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Admission Date: [**2186-4-5**] Discharge Date: [**2186-5-1**]
Date of Birth: [**2126-1-11**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Ciprofloxacin / Ertapenem / Meropenem
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Acute renal failure, urinary tract infection
Major Surgical or Invasive Procedure:
Bedside HD line placement, IR guided HD line placement, IR
guided tunnelled HD line placement, PICC line placement,
paracentesis, central line placement, intubation, NG tube
placement
History of Present Illness:
Ms [**Known lastname 92101**] is a 60 year old woman with cirrhosis [**3-13**] methotrexate
(for psoriatic arthritis) and hepatitis C who initially
presented with acute on chronic renal failure; her course has
been complicated by UTI, bacteremia, respiratory distress
requiring ICU transfer as well as worsening ARF requiring HD who
is now stable for call out of the ICU to the floor.
.
The patient was recently admitted to [**Hospital1 18**] from [**3-8**] to [**2186-3-14**]
for an infected bullae. The patient was then discharged to
rehab, where she was feeling well and had no specific
complaints. The patient had routine labs drawn on [**4-3**], which a
Cr of 3.0 (baseline 1.8-2.0).
.
On admission she was found to have a UTI which grew Pseudomonas,
Klebsiella, and ESBL E. coli on straight cath. She was initially
treated with first with Unasyn but developed a diffuse rash. She
was then switched to aztreonam due to allergies to
cephalosporins, penicillins, and fluoroquinolones but the
culture ultimately grew resistent ESBL Ecoli and Pseudomonas.
She was switched to meropenem but developed diffuse erythroderma
with eosinophilia after 3 days. The meropenem was stopped but a
repeat UA and Cx was notable only for yeast and no signs of
ongoing infection. She then became increasingly encephalopathic
and developed a fever. Her blood cultures grew coag negative
Staph x3 bottles and she was started on vancomycin. She also
being treated for hepatorenal syndrome with albumin, midodrine,
and octreotide. Unfortunately her renal function continued to
decline and it was felt that she would need HD. The renal team
was unable to place an HD cath at the bedside on Friday [**2186-4-14**].
She has some post procedure bleeding and was transfused 2U pRBC
the following day. She developed respiratory distress thought to
be due to volume overload on Sat [**4-15**]. ABG on RA 7.36/27/63. She
did not respond to lasix 80 IV, and was therefore transferred to
the ICU.
.
In the ICU a nitro gtt was initiated with relief of her
distress. On [**4-16**], the patient self d/c'd her PICC line. An IR
guided temporary HD cath with a VIP port was placed. She
underwent her first dialysis session on [**2186-4-17**]. She developed a
large hemorrhagic bulla at the site of her HD cath. DDAVP was
given. Hemolysis labs were difficult to interpret in the setting
of ESLD. Wound care was consulted. Her O2 was weaned to 2L NC
(from 4L). Blood culture from [**2186-4-15**] grew VRE and her
antibiotics were changed to Dapto. She also was noted to have AM
hypoglycemia so her evening glargine was decreased to 10U from
20U. Her course has further been complicated by ongoing
encephalopathy which responded to lactulose.
.
On the floor now she is comfortable on 2L NC but remains
encephalopathic. She has no particular complaints but is A&O x
1. She continues to require HD with poor UOP.
Past Medical History:
Hepatitis C, Genotype 1: Diagnosed in [**2185-1-8**] with last
VL 263,000 in [**8-/2185**]
Cirrhosis (Methotrexate and Hepatitis C Induced) s/p TIPS,
complicated by hepatic encephalopathy and ascites
Chronic Kidney Disease with baseline Cr 1.8-2.0
Diastolic CHF: Grade I diastolic dysfunction [**7-17**], EF 75%
Esophageal Varices per report; however, EGD [**7-/2185**] reports
normal esophagus
Psoriasis with Arthropathy - s/p Methotrexate x 15 years (MTX
d/c in 12.07 when patient developed ascites and now uses
halobetasol cream)
Anemia with baseline Hct 25-30
Thyroid nodule 2.2cm identified on ultrasound [**9-16**]
Foot drop from peroneal nerve injury during TIPS procedure (per
DC summary)
Social History:
Quit smoking in [**2184**]. No alcohol problems, no drugs. Formerly
taught hairdressing. Had been living with her son and father
until recent admission after which she went to [**Hospital1 **]. Uses a
walker but has a very difficult time getting around.
Family History:
No known history of liver disease
Physical Exam:
GENERAL: Elderly, pleasant woman in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
NECK: Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Harsh 3/6 systolic murmur.
Nl S1 and S2
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft. Diffusely distended. Non-tender.
EXTREMITIES: 3+ edema bilaterally. Bullae on lower extremities
bilaterally, covered with gauze.
SKIN: Diffusely dry skin with multiple skin tears.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-10**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred. No
asterixis
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
(From NH)
Hct 26
Na 129
K 5.8
Creat 3.03 (baseline 2.0-2.4)
Admission labs:
[**2186-4-5**] 12:23PM BLOOD WBC-19.6*# RBC-2.90* Hgb-8.8* Hct-26.3*
MCV-91 MCH-30.4 MCHC-33.6 RDW-16.7* Plt Ct-126*
[**2186-4-5**] 12:23PM BLOOD PT-19.6* PTT-47.4* INR(PT)-1.8*
[**2186-4-5**] 12:23PM BLOOD Glucose-127* UreaN-40* Creat-3.4*#
Na-130* K-5.4* Cl-103 HCO3-20* AnGap-12
[**2186-4-5**] 12:23PM BLOOD ALT-31 AST-43* LD(LDH)-216 AlkPhos-159*
TotBili-1.0
[**2186-4-5**] 12:23PM BLOOD Albumin-2.3* Calcium-9.1 Phos-3.9 Mg-1.9
.
Discharge labs:
[**2186-4-28**] 05:15AM BLOOD WBC-11.2* RBC-1.93* Hgb-6.2* Hct-18.1*
MCV-94 MCH-32.4* MCHC-34.5 RDW-21.0* Plt Ct-89*
[**2186-4-28**] 05:15AM BLOOD PT-20.9* PTT-50.9* INR(PT)-2.0*
[**2186-4-28**] 05:15AM BLOOD Glucose-50* UreaN-15 Creat-3.5*# Na-139
K-3.5 Cl-100 HCO3-29 AnGap-14
[**2186-4-28**] 05:15AM BLOOD ALT-20 AST-26 LD(LDH)-175 AlkPhos-111
TotBili-1.9*
[**2186-4-28**] 05:15AM BLOOD Albumin-3.2* Calcium-9.8 Phos-4.3# Mg-1.6
.
Culture data:
[**2186-4-5**] 2:15 pm URINE Source: Catheter.
**FINAL REPORT [**2186-4-9**]**
URINE CULTURE (Final [**2186-4-9**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. WARNING! This isolate is an
extended-spectrum beta-lactamase (ESBL) producer and should be
considered resistant to all penicillins, cephalosporins, and
aztreonam. Consider Infectious Disease consultation for serious
infections caused by ESBL-producing species. AZTREONAM = R.
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML. AZTREONAM = <=1
MCG/ML = S. PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.
