condition:
Stable
Discharge Instructions:
experience severe pain not relieved by medication, increased
swelling, decreased sensation, difficulty with movement, fevers
>101.5, shaking chills, redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your PCP regarding this admission and
any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You may not drive a car until cleared to do so by your
surgeon or your primary physician.
5. Please keep your wounds clean. You may get the wound wet or
take a shower starting 5 days after surgery, but no baths or
swimming for at least 4 weeks. No dressing is needed if wound
continues to be non-draining. Any stitches or staples that need
to be removed will be taken out in clinic by Dr. [**Last Name (STitle) **].
7. Please call your Dr. [**Last Name (STitle) **] office to schedule or confirm your
follow-up appointment at 2 weeks.
8. Please DO NOT take any NSAIDs (i.e. celebrex, ibuprofen,
advil, motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for 3 weeks to
prevent deep vein thrombosis (blood clots). After completing
the lovenox, please take Aspirin 325mg twice daily for an
additional three weeks.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower after POD#5 but do not take a tub-bath or
submerge your incision until 4 weeks after surgery. Please place
a dry sterile dressing on the wound each day if there is
drainage, otherwise leave it open to air. Check wound regularly
for signs of infection such as redness or thick yellow drainage.
Staples will be removed by VNA in 2 weeks. If you are going to
rehab, the rehab facility can remove the staples at 2 weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at 2 weeks after
surgery. please draw CBC,ESR,CRP, LFT, BUN, CREAT when home
every week per ID.
12. ACTIVITY: Weight bearing as tolerated on the operative leg.
No strenuous exercise or heavy lifting until follow up
appointment. ***Continue to use your CPM machine as
directed.***
.
13. Antibiotics:
Please continue vancomycin and zosyn through [**5-14**]. Once these
are discontinued, please restart LEVAQUIN 500 PO QDAY AND
RIFAMPIN 300MG PO BID FOR KNEE INFECTION. These can be continued
through his follow-up appointment with infectious disease.
Physical Therapy:
Per plastics. Okay for WBAT and ROM as tolerated per ortho.
Treatments Frequency:
Physical therapy -- WBAT. Wound checks. VNA to remove staples at
2 weeks.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-4-29**] 11:30
He should follow-up in plastics clinic one week after discharge:
[**Telephone/Fax (1) 4652**]. He should follow-up with Dr. [**Last Name (STitle) **] in orthopedics
clinic in 2 weeks: [**Telephone/Fax (1) 79748**], and should continue Lovenox
until that follow-up. He should follow-up in [**Hospital **] clinic
with Dr. [**Last Name (STitle) 11482**] Pe??????[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: [**Telephone/Fax (1) 170**]. He should
follow-up in infectious diseases clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
An appointment has been made for [**2188-5-27**] at 10am in the [**Hospital **]
Medical Office Bldg at [**Doctor First Name **] on the ground floor.
Dr. [**Last Name (STitle) **] has requested that all laboratory results be faxed
to infectious disease R.Ns. at [**Telephone/Fax (1) 432**]. All questions
regarding outpatient antibiotics should be directed to the
when clinic is closed.
Completed by:[**2188-5-10**]
|
[
"99592",
"78552",
"5849",
"51881",
"5070",
"5990",
"2851",
"2760",
"4280"
] |
Admission Date: [**2114-5-17**] Discharge Date: [**2114-6-29**]
Date of Birth: [**2114-5-17**] Sex: F
Service: NB
HISTORY: Patient was twin B, admitted at 30-4/7 weeks
gestation with prematurity born to a 48-year-old gravida 1,
para 0 woman with blood type B positive, antibody negative,
RPR nonreactive, rubella immune, hepatitis B surface antigen,
estimated date of delivery [**2114-7-22**]. Pregnancy was
notable for IVF or in [**Last Name (un) 5153**] fertilization, dichorionic,
diamniotic twin gestation which had been reduced from
triplets. Also notable for advanced maternal age and normal
fetal surveys x2, intermittent chronic vaginal bleeding
thought to be a marginal placenta previa. Gestational
diabetes and betamethasone treatment x2 course, complete on
[**4-19**].
Delivery was prompted by a decrease in the BPP score of 4 out
of 8. Infant had Apgars of 7 and 8 and was reasonably
vigorous. Initial measurements: Weight 1300 grams which was
50th percentile, length 40 cm which was 25th to 50th
percentile and head circumference 28 cm which was 25th to
50th percentile.