SENSITIVITIES: MIC expressed in MCG/ML
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| | PSEUDOMONAS
AERUGINOSA
| | |
AMIKACIN-------------- 8 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S 8 S
CEFAZOLIN------------- R <=4 S
CEFEPIME-------------- R <=1 S 32 R
CEFTAZIDIME----------- R <=1 S 32 R
CEFTRIAXONE----------- R <=1 S
CEFUROXIME------------ 32 R 2 S
CIPROFLOXACIN--------- =>4 R <=0.25 S =>4 R
GENTAMICIN------------ <=1 S <=1 S =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S 4 S
NITROFURANTOIN-------- <=16 S 32 S
PIPERACILLIN---------- R =>128 R
PIPERACILLIN/TAZO----- <=4 S <=4 S =>128 R
TOBRAMYCIN------------ <=1 S <=1 S =>16 R
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
.
[**2186-4-6**] 8:40 am BLOOD CULTURE
**FINAL REPORT [**2186-4-9**]**
Blood Culture, Routine (Final [**2186-4-9**]): STAPHYLOCOCCUS,
COAGULASE NEGATIVE.
Anaerobic Bottle Gram Stain (Final [**2186-4-7**]): GRAM POSITIVE
COCCI IN PAIRS AND CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2186-4-7**]): GRAM POSITIVE COCCI
IN PAIRS AND CLUSTERS.
.
[**2186-4-11**] 10:35 am URINE Source: Catheter. **FINAL REPORT
[**2186-4-12**]** URINE CULTURE (Final [**2186-4-12**]): YEAST. 10,000-100,000
ORGANISMS/ML.
.
[**2186-4-11**] 1:56 pm BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2186-4-18**]**
Blood Culture, Routine (Final [**2186-4-18**]): STAPHYLOCOCCUS,
COAGULASE NEGATIVE. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in MCG/ML
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final [**2186-4-13**]): GRAM POSITIVE
COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2186-4-13**]): GRAM POSITIVE COCCI
IN CLUSTERS.
.
[**2186-4-13**] 11:06 am URINE Source: Kidney. **FINAL REPORT
[**2186-4-14**]** URINE CULTURE (Final [**2186-4-14**]): YEAST.
10,000-100,000 ORGANISMS/ML.
.
[**2186-4-15**] 6:00 am BLOOD CULTURE **FINAL REPORT [**2186-4-21**]** Blood
Culture, Routine (Final [**2186-4-21**]): ENTEROCOCCUS FAECIUM. FINAL
SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500
mcg/ml of gentamicin. Screen predicts possible synergy with
selected penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml of
streptomycin. Screen predicts NO synergy with penicillins or
vancomycin. Consult ID for treatment options. Daptomycin =
3MCG/ML, Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in MCG/ML
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final [**2186-4-16**]): GRAM POSITIVE
COCCI. IN PAIRS AND CHAINS.
.
[**2186-4-17**] 3:18 pm URINE Source: Catheter. **FINAL REPORT
[**2186-4-19**]** URINE CULTURE (Final [**2186-4-19**]): YEAST. 10,000-100,000
ORGANISMS/ML.
.
[**2186-4-21**] 6:00 am BLOOD CULTURE Source: Line-vip. **FINAL REPORT
[**2186-4-27**]** Blood Culture, Routine (Final [**2186-4-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SENSITIVITIES PERFORMED ON
REQUEST. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 2ND STRAIN.
SENSITIVITIES PERFORMED ON REQUEST.
Anaerobic Bottle Gram Stain (Final [**2186-4-23**]): GRAM POSITIVE
COCCI IN PAIRS AND CLUSTERS.
.
IMAGING:
CHEST (PA & LAT)[**2186-4-18**]
[**4-16**] ECG: Sinus rhythm. Low precordial lead voltage. Compared to
the previous tracing of [**2186-4-5**] the precordial voltage is
diminished. Otherwise, no diagnostic interim change.
Brief Hospital Course:
60F with ESLD [**3-13**] HCV and MTX for psoaritic arthritis who
presented initially for ARF then developed a UTI which was
treated. The renal failure persisted consistent with HRS and she
was started on HD. She then developed coag neg Staph bacteremia
and ?VRE bacteremia versus contaminated BCx. Of note, she has
severe skin break down [**3-13**] unknown etiology (?psorasis and
cirrhotic edema and chronic steroid use). She had completed
treatment for bacteremia with vancomycin but the bacteremia with
coag neg Staph recurred almost as soon as the vancomycin was
stopped. She was againe treated with vancomycin for this. She
did poorly clinically with severe skin breakdown, ongoing
recurrent infections, and encephalopathy. She has been de-listed
for liver trasnplant. After long discussion on [**2186-4-29**] with
patient and family, it has been agreed that there the goals of
care will be palliation. She continues to suffer from skin
breakdown and hemorrhage.
.
#. Goals of care: Given inability to treat her infections [**3-13**]
skin breakdown and severe bleeding from heparin at HD, as well
as the reality that [**Known firstname **] will never be eligible for liver or
kidney [**Known firstname **], she and here family agreed to comfort care.
.
#. Anemia / bleeding: Pt with ongoing bleeding from skin with
minor trauma. She continues to lose blood at HD from
heparinization. She has required 1-2U pRCB per HD session for
seepage from her multiple wounds. Previously got epogen at HD.
Less bleeding on exam [**4-30**] and [**5-1**] off heparin for HD.
Transfusions discontinued given focus on comfort. Continue
multivitamins.
.
#. Skin breakdown: She has a large hemorrhagic bulla at the site
of her HD cath. She has two bullae on her legs bilaterally for
which she was recently hospitalized, which are much improved
now. She has skin tears on both arms and her back. She continues
to have extensive skin breakdown of unknown etilogy but presumed
to be from edema and psorasis. It seems likely that her skin
breakdown is etiologic to her recurrent bacteremia. Discontinued
Triamcinolone as psoriasis does not seem to be an active issue.
Minimized dressing changes and adhesives. Per derm, cover entire
skin surface with hydrated petrolatum [**Hospital1 **] for barrier protection
and enhanced moisturization. Per derm, apply bactroban to
erosions daily and cover with adaptic dressings. Continue
multivitamins. Was vitamin A def, which was repleted.
.
# Bacteremia: BCx positive coag neg Staph starting on [**4-11**] for
which she was initially on vancomycin. Then developed VRE
bacteremia x1 BCx and was switched to daptomycin on [**4-17**]. ID felt
this was a contaminant and DCed her daptomycin. She completed
treatment for coag neg Staph bacteremia on [**2186-4-21**] with
vancomycin. However a screening BCx from her HD line taken on
[**2186-4-21**] again grew GPCs. Her skin fragility/breakdown seems like
the most likely source for her recurrent bacteremia. There is
always the possibility that her multiple line placements
recently played a role (s/p PICC, HD attempt at beside, and HD
line at IR). The PICC and HD lines were both pulled and the HD
line was replaced at IR. In addition, urine Cx from [**3-/2106**] grew
ESBL Ecoli, pan-sensitive Klebsiella, and MDR Pseudomonas. She
had initially been treated with Unasyn, then aztreonam but
changed to meropenem once cultures grew out. She developed a
drug reaction with eosinophilia to meropenem, which was then
DCed. Repeat UA was positive only for yeast x 2. Appreciate
prior ID consult. Repeat UCx with yeast only so DC'd foley as
only small amount of urine produced. Discontinued Bactrim PCP
SBP [**Name9 (PRE) 5**] per comfort measures. Continue Rifaximin for bowel
decontamination. BCx from HD line on [**2186-4-21**] grew coag neg Staph
in [**3-13**] bottles. Restarted vancomycin and pulled line on [**2186-4-24**].