PHYSICAL EXAMINATION AT DISCHARGE: Weight is 2340 grams for
corrected gestational age of 36-5/7 weeks which is 10th to
25th percentile. Head circumference is 33 cm, which is 50th
percentile, Length is 45.5 cm which is 25th percentile. In
general, she is awake, alert, without distress. Her anterior
fontanelle is open and flat, her oropharynx is clear with
moist mucous membranes. She has a red reflex present
bilaterally. Cardiovascular, her rate is regular and normal
rhythm, she has a I-II/VI systolic ejection murmur heard at
both axillae and back consistent with peripheral pulmonic
stenosis (PPS). Pulmonary, she has clear breath sounds
bilaterally. Her abdomen is soft, nontender, nondistended
with bowel sounds present. She has normal external female
genitalia. Her extremities are warm and well-perfused, and
she has normal capillary refill. Neurologically, she moves
extremities equally, is reactive, and shows normal neonatal
reflexes.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: Patient was initially intubated and received
surfactant x1, was weaned to CPAP by day of life 2 and then
to room air by day of life 5. Patient did suffer from apnea
of prematurity and was treated with caffeine starting on day
of life 2 and was continued up until day of life 20 on [**6-6**] at which point caffeine was discontinued. Patient has not
had a significant bradycardic or apneic event in greater than
6 days at time of discharge.
CARDIOVASCULAR: No hypotension or vasopressor requirement
during course of stay. A murmur was noted at day of life 16
which was soft and clinically consistent with peripheral
pulmonic stenosis (PPS). Initial cardiac screen was done
including chest x-ray, electrocardiogram, 4 extremity blood
pressure and post ductal oxygen saturation all of which were
within normal limits. This murmur is therefore clinically
diagnosed as peripheral pulmonic stenosis.
FLUIDS, ELECTROLYTES AND NUTRITION: The patient received
parenteral nutrition until enteral feeds were started on day
of life 2 and increased until patient was on full feeds on
day of life 8. Since that time patient's calories were
increased up to a maximum of 28 kilocalories per ounce of
formula and patient showed good growth at which point
calories were decreased slightly on [**2114-6-18**] in
preparation for discharge to 26 kilocalories per ounce.
GASTROINTESTINAL: The patient had a maximum bilirubin
concentration of 6.2 on day of life 6 and underwent
phototherapy starting day of life 2 and was discontinued on
day of life 5, restarted and then discontinued again on day
of life 8. Two rebound bilirubins were obtained off
phototherapy, one on day of life 11 which was 4.9/0.3 and a
second rebound on day of life 13 which was 4.5/0.3.
HEMATOLOGY: Patient's initial hematocrit was 40 and platelets
of 281. Initial white count was low at 4.3 with 12% polys
and 0 bands, with borderline neutropenia. The patient was
treated for 1 week with antibiotics. The repeat CBC on day of
life 2 showed a hematocrit of 43 and again a white count of
8 with improved neutrophil 13% and ANC of 1240. Patient
consistently had adequate platelet counts of 281, 295, and
435. Last hematocrit was on [**2114-6-12**] and was 28.2.
INFECTIOUS DISEASE: Patient was treated with 7 days of
ampicillin and gentamicin after birth and lumbar puncture
performed prior to cessation of antibiotics was negative for
infection with 6 red blood cells and 7 white blood cells of
which 0% were polys and 96% were monocytes. Glucose was 54,
protein was 141. Gram stain was negative. Blood culture was
also negative from initial sample.
NEUROLOGY: Patient had a normal head ultrasounds on [**2114-5-24**] and [**2114-6-18**].
SENSORY: Audiology: Hearing screening was performed with
automated brain stem responses and passed.
Ophthalmology:
Patient's eyes were first examined on [**2114-6-11**] and were
found to be immature zone 3 with follow up recommended in 3
weeks. An appointment should be made with Dr. [**Last Name (STitle) **],
[**Location (un) **] Office. Sibling has an appointment [**7-11**],
perhaps they both can be seen at the same visit.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] ([**Location (un) **]).
CARE RECOMMENDATIONS:
FEEDS AT DISCHARGE: Ad Lib P.O. Enfamil 26 kilocalories per
ounce. 24 calories/ounce by concentration then add 2
calories/ounce of corn oil to equal a final concentration of
26 calories/ounce.
Medications: Ferrous sulfate (25 mg/mL concentration) 0.2 mL
PO daily.
Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age. All
infants fed predominantly breast milk should received
vitamin D supplementation at 200 international units. [**Month (only) 116**]
be provided as multivitamin preparation until 12 months
corrected age.
CAR SEAT POSITION SCREENING: Was performed and was passed on
[**6-28**].
STATE NEWBORN SCREENING STATUS: State Newborn Screening have
been sent per protocol with no reported abnormal results.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**2114-6-19**].
IMMUNIZATIONS RECOMMENDED:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following 4
criteria: 1) Born at less than 32 weeks. 2) Born within 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. 3) Chronic lung
disease. 4) Hemodynamically significant congenital heart
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 care-givers.