New line was placed on [**2186-4-26**] by IR. Subsequent cultures
negative. Status post 7 day course of treatment with vanco from
[**4-24**]. Pus noted on R forearm [**2186-4-27**]. Culture growing yeast.
Holding treatment for comfort measures. No further antibiotics
planned.
.
#. Acute on Chronic Kidney Injury: Patient's baseline Cr PTA was
1.8-1.9. She now seems to have HRS. Her Cr did no respond to
increasing doses of octreotide, midorine, and albumin and she
was unable to manage her volume status with a Cr around 3. She
was ultimately started on HD for respiratory distress [**3-13**]
hypervolemia. She is now essentially anuric. Discontinued
octreotide once on HD to preserve skin integrity. Discontinued
midodrine as hypertensive. Discontinued albumin as ineffective.
Goals of care are palliative at this point, discontinuing HD for
ongoing severe hemorrhage from heparin from lines.
.
#. Encephalopathy: Ongoing hepatic encephalopathy likely
complicated by delirium. Continue Lactulose and rifaximin with
goal to keep patient lucid, may refuse if she wants.
.
# Respiratory Distress: Patient transferred to ICU with
respiratory distress on [**4-15**], thought to be [**3-13**] volume overload.
Her respiratory symptoms improved with initiation of HD.
.
#. HCV and MTX Cirrhosis: MELD rising now that on HD, but not a
candidate for [**Month/Day (2) **] give poor clinical status and risks of
surgery and immune suppression in this patient. Continue
management of hepatic encephalopathy as above. Discontinued
bactrim given focus on comfort.
.
#. Type II Diabetes Mellitus: Lantus only with QAM fingersticks.
.
ICU course: Was transferred to the MICU on HOD 11 ([**2186-4-16**]) for
worsening respiratory distress and fatigue with tachypnea to
30's, hypoxemia requiring 4L NC (previously on RA). CXR c/w
volume overload and team requesting ICU transfer. The patient
received 2U PRBCs and it was thought that fluid overload and
renal failure played a role in the respiratory distress. The
patient pulled out her PICC line, so IR placed a VIP port.
Lactulose was started with good effect of large BMs. Blood
cultures were positive for VRE and the patient was started on
daptomycin. She received hemodialysis on HOD 12 ([**2186-4-18**]). Was
transferred back to the floor after O2 supplementation was
weaned to room air.
Medications on Admission:
Rifaximin 400 mg TID
Metoclopramide 5 mg TID
Prochlorperazine Maleate 5 mg q6h prn for nausea
Triamcinolone Acetonide 0.1 % Cream [**Hospital1 **]
Famotidine 20 mg daily
Lactulose 30 mL qid
Glargine Insulin 20 U daily
RISS
Albuterol nebulizations q4h prn
Ascorbic Acid 500 mg [**Hospital1 **]
Zinc Sulfate 220 mg daily
Bacrim SS daily
Midodrine 5 mg TID
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
2. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
4. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO TID (3
times a day).
5. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical DAILY
(Daily): To erosions on chest, legs, and arms daily and cover
with telfa gauze and tegaderm.
6. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Thrombin (Bovine) 5,000 unit Recon Soln Sig: One (1) Recon
Soln Topical PRN (as needed): apply to bleeding areas for
hemostasis.
9. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Morphine 10 mg/5 mL Solution Sig: 5-10 mg PO Q2H (every 2
hours) as needed.
14. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
15. Simethicone 80 mg Tablet, Chewable Sig: [**2-10**] Tablet,
Chewables PO BID (2 times a day) as needed for gas.
16. Insulin Glargine 100 unit/mL Solution Sig: Five (5) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] [**Doctor Last Name **] Nursing and Rehabilitation Center
Discharge Diagnosis:
Primary diagnosis: Urinary tract infection, recurrent
bacteremia, hepatorenal syndrome, cirrhosis, hepatic
encephalopathy
.
Secondary diagnosis: Diabetes, depression
Discharge Condition:
Stable vital signs, tolerating POs, alert and oriented x 2, poor
skin integrity
Discharge Instructions:
It has been a pleasure taking care of you at [**Hospital1 771**].
.
You were admitted for renal failure and a urinary tract
infection. You ultimately needed to start dialysis for your
renal failure. Your hospital course was complicated by multiple
infections attributed to your skin problems. Dermatology
consulted on your skin problems but despite our best efforts you
continue to have skin breakdown. You have had several infections
of your blood which have been treated with antibiotics. Because
of your ongoing bleeding we cannot continue with dialysis.
.
At this point the goal of your care is comfort. Given that, you
have the right to refuse any treatments we offer. We have
thinned your medication list to those things which will make
your life more comfortable.
Followup Instructions:
None
Completed by:[**2186-5-1**]
|
[
"5849",
"5990",
"2761",
"5859",
"4280",
"V5867"
] |
Admission Date: [**2164-4-5**] Discharge Date: [**2164-4-7**]
Date of Birth: [**2100-9-22**] Sex: F
Service: MEDICINE
Allergies:
Gentamicin
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Anemia, coaguloathy.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 63 year-old woman with history of CVA and renal
transplant in [**2147**] at [**Hospital1 112**], on coumadin s/p CVA and for blood
clot in her legs many years ago. Two weeks ago she banged her
right leg which subsequently became red and swollen; she saw her
PCP; there was no fracture, and she was started on Keflex for
possible cellulitis. Reportedly there was no adjustment in
coumadin dosing. Patient did well but did experience some mild
nausea, and extensive bruising on left wrist, right leg,
abdomen. She also felt very ill and tired. She held her coumadin
for the last 2 days for bruising. She went back to her PCP who
drew labs notable for INR 8, Hct 16, and Cr 3.5 (unclear
baseline, but closer to normal). Patient was advised to come to
the ED for evaluation, where initial vs were: T 97.9, HR 85, BP
179/81, RR 16, O2 sat 99% RA. Exam: multiple ecchymoses. There
was a cellulitic area on the RLE but no fluctuance. She was
guiaic positive, but there was minimal BRBPR. Labs were notable
for WBC 15, Hct 15, Plt nml. INR was 24. Cr was 3.7, foley with
good UOP, LFT's okay, CXR nml, FAST scan negative. Patient was
given CTX/vanco, 2 units FFP, 2 units PRBC's morphine and
zofran.
.
She was admitted to the MICU given her low hematocrit and
bleeding risk. In the MICU she recieved 4 units FFP, Vitamin K,
and 4 units of blood. CT abdomen showed no retroperitoneal
bleed. When her hematocrit remained stable, she was transferred
to the floors.