This infant has not received rotavirus vaccine. The American
Academy of Pediatrics recommends an initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable and at least 6 weeks but within
12 weeks of age.
FOLLOW UP:
1. Pediatrician within a few days of discharge
2. VNA services - referral made
3. Minuteman Early Intervention - referral made
4. Ophthalmology within 3 weeks from last eye appointment
DISCHARGE DIAGNOSES LIST:
1) Prematurity, twin gestation
2) Respiratory distress syndrome, resolved
3) Apnea of prematurity, resolved
4) Presumed sepsis, resolved
5) Hyperbilirubinemia, resolved
6) Conjunctivitis, resolved
7) Murmur, clinical impression -peripheral pulmonic stenosis
8) Immature retina vascularization
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (STitle) 72769**]
MEDQUIST36
D: [**2114-6-28**] 17:57:02
T: [**2114-6-28**] 18:55:34
Job#: [**Job Number **]
|
[
"7742",
"V053"
] |
Admission Date: [**2184-5-27**] Discharge Date: [**2184-6-12**]
Date of Birth: [**2125-8-16**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
C difficile, liver failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58F with a h/o Hepatitis C cirrhosis c/b variceal bleeding,
encephalopathy, ascites, DM2 presented to [**Hospital 7188**] hospital on
[**5-12**] with the c/o fever to 104 x1 wk w/ ST, diarrhea and 1
episode of hematemesis.
.
On review of OSH records, it appears that the pt was admitted to
the ICU for Group A Strep sepsis (source thought to be dental
work done 1 wk prior) and C.diff colitis (confirmed with
positive stool toxin). She was intubated and required levophed
and dopamine for fluid-refractory hypotension. Antibiotics
included IV vancomycin/clindamycin as well as IV flagyl and PO
vanc. An ex-lap was performed on [**5-14**] due to the concern for
ischemic bowel and was negative. Ascitic fluid culture was
negative at that time. Pressors were weaned and the pt was
extubated on [**5-16**] and transferred to the floor.
.
In regards to the hematemesis, EGD revealed 3 non-bleeding grade
2 varices which were banded [**5-14**]. No further
bleeding/hematemesis.
.
The pt had episodic PAF and bounced back to the ICU on [**5-26**] with
AF w/ RVR to the 150s refractory to prn dilt and metoprolol at
which time she was started on digoxin.
.
The pt developed worsening hyperbilirubinemia over the course of
the admission- Tbili of 2.3 on presentation trended up to 17
with direct bili of 10.2. INR 2.1 and albumin 2. Cr 1.2,
trending down from high of 2.6 while pt was septic. A RUQ U/S
today reportedly showed portal vein thrombosis.
The patient was transferred to [**Hospital1 18**] for further transplant
workup.
.
On arrival to the floor, pt states she is sore all over and
hasn't gotten OOB for several wks and now feels too weak to do
so. Also, states that she is incontinent of stool having [**5-4**]
BMs/ day. She c/o fluid retention all over her body. She is
anxious about being at [**Hospital1 **] and states she has had some
anxiety-related SOB and palpitations at the OSH intermittently.
She c/o mild intermittent HA. She states she sometimes has
vision changes with changes in her blood sugars. She states she
is hungry and has been eating OK at OSH. She states she
occassionally has burning around her foley catheter and abd pain
around her incision site. She is also c/o chills and rectal temp
at OSH today was 95 per nursing sign out.
Past Medical History:
1. Hepatitis C with cirrhosis c/b ascites (last para summer
[**2183**]), encephalopathy and variceal bleeds ([**2179**] and this
admission to OSH)
2. Pelvic abscess secondary to IUD in [**2151**] with surgery.
3. Type 2 diabetes.
4. Cholecystectomy in [**2183**].
5. h/o panic attacks
Social History:
She is divorced with no children. She works as an artist. She
does not smoke. She does not drink alcohol at all at the moment
and never drank heavily in the past. Denies h/o drug use
Family History:
Both parents had diabetes. Her father had prostate cancer.
Pertinent Results:
[**2184-6-11**] 04:11AM BLOOD WBC-10.8 RBC-3.91* Hgb-12.1 Hct-36.6
MCV-94 MCH-30.9 MCHC-33.1 RDW-21.2* Plt Ct-65*
[**2184-5-27**] 07:39PM BLOOD WBC-9.3# RBC-3.51* Hgb-10.4* Hct-31.0*
MCV-88 MCH-29.6 MCHC-33.5 RDW-22.5* Plt Ct-135*
[**2184-6-11**] 04:11AM BLOOD Plt Ct-65*
[**2184-6-11**] 04:11AM BLOOD PT-21.2* PTT-43.4* INR(PT)-2.0*
[**2184-5-27**] 07:39PM BLOOD PT-21.2* PTT-39.1* INR(PT)-2.0*
[**2184-5-27**] 07:39PM BLOOD Plt Ct-135*
[**2184-6-11**] 04:11AM BLOOD Glucose-240* UreaN-11 Creat-0.6 Na-134
K-4.1 Cl-103 HCO3-18* AnGap-17
[**2184-6-11**] 04:11AM BLOOD ALT-33 AST-101* AlkPhos-91 TotBili-27.2*
[**2184-5-27**] 07:39PM BLOOD ALT-11 AST-46* LD(LDH)-121 AlkPhos-53
TotBili-18.1*
[**2184-6-11**] 04:11AM BLOOD Calcium-10.9* Phos-1.8* Mg-2.1
[**2184-5-27**] 07:39PM BLOOD Albumin-2.2* Calcium-8.2* Phos-3.9 Mg-2.0
[**2184-6-11**] 04:27AM BLOOD Type-ART pO2-109* pCO2-40 pH-7.32*
calTCO2-22 Base XS--5
[**2184-6-9**] 10:36PM BLOOD Lactate-2.4*
[**2184-5-27**] 07:50PM BLOOD Lactate-1.9
[**2184-6-3**] 02:31AM URINE RBC-[**7-8**]* WBC-[**12-18**]* Bacteri-MOD
Yeast-MANY Epi-0-2
[**2184-6-3**] 02:31AM URINE Blood-LG Nitrite-NEG Protein-150
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-NEG pH-6.5 Leuks-TR
[**2184-6-3**] 02:31AM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.020
Brief Hospital Course:
This is a 58 yo F w/ h/o Hep C cirrhosis c/b ascites, esophageal
varices, and encephalopathy who was transferred from OSH after a
long course with group A strep bacteremia, c difficile
infection, an ex lap for ?ischemic bowel, worsening liver
failure and possible portal venous clot transferred here for
transplant workup. Pt was anticoagulated for confirmed portal
venous clot and subsequently developed massive variceal bleed
which necessitated intubation. Was stabilized hemodynamically
but liver function and Cr continued to worsen. Ultimately
deemed not a transplant candidate because clot in portal system
extended too close to SMV which would be the attachment point
for the new organ.
.
# Worsening liver failure- Steadily rising Tbili and Cr
throughout hospital course. Initial DDX considered included
advancing hepatitis C cirrhosis, infection vs. portal venous
clot vs. GIB. On arrival to the ICU, the patient was
pan-cultured. RUQ U/S and CT of the abdomen were also performed
which showed complete occlusion of the portal vein. She was
transferred to the floor for continuation of her transplant
workup where she was started on heparin for the portal clot.
The patient was noted to be too weak to complete PFTs or go for
mammography to complete the workup. On the same day, the
patient had the sudden onset of massive hematemesis, coded on
the floor, was intubated and transferred to the ICU. EGD was
performed which showed bleeding esophageal and gastric varices.
Hemostasis was achieved and the pt remained sedated on the
ventilator for several days. Hcts were stable throughout that
time.
.
Given pts low probability of completing the transplant workup
given the new massive GIB and steadily rising LFTs and Cr
thought to represent HRS, the pts HCP chose to make her [**Name (NI) 3225**].
The patient was extubated for several days, at which point her
mental status improved and she expressed a desire to continue
the workup for transplant. The patient was re-started on CVVH
and lactulose. CTV of the abdomen was performed several days in
which showed clot in the portal venous system that encroached
upon the SMV. Unfortunately, transplant attendings x2 felt that
this was an absolute contraindication for transplant now or in
the future. In discussion with the HCP and with the patinet,
she was again made [**Name (NI) 3225**] and plan put in place to transfer for
home hospice.
Medications on Admission:
Inderal 5 mg [**Hospital1 **]
Digoxin 250 mcg daily
Flagyl 500 mg TID x7 more days for C. diff.
Lasix 40 mg IV daily
ISS
Lactulose 20g TID
Morphine 2 mg q4h prn
Prilosec 30 mg daily
zofran 4 mg q2h prn
aldactone 50 mg daily
ursodiol 300 mg [**Hospital1 **]
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 2.5 mg PO every
four (4) hours as needed for pain.
2. Hospital Bed
Please provide a hospital bed for the pt
Discharge Disposition:
Home With Service
Facility:
Home and hospice of RI
Discharge Diagnosis:
End stage Hepatitis C-related liver failure
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were evaluated in the hospital for a possible liver
transplant. Unfortunately you are not a candidate. You have
irreversible liver and kidney failure. You are returning home
for hospice care.