Past Medical History:
- CVA
- s/p renal transplant ([**3-5**] to HTN, high cholesterol)
- hypertension
- hypercholesterolemia
- s/p R-hip replacement at [**Hospital1 112**]
- history of DVT 12 years ago, diagnosed with hypercoaguable
state at that time, ? etiology
Social History:
She quit tobacco in [**2146**], denies etoh use, lives with husband,
works at [**Name (NI) 80897**].
Family History:
Father deceased from CAD, h/o mouth cancer; mother deceased from
brain cancer.
Physical Exam:
Vitals: T: 99.0 BP: 127/59 P: 83 RR: 20 O2Sat: 99% RA
Gen: no acute distress
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. [**4-6**] murmuer LUSB, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. Large ecchymosis on abdomen
EXT: 3+ edema. 2+ DP pulses BL. Right ankle swollen,
erythmatous, painful.
SKIN: numerous ecchymoses on upper extremities; small nodule on
volar aspect of left wrist, ?hematoma versus subcutaneous nodule
?gout.
Pertinent Results:
Labs at Admission:
[**2164-4-4**] 11:20PM BLOOD WBC-15.7* RBC-1.77* Hgb-5.0* Hct-15.0*
MCV-85 MCH-28.1 MCHC-33.0 RDW-16.2* Plt Ct-428
[**2164-4-4**] 11:20PM BLOOD Neuts-82.6* Lymphs-13.5* Monos-3.4
Eos-0.4 Baso-0.1
[**2164-4-4**] 11:20PM BLOOD PT-138.5* PTT-52.1* INR(PT)-24.6*
[**2164-4-4**] 11:50PM BLOOD Fibrino-306
[**2164-4-4**] 11:50PM BLOOD Ret Aut-3.6*
[**2164-4-6**] 05:45AM BLOOD ACA IgG-4.0 ACA IgM-8.2
[**2164-4-4**] 11:20PM BLOOD Glucose-154* UreaN-136* Creat-3.7* Na-138
K-4.3 Cl-101 HCO3-20* AnGap-21
[**2164-4-4**] 11:50PM BLOOD ALT-16 AST-36 CK(CPK)-1152* AlkPhos-30*
TotBili-0.6 DirBili-0.3 IndBili-0.3
[**2164-4-4**] 11:50PM BLOOD Albumin-3.7 Calcium-9.1 Phos-4.9* Mg-1.7
Iron-182*
[**2164-4-4**] 11:50PM BLOOD calTIBC-432 VitB12-442 Folate-9.4
Hapto-<20* Ferritn-532* TRF-332
[**2164-4-5**] 05:44AM BLOOD Cyclspr-58*
.
Labs at Discharge:
[**2164-4-7**] 06:45AM BLOOD WBC-10.1 RBC-3.19*# Hgb-9.9*# Hct-27.0*
MCV-85 MCH-30.9 MCHC-36.5* RDW-16.0* Plt Ct-290
[**2164-4-7**] 01:45PM BLOOD WBC-10.4 RBC-3.29* Hgb-10.4* Hct-27.9*
MCV-85 MCH-31.5 MCHC-37.1* RDW-16.0* Plt Ct-307
[**2164-4-7**] 02:20PM BLOOD Hct-28.3*
[**2164-4-7**] 06:45AM BLOOD Glucose-98 UreaN-81* Creat-2.2* Na-141
K-3.6 Cl-105 HCO3-24 AnGap-16
[**2164-4-7**] 06:45AM BLOOD Hapto-30
[**2164-4-7**] 06:45AM BLOOD LD(LDH)-555*
.
Studies:
.
Renal transplant ultrasound ([**4-5**]):
1. Mildly elevated intrarenal resistive indices of unknown
chronicity or significance (in the absence of previous imaging
studies).
2. No hydronephrosis. Anechoic structure in right renal hilum,
likely a parapelvic cyst.
.
Right ankle x-ray ([**4-5**]): Distal pretibial soft tissue swelling
without radiographic evidence of osteomyelitis.
.
CT abdomen and pelvis ([**4-5**]):
1. No evidence of retroperitoneal hematoma.
2. Atherosclerotic disease is seen in the coronary arteries and
aorta.
3. Small hiatal hernia.
4. Renal lesions in the interpolar region of both the right and
left kidney
which are not fully characterized on this study.
Brief Hospital Course:
A 63 year-old woman with history of HTN/ESRD s/p LRRT [**2147**]
presented [**4-5**] with supratherapeutic INR to 24 and hct 15
(admitted overnight to MICU [**4-5**]-->[**4-6**]), now s/p FFP and vitamin
K with INR 1.3 and s/p 6U PRBCs with hct 21 and stable.
.
Anemia.
Her drop in hematocrit (from baseline mid 30s per OSH records)
was felt to be due to extensive subcutaneous ecchymoses and GI
losses in the setting of an INR >24 on presentation. She was
guiaic positive in the ED and on the floors; however, it is
unclear how useful this test is in the setting of such a high
INR. Per patient, she had a normal colonoscopy within the last 3
years. Because her hematocrit stabilized once her INR corrected,
we felt that inpatient colonoscopy was not necessary. Her CBC
could be followed up as outpatient, and stool guiaics repeated
if her hematocrit does not return to baseline.
In total during this admission, she was transfused 8U PRBCs. At
time of discharge, her hematocrit was 27-->28 without any
additional transfusions. This remained stable for over 24 hours.
Her INR was 1.3.
.
Supratherapeutic INR.
This was likely due to an interaction between coumadin and
Keflex. She denied any recent changes to her diet or herbal
supplements although several other of her medications were
recently adjusted. She received FFP and vitamin K and her INR
came down to 1.3. We did not restart her coumadin. She will
follow-up with her primary physician and hematologist regarding
when to restart this medicine. We stopped the Keflex as she had
already completed a 14-day course for cellulitis.
.
Acute on Chronic Renal Failure.
Her baseline renal function was not clear, since most of her
care is at [**Hospital1 112**]. However, patient believed her baseline
creatinine to be 1.8. At presentation her creatinine was 3.7.
This came down to 2.2 after the blood transfusions. Thus the
most likely cause for her renal failure was decreased renal
perfusion from acute blood loss. In support of this was a FeNA
<1% at admission. During this admission, we continued her
Cellcept and prednisone; cyclosporine dose was adjusted slightly
because levels were low. She will follow-up with her
nephrologist at [**Hospital1 112**].
.
Leukocytosis/cellulitis.
Her leukocytosis resolved on the first hospital day. She was
continued on nafcillin for treatment of RLE cellulitis. However,
when it was clear that she had already completed a 14-day course
of treatment, antibiotics were stopped. X-rays of her right
ankle were negative for osteomyelitis.
.
Left wrist swelling.
Plastics (hand surgery) was consulted in the emergency room and
recommended for light compression with ACE bandage and a volar
resting splint from OT. They did not believe there was
hemarthrosis. She can follow up in hand clinic at [**Hospital1 18**].
.
Hypertension.
We held her outpatient antihypertensives initially in the
setting of possible bleed. When it was clear that her hematocrit
was stable and that she was not actively bleeding, metoprolol
and Lasix were restarted. We have held her ACEI until she
follows up with her primary physician.
.
CVA/Hypercoagable state.
As above, coumadin was held due to supratherapeutic INR. This
can be restarted after she discusses with her primary care
physician and hematologist.
.