You will be receiving morphine as needed to help make your
comfortable.
A hospital bed should be delivered to your home.
Followup Instructions:
You do not need to follow up with any physicians at this time.
|
[
"5849",
"51881",
"2761",
"2851",
"25000",
"42731"
] |
Admission Date: [**2164-6-17**] Discharge Date: [**2164-8-8**]
Date of Birth: [**2109-1-17**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Erythromycin
Base / Shellfish / Motrin
Attending:[**First Name3 (LF) 8810**]
Chief Complaint:
AML
Major Surgical or Invasive Procedure:
PICC placement
Bone marrow biopsy
Bronchoscopy
Intubation
History of Present Illness:
55yo male with no known significant past medical history
presents with new diagnosis of acute leukemia.
.
He has went to [**Hospital **] Hospital outpatient clinic for evaluation
for fatigue and redness of the left lower extremity. He had a
CBC drawn and was asked to return to the ER the same day for
concerning blood work (CBC from [**Hospital **] Hospital: wbc 15 with
53% blasts; h&h 6.8 & 20; plt 29K). He was transferred to [**Hospital1 18**]
ER and then admitted to medicine service. His CBC at [**Hospital1 18**]
showed wbc 13 with 48% blasts.
.
Patient was also started on vancomycin IV for cellulitis of the
left lower extremity.
.
He reports that he noticed fatigue for several months now but
got much worse over the past week. He couldn't exercise as he
usually does. Felt short of breath climbing stairs and carrying
grocery bags.
.
No chest pain, fevers, chills, night sweats. No weight loss or
headaches. No loss of appetite. No diarrhea or abdominal pain.
No nausea or vomiting. No neurologic symptoms.
Past Medical History:
BPH
HTN
HL
anxiety
Social History:
Work as a clerk at the [**Company **].
Lives with his companian/girlfriend for the past ten years.
No children.
He has one sister (here with him today) who lives in [**Hospital1 **].
No history of smoking. Does not drink alcohol. Does not do
illicit drugs.
Family History:
Father had prostate cancer in his 70's but died from congestive
heart failure.
Mother deceased.
Sister healthy
Physical Exam:
ADMISSION EXAM:
GEN: AOx3, in NAD
HEENT: PERRLA. MM dry.
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: BS+, soft, NT, no rebound/guarding,
Extremities: left lower leg cellulitis over the shin area.
appears improved from initial marking.
Skin: dry, no rashes or bruising
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. gait
WNL.
.
Exam on Transfer to [**Hospital Unit Name 153**]
Vitals: T: 100.8 BP: 89/61 P: 168 R: 28 O2: 98% on 4L
General: Alert, oriented, appears comfortable despite increased
respiratory rate
HEENT: Sclera anicteric, pale, dry mucous membranes
Lungs: rhochi throughout, RUL more pronounced
CV: tachycardic
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, no clubbing, cyanosis or edema
Skin: resolving erythema over left lower leg, no tenderness or
warmth, left sided PICC- clean dressing, right upper neck with
area of scale and erythema at site of former CVL, marker
circling spot
.
Exam on transfer back to BMT:
vs: T 96.2, BP 136/68, HR 84, RR 24, O2 sat 96% on 2L NC.
GEN: sleepy, easily arousable; slow to answer but is appropriate
HEENT: NCAT, anisocoria (L>R) secondary to past cataract surgery
but pupils react appropriately to light; MMM, OP clear.
Cards: RRR, nl S1/S2, no m/r/g
Pulm: poor air movement throughout, decreased breath sounds in
RUL, no crackles or wheezes
Abd: +BS, nondistended, nontender to palpation
GU: +foley draining clear urine
Extremities: DP 2+ bilaterally, no c/c/e
Skin: scab over R IJ site, scab over R antecubital area; L PICC
line site c/d and without surrounding erythema or tenderness.
Neuro: CN II-VII intact, follows commands slowly.
Exam on discharge:
VS: T 96.2 BP 148/72 HR 76 RR 18 O2 97% RA
GEN: anxious, sitting up in a chair, NAD
HEENT: NCAT, anisocoria (L>R) secondary to past cataract surgery
but pupils react appropriately to light; MMM, OP with mild
thrush.
CV: RRR, nl S1/S2, no m/r/g
Pulm: good air movement throughout, no crackles or wheezes
Abd: +BS, soft, nondistended, nontender to palpation
GU: no foley
Extremities: trace peripheral edema, warm to palpation
Skin: L PICC line site c/d and without surrounding erythema or
tenderness.
Neuro: language intact, gait ok with cane. CN II-XII intact.