She was kept on a regular diet. Her code status is full code.
Medications on Admission:
- coumadin 5mg daily
- prednisone 5mg daily
- cellcept [**Pager number **]/750
- cyclosporine 100/50
- metoprolol 25 [**Hospital1 **]
- lisinopril 20 mg daily
- tricor (?) 145mg
- crestor 40 mg daily
- lasix 20 mg daily
Discharge Medications:
1. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule PO
Q12H (every 12 hours).
Disp:*180 Capsule(s)* Refills:*0*
2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours as needed: No more than 200 mg total in one day.
Disp:*30 Tablet(s)* Refills:*0*
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Mycophenolate Mofetil 250 mg Capsule Sig: Three (3) Capsule
PO BID (2 times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
8. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses
Supratherapeutic INR
Anemia from blood loss
Acute on chronic renal failure
.
Secondary Diagnoses
Hypertension
Hypercholesterolemia
Discharge Condition:
Vital signs stable. Hematocrit stable. Renal function improving.
Discharge Instructions:
You were hospitalized because your INR was supratherapeutic and
there was concern of bleeding risk. Your hematocrit was also
found to be very low (15), which we suspect was due to bleeding
into the skin and probably a small amount of blood loss into the
gastrointestinal tract. We treated the symptoms with fresh
frozen plasma (FFP) and vitamin K to help reverse the effects of
coumadin. You also received several units of blood transfusions
to help increase the hematocrit. At the time of discharge, the
hematocrit is 27 and stable. We do not think there is any active
bleeding.
.
We have made several changes to your medicines:
1. We changed the dose of cyclosporine to 75 mg twice daily.
2. We stopped the Keflex. You have finished a sufficient course
of antibiotics for treatment of cellulitis.
3. We stopped the coumadin. Please discuss with your primary
care provider and your hematologist when the appropriate time to
restart this medicine is.
4. We stopped the lisinopril due to acute renal failure (now
resolving). Please discuss with your primary care physician when
to restart this medicine. He may want to check your renal
function before restarting.
5. We added Tramadol. This can be taken up to two times daily
for pain related to the right leg trauma.
.
Please follow-up with your primary physician next week. It will
be important to see your hematologist and nephrologist in the
next couple weeks, to discuss this admission and some of the
medication changes.
.
Please call your doctor or return to the emergency room if you
have bleeding, fever, or other symptoms that are concerning to
you.
Followup Instructions:
1. Please follow-up with your primary physician next week.
2. Please schedule follow-up with your hematologist to discuss
when to restart warfarin.
3. Please schedule follow-up with your nephrologist.
4. If you would like, you can schedule a follow-up appointment
in the hand clinic at [**Hospital1 18**]. The number to call is [**Telephone/Fax (1) 3009**].
They have clinic on Tuesday afternoons.
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2164-4-8**]
|
[
"5849",
"2851",
"5859",
"40390",
"2720"
] |
Admission Date: [**2125-4-14**] Discharge Date: [**2125-4-24**]
Date of Birth: [**2073-11-30**] Sex: M
Service: TRANSPLANT SERVICE
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
male with a history of end-stage renal disease secondary to
immune complex glomerulonephritis on hemodialysis, who
underwent a right arm AV graft placement on the day prior to
admission. The patient had been discharged to the nursing
home where he resides, in good condition with a palpable
thrill.
The patient noted that after returning to the nursing home,
he had increased pain and swelling of the right arm. The
nursing home noted increased erythema on postoperative day
#1. The patient had a low-grade temperature and was then
sent to the Emergency Room for further evaluation.
He denied any rigors or chills. The patient had one episode
of emesis. No shortness of breath or chest pain. In
addition, the patient had preoperative vein mapping by
ultrasound which showed patent bilateral cephalic, basilic
and proximal deep venous systems.
PAST MEDICAL HISTORY: 1. End-stage renal disease secondary
to glomerulonephritis on hemodialysis. 2. End-stage liver
disease. 3. Hepatitis C cirrhosis. 4. Hypertension. 5.
History of lymphatic encephalopathy requiring multiple
admissions. 6. Esophageal varices, grade II. 7.
Esophageal reflux disease. 8. Peripheral neuropathy.
PAST SURGICAL HISTORY: Left AV fistula creation on [**2125-4-13**].
MEDICATIONS ON ADMISSION: Lopressor 100 mg p.o. b.i.d.,
Prevacid 30 mg p.o. b.i.d., Calcium Carbonate 500 mg p.o.
t.i.d., .................... 1 g q.i.d., Elavil 40 mg p.o.
q.h.s., Milk of Magnesia p.r.n., Lactulose, Oxycodone [**12-28**]
5-10 mg p.o. q.4-6 hours p.r.n.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient has a history of smoking one
pack a day. History of ETOH abuse and intravenous drug abuse
in the past.
PHYSICAL EXAMINATION: Vital signs: On admission the patient
had a temperature of 100.6??????, heart rate 78, blood pressure
180/107, 100% oxygen saturation. General: He was alert and
uncomfortable. Neck: Supple. No carotid bruits. Chest:
Clear to auscultation bilaterally. Heart: Regular, rate and
rhythm. Abdomen: Soft, nontender, nondistended.
Extremities: The right arm had palpable radial and ulnar
pulses. Sensation was equal bilaterally. There was an
incision on the right forearm which was clean, dry, and
intact with erythema medially. There was 2+ edema.
Bilateral lower extremities were warm.
LABORATORY DATA: White count 10.5, hematocrit 37.4, platelet
count 93, BUN 63, creatinine 6.6, potassium 6.2.
Chest x-ray on admission revealed no evidence of infiltrate
or congestion.
HOSPITAL COURSE: The patient was admitted to the Transplant
Service and was placed on Vancomycin, Ciprofloxacin and
Flagyl for presumed right arm cellulitis.
over the next several days, his swelling continued to worsen,
but the patient remained afebrile, and his white count
normalized.
The night of hospital day #3, the patient was complaining of
shortness of breath, and oxygen saturation was checked which
was found to be 78%. The patient was immediately placed on a
nonrebreather, and his oxygen saturation improved to 100%.
(To be continued)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 106549**]
MEDQUIST36
D: [**2125-4-23**] 13:25
T: [**2125-4-23**] 13:28
JOB#: [**Job Number **]
|
[
"40391",
"5180",
"2762",
"5070",
"51881"
] |
Admission Date: [**2171-4-2**] Discharge Date: [**2171-4-4**]
Date of Birth: [**2117-12-21**] Sex: M
Service: NEUROSURGERY
Allergies:
Heparin Agents / Keppra
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
brain tumor
Major Surgical or Invasive Procedure:
left frontal-parietal craniotomy
History of Present Illness:
53yo male underwent craniotomy for GBM [**9-6**], went to rehab and
returned few weeks later for wound debridement with subsequent
IV antibiotic treatment. He has been undergoing treatment of
Temodar. He experienced seizure [**2171-3-10**] and had repeat studies
showing increase in tumor size.
Past Medical History:
ileostomy secondary to IBD [**2143**]
GERD
HTN
hyperlipidemia
Social History:
married
Family History:
not obtained
Physical Exam:
awake looking around, occasionally nods appropriately
PERRLA
face symmetric
follows a few commands
no movement on right
DTR: 2+ left UE/LE
2+ right LE, absent UE
Pertinent Results:
[**2171-4-2**] 05:07PM GLUCOSE-118* UREA N-10 CREAT-0.7 SODIUM-131*
POTASSIUM-4.1 CHLORIDE-96 TOTAL CO2-26 ANION GAP-13
[**2171-4-2**] 05:07PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.6
[**2171-4-2**] 05:07PM WBC-6.7 RBC-3.71* HGB-13.8* HCT-37.6*
MCV-102* MCH-37.3* MCHC-36.7* RDW-13.2
[**2171-4-2**] 05:07PM PLT COUNT-176
[**2171-4-2**] 05:07PM PT-12.6 PTT-24.6 INR(PT)-1.1
Brief Hospital Course:
Pt was admitted and brought to the OR where under general
anesthesia he underwent a left frontal-parietal craniotomy for
biopsy. Post op he was transferred to PACU for close neurologic
monitoring. A post op head CT showed minimal blood in surgical
bed consistent with normal post op changes. He had a repeat head
Ct on the morning of post op day #1 for questionable decreased
mental status which was stable. He was transferred to the
floor. He was seen by Dr. [**Last Name (STitle) 4253**] from neurooncology. She had
long discussion with pt and wife about treatment plans. His
vital signs remained stable. His diet was advanced and
supplemented with tube feeding via PEG. He was discharged home.
Medications on Admission:
albuterol
baclofen
decadron (during temodar cycles - last one [**2171-3-4**])
flomax
metoprolol
prilosec
adderall
namenda
exelon
tegretol
coumadin dc'd [**2171-3-26**]
zofran prn
Discharge Medications:
1. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release
24HR Sig: One (1) Capsule, Sust. Release 24HR PO q day ().
2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. Temodar 100 mg Capsule Sig: Four (4) Capsule PO hs (): takes
5 out of 28 days.
4. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO 3 () as
needed: at 3pm.
5. Carbamazepine 300 mg Cap, Multiphasic Release 12 HR Sig: One
(1) Cap, Multiphasic Release 12 HR PO BID (2 times a day).
6. Rivastigmine 3 mg Capsule Sig: Two (2) Capsule PO bid ().
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
8. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
12. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO DAILY (Daily).
14. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
15. Oxycodone 5 mg/5 mL Solution Sig: [**2-4**] PO Q4-6H (every 4 to
6 hours) as needed.
Disp:*1 bottle* Refills:*1*
16. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
17. Amphetamine-Dextroamphetamine 20 mg Capsule, Sust. Release
24HR Sig: Three (3) Capsule, Sust. Release 24HR PO q day ().
18. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO 3 () as
needed.
19. Carbamazepine 300 mg Cap, Multiphasic Release 12 HR Sig: One
(1) Cap, Multiphasic Release 12 HR PO BID (2 times a day).
20. Rivastigmine 3 mg Capsule Sig: Two (2) Capsule PO bid ().
21. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*1*
22. saline Sig: One (1) capsule Inhalation every six (6) hours
as needed for shortness of breath or wheezing: use with
albuteral nebulizer.
Disp:*60 capsule* Refills:*1*
23. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed.
Disp:*60 Tablet(s)* Refills:*0*
24. Insulin Regular Human 100 unit/mL Solution Sig: One (1) ml
Injection qid as needed: prn sliding scale chart.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Glioblastoma multiforme
Discharge Condition:
neurologically unchanged
Discharge Instructions:
Keep staples dry. Call for fever or any signs of infection -
redness, swelling or drainage from wound.
Followup Instructions:
Follow up for staple removal in 10 to 14 days. Call Dr. [**Name (NI) 14075**] office for appt [**Telephone/Fax (1) 1669**] if not able to have
visiting nurse remove.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2171-4-4**]
|
[
"4019",
"V5861"
] |
Admission Date: [**2186-8-22**] Discharge Date: [**2186-8-29**]
Date of Birth: [**2139-5-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
abdominal pain, bloody stools
Major Surgical or Invasive Procedure:
Diagnostic paracentesis
[**First Name3 (LF) **] transfusion
History of Present Illness:
47 year old female with a history of EtOH abuse, untreated HCV -
likely cirrhosis, Grade I esophageal varices, esophagitis and
GAVE on endoscopy ([**7-9**]), and recent hospitalization for c. diff
colitis presents with persistent abdominal pain and 1 week of
bloody stools (describes as coffee ground w/ some [**Month/Year (2) **]
streaking). She states that her abdominal pain did not really
resolve after discharge and she did take the remaining doses of
Flagyl. In the meantime she presented to [**Hospital1 336**] about 1 week ago
for [**Hospital1 **] in her stools, she was hospitalized for 4 days,
reportedly had a negative C.dif, and receieved 2 units of pRBCs.
Per patient report she did not get any additional imaging. She
reports that she had a small amount of emesis with red [**Hospital1 **] in
it. She has also noticed that her abdomen is much more distended
than usual since her C.dif infection, and even seems worse. She
needs to force food down to eat because she is uncomfortable,
but no nausea. She reports low grade temp 99-100 with chills,
+fatigue, but denies chest pain, cough, or dyspnea. No sick
contacts. She reports drinking 6 beers yesterday evening.
.
In ED, initial vitals Temp 97.8 P 108 BP 98/62 RR 12 POx 99% RA.
Patient got 2 IVs, IV PPI, 5mg vitamin K, 2mg morphine for pain,
IL NS. T&S and 2 units pRBCs ordered. Started valium CIWA scale.
KUB ordered, started on cipro/flagyl. Hepatology was contact[**Name (NI) **],
and recommended serial hct, no NGT or octreotide for now, [**Hospital1 **]
PPI, add [**Doctor First Name **]/lip, utox, C. diff, stool cx E. coli, liver u/s, CT
abd if HD unstable.
Past Medical History:
1. Depression
2. Raynaud's
3. Polysubstance Abuse- Past history of IV drug use with heroin
and cocaine (none in many years). Continues to drink alcohol, up
to one pint of vodka daily, less recently. Continues to smoke
tobacco -[**12-2**] PPD
4. Hepatitis C Infection
5. Presumed Cirrhosis c/b grade 1 esophageal varices (EGD [**7-9**])
6. Anemia
7. Chronic Abdominal Pain
8. Lumbar Stenosis
9. Lumbar Disk Herniation
10. History of an upper GI Bleed
11. History of C.diff colitis in [**9-3**]
12. History of restless legs syndrome noted in [**9-3**]
13. History of Cholecystitis s/p Cholecystotomy tube at [**Hospital1 336**]
14. History of facial cellulitis in [**5-6**]
15. History of alcoholic pancreatitis
16. History of ampullary stenosis s/p sphincterotomy and ERCP in
[**8-4**]
17. s/p sexual assault in [**2180**] while hospitalized at a
psychiatric institution
Social History:
Tobacco - [**12-2**] PPD x 20 years
EtOH - up to 1 pint vodka daily
Drugs - previous history of cocaine and IV heroin
Lives with boyfriend; has an 18 yo daughter.
Family History:
Not elicited.