Pertinent Results:
ADMISSION LAB:
[**2164-6-16**] 11:25PM COMMENTS-GREEN TOP
[**2164-6-16**] 11:25PM LACTATE-0.9
[**2164-6-16**] 11:17PM GLUCOSE-124* UREA N-15 CREAT-1.0 SODIUM-137
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-13
[**2164-6-16**] 11:17PM ALT(SGPT)-25 AST(SGOT)-24 LD(LDH)-506* ALK
PHOS-92 TOT BILI-0.3
[**2164-6-16**] 11:17PM LIPASE-21
[**2164-6-16**] 11:17PM ALBUMIN-4.1 CALCIUM-8.4 PHOSPHATE-2.9
MAGNESIUM-1.9
[**2164-6-16**] 11:17PM WBC-13.5* RBC-1.72* HGB-7.1* HCT-19.8*
MCV-115* MCH-41.4* MCHC-36.1* RDW-14.8
[**2164-6-16**] 11:17PM NEUTS-26* BANDS-0 LYMPHS-21 MONOS-3 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 OTHER-48*
[**2164-6-16**] 11:17PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2164-6-16**] 11:17PM PLT SMR-VERY LOW PLT COUNT-30*
[**2164-6-16**] 11:17PM FIBRINOGE-470*
[**2164-6-16**] 11:17PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2164-6-16**] 11:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
DISCHARGE LAB:
XXXXXXXXXXXXXXXXXXXXXX
IMAGING:
========
CT Head [**6-16**]: IMPRESSION: No acute intracranial hemorrhage or
mass effect.
.
ECHO [**2164-6-18**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The aortic arch is mildly
dilated.The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
global and regional biventricular systolic function. Mild mitral
regurgitation with normal valve morphology.
.
Left lower extremity ultrasound [**2164-6-18**]
IMPRESSION: No evidence of DVT.
.
CT CHEST [**2164-7-12**]:
Right PICC line tip is in the proximal right atrium. Aorta is
normal in
diameter. Main pulmonary artery is not enlarged, but right main
pulmonary rtery is 3 cm in diameter, might be reflecting
pulmonary hypertension.
Coronary calcifications are extensive. There is minimal amount
of pericardial effusion, grossly unchanged since the prior
study. Small but new bilateral pleural effusion is noted. Within
the axilla, there are multiple minimally enlarged lymph nodes.
There are no bone lesions worrisome for infection or neoplasm.
Airways are patent till the level of subsegmental bronchi
bilaterally. Right upper lobe consolidation seen on the prior CT
and radiographs has significantly progressed since the prior
study, currently involving the apical posterior aspect of the
right upper lobe as well as superior aspect of right lower lobe.
There is lucency within the lateral aspect of the consolidation
in the right upper lobe, most likely representing still aerated
lung and unlikely to represent cavitation although should be
closely monitored. The left lung is clear except for basal
opacities that in part might represent atelectasis and unlikely
to represent infectious process. The progression of the
consolidation has been also demonstrated on the chest radiograph
when compared to [**2164-7-8**], thus further followup of the
abnormality can be obtained with chest radiographs. The
differential diagnosis would include rapidly progressing
bacterial pneumonia. The other options would be invasive
aspergillosis (less likely) as well as massive aspiration
(unlikely).
.
TTE [**2164-7-13**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic arch is mildly dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Compared with the prior study (images reviewed) of [**2164-6-18**],
the heart rate and estimated pulmonary artery pressures are
higher. Other findings are similar
.
CT Torso [**2164-7-19**]
Impression: 1. Continued interval worsening of multifocal
pulmonary consolidations now involving most of the right upper
lobe and majority of the lower lobe basal segments bilaterally.
This process began only involving the posterior segment of the
right upper lobe and has been slowly worsening over prior last
10 days. Small bilateral pleural effusions have also increased.
2. No significant pathology noted within the abdomen and pelvis
other than slight interval increase of soft tissue anasarca and
mild amount of intra-abdominal ascites. There are no findings of
ileus or obstruction.
.
Liver and Gallbladder US [**2164-7-22**]
IMPRESSION: Limited right upper quadrant ultrasound demonstrates
a normal
gallbladder without evidence of acute cholecystitis.
.
CT Chest [**2164-7-30**]
As compared to the prior CT torso from [**2164-7-19**], there is
significant
interval improvement in the right upper lobe consolidation and
left lower lobe consolidation with improved aeration of both
lobes. The consolidation which are currently present are still
substantial and involve the posterior segment of right upper
lobe as well as apical and part of the basal segments of right
lower lobe. There is interval improvement of pleural effusion,
small. In the left lung, there is interval resolution of left
lower lobe consolidation with only minimal residual present.