Physical Exam:
Vitals: Afebrile BP 115/80 HR 80 O2 100% on 2L
Gnl: NAD, Alert and oriented x 3
HEENT: Anicteric, MMM
CV: RRR, Normal S1 + S2, No murmurs, rubs or gallops
Resp: Clear to auscultation bilaterally, No wheezes or crackles
Abd: +Distention, no appreciable fluid wave, +TTP, no guarding,
no rebound, no discernable HSM
Extremities: No cyanosis, clubbing or edema
Neuro: AAOx3. Strength grossly intact throughout. No sensory
deficits to light touch appreciated.
Rectal (by ED resident): guaiac pos x2, dark red clot
Pertinent Results:
Labs on admission:
[**2186-8-22**] 10:29PM WBC-4.5 RBC-2.93* HGB-8.5* HCT-27.1* MCV-93
MCH-29.2 MCHC-31.5 RDW-19.7*
[**2186-8-22**] 10:29PM PLT COUNT-168
[**2186-8-22**] 10:29PM PT-16.7* PTT-37.3* INR(PT)-1.5*
[**2186-8-22**] 08:30AM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2186-8-22**] 12:48AM ALT(SGPT)-9 AST(SGOT)-51* ALK PHOS-125*
AMYLASE-67 TOT BILI-0.6
[**2186-8-22**] 12:48AM ASA-NEG ETHANOL-293* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Imaging:
KUB:
IMPRESSION: Non-obstructive bowel gas pattern.
CT abd/pelvis:
Increase in ascites since prior study. Persistent wall
thickening and edema of the ascending and transverse colon, with
new/worsened edema involving the stomach and proximal small
bowel. No perforation, obstruction or abscess formation.
EGD [**2186-7-27**]: 3 grade 1 varices at the lower third of the
esophagus, friable erosive esophagitis, erythema, friability,
congestion and abnormal vascularity in the whole stomach
compatible with portal hypertensive gastropathy. Linear
erythematous streaks radiating from the pyloris in the antrum
and pylorus compatible with Gastric Antral Vascular Ectasia.
Small sliding hiatal hernia. Otherwise normal EGD to third part
of the duodenum
Micro:
[**2186-8-22**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2186-8-22**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
[**2186-8-22**] [**Year (4 digits) 3143**] CULTURE [**Year (4 digits) **] Culture, Routine-PENDING
INPATIENT
[**2186-8-22**] [**Year (4 digits) 3143**] CULTURE [**Year (4 digits) **] Culture, Routine-PENDING
INPATIENT
[**2186-8-22**] URINE URINE CULTURE-PENDING INPATIENT
Brief Hospital Course:
47 year old lady with a history of untreated HCV, likely
cirrhosis, portal gastropathy + grade I varices, and recent
hospitalization for c. diff colitis who presents with persistent
abd pain, apparent GI bleed and worsening anemia.
1. Acute [**Year (4 digits) **] loss/ anemia: Original concern for upper GI bleed
vs lower GI bleed. Recent endoscopy showed grade I varices so
these are less likely cause. Either gastritis, esophagitis or
vascular ectasia more likely subacute source. Has not had recent
colonoscopy in setting of recent C.diff infection, so may also
have a lower source. Transfused 2 units pRBCs in ED with
appropriate bump in CRIT. Stable hematocrits since. Continued
on IV PPI [**Hospital1 **] and then changed to PO. Hct remained stable. Had
HCT of 25 on D/C which is her baseline. No further transfusions
were necessary. Was placed on IV PPI as per hepatology on [**8-29**]
but On discharge, was transitioned to PO PPI [**Hospital1 **]. As per
hepatology recs, she is scheduled for outpatient colonoscopy on
Friday [**9-1**].
2. Abdominal pain/recent C.diff infection: Given abdominal pain
and at least transient hypotension, concern for continued more
severe infection. Sent stool for Cdiff but this was negative.
She was maintained on PO vanco. CT showed thickening of bowel
wall/edema (likely from Cdiff). She will need a colonoscopy as
an outpatient. Also with ascites on CT. Got diagnostic
paracentesis for possible subacute SBP, which was unremarkable.
Pain controlled with oxycodone. She was discharged on 9 more
days of PO vancomycin 125mg q6 hours for a total treatment
course of 14 days (started [**2186-8-24**] to end on [**2186-9-6**])
3. EtOH Abuse: Intoxicated on admission. Maintained on valium
CIWA, thiamine, folic acid, social work consulted. CIWA stopped
as pt not requiring it, not having symptoms of withdrawal.
Counseling, education and social work consult done.
4. Cirrhosis - History of EtOH abuse and Hepatitis C. EGD
w/findings c/w esopagitis and portal gastropathy. Abdominal
ultrasound showed 1. Findings consistent with hepatic cirrhosis
with patent hepatic vasculature
and appropriate directionality of flow. 2. Small amount of
ascites. 3. Right renal cyst. There was also a question of
autoimmune hepatitis as: [**Doctor First Name **] of 1:640, +[**Last Name (un) 15412**] and elevated IgG.
Known Raynaud's. All labs at baseline. Hepatology followed and
did not recommend tap or starting diuretics as there was only a
small amount of ascites fluid on ultrasound. She will follow-up
in Liver clinic.
Medications on Admission:
1. Methadone 10 mg Tablet Sig: Four (4) Tablet PO once a day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Discharge Medications:
1. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID:prn as needed for
constipation.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO four times a
day.
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
10. Alum-Mag Hydroxide-Simeth 200-200-20 mg Tablet, Chewable
Sig: One (1) Tablet, Chewable PO four times a day as needed for
constipation.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
13. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 9 days.
Disp:*36 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
GI bleed
Secondary:
Cirrhosis
Hepatitis C infection
Depression
History of polysubstance abuse
History of bulimia
Anemia
Discharge Condition:
Afebrile, hemodynamically stable, breathing comfortably,
tolerating po intake.
Discharge Instructions:
You were admitted to the hospital because of concern that you
were bleeding from your GI tract. We monitored your bleeding
and transfused red [**Last Name (un) **] cells when your hematocrit was low. We
also gave you antibiotics for concern of C.diff infection
contracted on a previous hospitalization. We also performed a
diagnostic paracentesis where we drained fluid from your
abdomen.
Medication changes:
- Please take all medications as prescribed, please take all
vitamins and supplements as well.
- Please take the antibiotic Vancomycin 125mg by mouth every 6
hours (ie 4 times per day) for 9 more days to complete a 14 day
course. You started this medication on [**8-24**] and you will
take your last dose
on [**9-6**].
Please follow-up with outpatient Liver Clinic and get your
colonoscopy this Friday [**9-1**].
Please call your doctor or seek medical attention if you
experience fever>101.4, see [**Month (only) **] in your stool or vomit, if you
have difficulty breathing, persistent diarrhea, worsening
abdominal pain, marked distention of your belly, or any other
symptoms which are concerning to you.
.
It was a pleasure participating in your medical care.