There are multiple mediastinal lymph nodes, but none of them
pathologically enlarged. Extensive coronary calcifications are
present, unchanged. There is small amount of pericardial
effusion, minimally increased since the prior study. There is
evidence of anemia. The aorta is normal in diameter.
Airways are patent to the level of subsegmental bronchi
bilaterally.
The left PICC line tip is at the cavoatrial junction level.
Right lung
pulmonary nodules are noted in the previously consolidated area
of the lungs, most likely representing residua of prior
infection, with similar appearance in the left lower lobe and
might be reevaluated in three months for documentation of
resolution. No evidence of interstitial abnormality is present.
=======================
MICRO:
BCx: all sterile
UCx: all sterile
Cryptococcal antigen: negative
BAL ([**2164-7-10**]): neg Gram stain, commensal respiratory Cx, neg for
legionella/KOH prep/PCP/fungus/nocardia/AFB/mycobacteria/CMV
BAL ([**2164-7-14**]): Gram stain +leukocyte, no microorganism; neg
respiratory Cx, neg for legionella/KOH
prep/PCP/fungus/nocardia/AFB/mycobacteria/CMV
MRSA screen negative
Respiratory viral Cx ([**2164-7-20**]): negative
C diff toxin ([**2164-7-25**]): negative
Brief Hospital Course:
Mr. [**Known lastname 88668**] is a 55yo male with no significant past medical
history who presented with cellulitis and elevated WBC with high
percentage of blasts and was diagnosed with AML-M2 carrying a
(8:21) translocation.
.
# AML: Patient presented for evaluation of cellulitis and was
found to have WBC 22 with 85% blasts. He underwent bone marrow
biopsy [**6-27**] which showed new acute leukemia, AML-M2 with
cytogenetics carrying translocations at ETO at 8q21 which is
considered a to be a good prognostic indicator. Baseline ECHO
showed mild MR and was otherwise unremarkable. He was treated
with 7+3 induction chemotherapy and tolerated chemotherapy well.
Day 14 bone marrow biopsy was hypocellular consistent with
ablated marrow. ANC nadir was 0, and recovery began on day 18.
His recovery bone marrow biopsy done on day 37 also showed
complete remission. He will follow up with Dr. [**Last Name (STitle) 3759**] for
consolidation chemotherapy.
.
# Pneumonia: Patient developed productive cough [**7-8**] in the
setting of neutropenic fever, a CT chest showed a right upper
lobe round infiltrate with surrounding ground glass opacities
(halo sign). Concern for invasive aspergilosis was raised, ID
was consulted and he was started on voriconazole (in addition to
vancomycin and cefepime). He underwent broncheoalveolar lavage
which revealed purulent material in the right upper lobe,
cultures were taken which was unrevealing. He developed hypoxia
and tachypenia and repeat CT showed progression of the
previously seen right upper lobe infiltrate. His ANC had begun
to recover at this time and clinical deterioration was partly
due to immunereconstitution. Given tenuous respiratory status,
he was transferred to the ICU for close monitoring in the
context of tachycardia and hypotension. He had persistently high
work of breathing during his second night, and failed treatment
with BiPAP necessitating intubation. Repeat imaging showed
worsening of his right upper lobe pneumonia, with opacities
extending throughout the right hemithorax. As he failed to
improve with broad spectrum antibiotics and fungal coverage, and
as BAL failed to reveal a microbial pathogen on culture, a lung
biopsy was initially pursued, though eventually postponed due to
elevated PEEP and for fear of inciting pneumothorax in a tenuous
patient. Flagyl and ciprofloxacin were added for c diff
prophylaxis and additive GNR coverage, respectively. BAL was
repeated on [**2164-7-14**] and [**2164-7-20**], which again failed to show any
pathogenic culprit. He received a single dose of steroids on
[**7-22**] in treatment of questionable BOOP, though this was
discontinued in discussion with the BMT team who felt that
infection was still most likely. He was eventually extubated on
[**7-23**] to room air. He was transferred back to BMT on [**7-26**] and his
antibiotics were stopped slowly. He is being covered with
posaconazole at the time of discharge, and will continue this
medication until end of his consolidation chemotherapy. The
repeat Chest CT on [**2164-7-30**] showed significant improvement of
pneumonia, but still significant consolidation of R lung and
pulmonary nodules, likely infectious.
.
# Leukocytosis/Fever. Thought to be infectious with most likely
source being in the lungs based on clinical presentation,
imaging, and bronchoscopy. See above for management of
pneumonia. However, BAL has not been revealing in terms of the
causative microbe, but there is concern for fungal vs. bacterial
pneumonia. He was started on broad spectrum antimicrobials. C.
diff was also suspected given his ileus and rapid rise in WBC;
therefore, he was started on IV flagyl and vancomycin enema,
although he has been unable to tolerate vancomycin enemea. C.
diff PCR was ordered for more definitive diagnosis, but he has
not had BM. BMT service believes taht his leukocytosis and
fever could be partly from robust return of his bone marrow s/p
7+3. After transfer back to the BMT service and with
improvement of his pneumonia, he remained afebrile on the floor
until discharge.
.
# Atrial fibrillation/flutter: Patient had new onset of atrial
fibrillation with rapid ventricular response in the setting of
sepsis from the above noted pulmonary infection. He was treated
with metoprolol IV and PO and went in and out of sinus rhythm.
He was transferred to the ICU as above in atrial fibrillation,
though spontaneously converted soon after transfer in response
to IV lopressor. He was placed on TID PO lopressor though again
reverted to a fast atrial flutter at 150bpm during his second
ICU night with hypotension to 80s systolic. He received bolus
diltiazem and then diltiazem gtt with levophed support, and he
eventually reverted to sinus rhythm. He began amiodarone
loading to prevent further arrhythmia. He received IV
amiodarone until [**2164-7-20**] because of concern for ileus, resumed
po as bowel sounds returned, but ultimately stopped on [**7-21**] as
he was persistently in sinus rhythm and with increasing alkaline
phosphatase, thought [**3-7**] medications. His heart remained in
normal rate at the time of discharge.
.
# Hypotension: He had hypotension to 80s systolic while in the
MICU, which was initially fluid responsive. These pressures had
occurred with his tachycardia and nodal blockade, and he was
eventually placed on pressors as we struggled to control his HR.
He remained hypotensive on high doses of fentanyl/midazolam to
control agitation. While likely septic, his pressure improved
with sedation weaning, suggesting a substantial iatrogenic
source. He was weaned off pressors. He was eventually
extubated, and his SBP remained in 110-130s on the floor.
.
# Cellulitis: Patient was presented with a left lower leg
swelling and erythemia. Ultrasound was negative for DVT. He was
diagnosed with cellulitis and treated with Vancomycin and
Cefepime for an extended course given neutropenia. He completed
a 24 day course of antibiotics and his cellulitis resolved.
.
# Rash: patient developed an erythematous, maculopapular non
puritic rash over the extensor surface of his forearms
bilatearlly. At the time, he had been treated with cefepime for
14 days and drug rash was considered possible. The rash was not
severe and cefepime was continued given ongoing neutropenia. The
rash resolved over time.
.
# Social Issues: The patient was very hesistant towards
treatment throughout his stay and required encouragement to
start chemotherapy. He benefited greatly from social work and
chaplain support.
.
# Ileus. Tubefeeds restarted and now at 40 cc/ml. Still no
bowel movement.
- off vancomycin enema as above
- on mostly IV formulation for meds at this time
- continue bisacodyl pr prn
- continue TF, check residual
Medications on Admission:
Trazodone
Aspirin 81mg
Terazosin
Alprazolam
Discharge Medications:
1. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
2. posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: 5 (five)
mL PO Q6H (every 6 hours).
Disp:*600 mL* Refills:*2*
3. Xanax 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
AML (acute myeloid leukemia)
Pneumonia (infection of lung)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (cane).
Discharge Instructions:
Mr. [**Known lastname 88668**],
.
It was a pleasure taking care of you in the hospital. You were
admitted with new AML. You were treated with induction
chemotherapy. We also treated cellulitis with antibiotics and
this improved greatly. You developed neutropenia (low white cell
counts) with chemotherapy and had fevers, for which you received
antibiotics and had CT scan of your chest. CT scan of your chest
showed pneumonia (infection of lungs) in your right lung, which
was treated with antifungal medications. You also developed
irregular, rapid heartbeat which were treated with medications,
and your heartbeats are now normal. Because you had difficulty
breathing with your pneumonia, you had to be intubated and have
help with breathing for a while. You came out of the ICU, and
did well on the floor with PT. You are still being treated with
posaconazole for your pneumonia. You will continue taking this
medication through the second round of chemotherapy.
.
We made many changes to your medications. Please see attached
list to know what medications you should be taking.
.
-STARTED Posaconazole suspension 200 mg by mouth every 6 hours
for your pneumonia. Please take this with fatty foods to
increase the absorption of the medication.
-STOPPED terazosin for your benign prostatic hypertrophy, you
can restart this medication after discussing it with your
primary care physician.
[**Name10 (NameIs) 88669**] aspirin, please do not start taking this medication
before discussing it with Dr. [**Last Name (STitle) 3759**].
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2164-8-10**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/BMT; Infectious Diseases Doctor
When: THURSDAY [**2164-8-23**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"0389",
"51881",
"2760",
"99592",
"42731",
"4019",
"2724",
"2859"
] |
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