Followup Instructions:
Please keep the following appointments:
1.) Post hospitalization check up
Provider: [**Name10 (NameIs) 191**] POST [**Hospital 894**] CLINIC Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2186-9-4**] 8:10
2.) Hepatology follow up appointment:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2186-10-19**] 4:40
3. Colonoscopy GI [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2186-9-1**]
9:30
Completed by:[**2186-8-30**]
|
[
"2851",
"311",
"3051"
] |
Admission Date: [**2146-1-17**] Discharge Date: [**2146-1-22**]
Date of Birth: [**2100-9-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Latex / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue/Dyspnea/Chest pain
Major Surgical or Invasive Procedure:
[**2146-1-18**]
Coronary Artery Bypass Graft x 2 with reverse saphenous vein
graft --> Right coronary artery and Diagonal
History of Present Illness:
45 year old gentleman with a cardiac history significant for a
myocardial infraction in [**2142**] with subsequent percutaneous
intervention to his circumflex and second obtuse marginal
artery. He did well until [**2145-6-12**] when he developed chest pain
and was admitted to [**Hospital6 5016**]. A cardiac
catheterization
revealed an anomalous right coronary artery (unsure if this is a
new finding), a 60% first diagonal artery stenosis and no other
significant coronary artery disease. Nuclear stess testing
showed stress induced myocardial ischemia in the inferolateral
wall. He continued to complain of daily chest pain, fatigue and
dyspnea. Given his symptoms and the findings of his stress test,
he had been referred for reimplantation if his anomalous right
coronary artery versus coronary artery bypass grafting.
Cardiac Catheterization: Date: [**2145-6-18**] Place: [**Hospital3 **]
Left dominate system with anomalous right coronary artery off
the
left main, patent left main, patent left anterior descedning,
60%
first diagonal artery, patent RCA. LVEF 60%. Patent left
Circumflex stent.
Stress test: [**2145-6-19**]
EKG negative and no angina with exertion.
Scan showed mixed moderate persistent and stress induced
myocardial ischemia in the inferolateral wall of the LV. LVEF
45%
with exercise. Mild to moderate hypokinesia in the lateral wall
and apical portion of the LV. Moderate persistent LV
enlargement.
Past Medical History:
Myocardial infarction [**1-/2143**]
Coronary artery disease
Hyperlipidemia
Hypertension
Hemorrhoids
Gastroesophageal Reflux Disease
Depression
Anxiety
Obstructive Sleep Apnea, on CPAP
Past Surgical History:
- [**2143-1-26**] - Angioplasty/stenting (DES) of circumflex artery and
angioplasty of second obtuse marginal artery.
- Cyst Removal, Left Groin
Social History:
Race: Latino
Last Dental Exam: remote
Lives with: Wife
Occupation: Disabled
Tobacco: 3 cigarettes per day for last 20 years
ETOH: 1-3 beers daily
Family History:
(+) Mother with MI at age 55 and father with MI at 50. Sister
with CABG in her 50's.
Physical Exam:
BP: 151/91 HR: 69 RR/SAT: 18, 100%
5'9" 183#
General: WDWN male in NAD
Cardiac: RRR [x] Irregular [] Murmur - none
Chest: Lungs clear bilateral [x]
Abdomen: Soft [x] Nontender [x] Nondistended [x]
Extremities: Warm [x] Well perfused [x]
Edema: none
Pertinent Results:
[**2146-1-18**] 12:45AM BLOOD %HbA1c-5.8 eAG-120
Conclusions
PRE-BYPASS: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque. There are three aortic valve
leaflets. The aortic valve leaflets (3) are mildly thickened.
Trace aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a trivial/physiologic pericardial effusion.
POST CPB:
1.Preserved [**Hospital1 **]-ventricular function
2. No change in valve structure and function
3. Intact aorta
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2146-1-18**] 10:43
[**2146-1-22**] 05:30AM BLOOD WBC-6.7 RBC-2.88* Hgb-9.5* Hct-28.3*
MCV-98 MCH-33.1* MCHC-33.7 RDW-12.9 Plt Ct-162
[**2146-1-20**] 04:15AM BLOOD Glucose-111* UreaN-11 Creat-0.9 Na-138
K-4.6 Cl-103 HCO3-31 AnGap-9
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2146-1-18**] where the patient underwent coronary
artery bypass graft surgery x 2. See operative note for full
details. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically stable
on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 4 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. Gently diuresed toward his
preop weight.The patient was cleared for discharge home with VNA
services in good condition with appropriate follow up
instructions on POD #4.
Medications on Admission:
CLONAZEPAM - (Prescribed by Other Provider) - 0.5 mg Tablet - 1
Tablet(s) by mouth four times a day
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day
DIAZEPAM [VALIUM] - (Prescribed by Other Provider) - 2 mg
Tablet
- 1 Tablet(s) by mouth four times a day as needed
FAMOTIDINE - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
FLUOXETINE - (Prescribed by Other Provider) - 40 mg Capsule - 1
Capsule(s) by mouth once a day
IBUPROFEN - (Prescribed by Other Provider) - 800 mg Tablet -
[**3-17**]
Tablet(s) by mouth prn
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Sustained Release 24 hr - 2 Tablet(s) by mouth twice a
day
OMEPRAZOLE [PRILOSEC] - (Prescribed by Other Provider) - Dosage
uncertain
RISPERIDONE - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth twice a day and 1 prn
SIMVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet - 1
Tablet(s) by mouth once a day
TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth every nite
ZOLPIDEM [AMBIEN] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth as needed at nite for insomnia
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth once a day
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- 1,000 mg Capsule - 1 Capsule(s) by mouth twice a day
Allergies: Latex, Zocor (Myalgias)
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
6. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*0*
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*1*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
9. 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*
10. sodium chloride 0.65 % Aerosol, Spray Sig: [**2-13**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
Disp:*1 1* Refills:*0*
11. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO four times a
day as needed for anxiety.
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Valium 2 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for anxiety.
14. Trazadone Sig: One (1) 50 mg once a day as needed for
insomnia.
15. simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Allcare VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease s/p cabg x2
gastroesophageal reflux disease
anxiety
Myocardial infarction [**1-/2143**]
Hyperlipidemia
Hypertension
Hemorrhoids
Depression
Obstructive Sleep Apnea, on CPAP
Past Surgical History:
- [**2143-1-26**] - Angioplasty/stenting (DES) of circumflex artery and
angioplasty of second obtuse marginal artery.
- Cyst Removal, Left Groin
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] on [**2145-2-17**] at 1:30 PM
Cardiologist: Dr. [**Last Name (STitle) **] [**Name (STitle) 4922**] [**2145-2-25**] at 1:15 PM
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 16254**] in [**5-17**] weeks [**Telephone/Fax (1) 63099**]
**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:[**2146-1-22**]
|
[
"41401",
"4019",
"2724",
"32723",
"3051",
"412"
] |
Admission Date: [**2160-10-7**] Discharge Date: [**2160-10-11**]
Date of Birth: [**2089-9-14**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
cough, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 F with a h/o COPD who has had multiple admissions for COPD in
the past who presented to her PCP [**Name Initial (PRE) **] 5 days of nasal
congestion, rhinorrhea and cough. Her cough was productive of
sputum, but she had not noted the color. Her SOB was slightly
worse than baseline, but she has been able to do all of her
ADLs. She denies chest pain or pressure. She reports a minor
chronic daily cough at baseline. At her PCP's office she was
noted to desat to the mid-80s and she was send to ED for further
evaluation. She has been on home O2 in the past but not
recently. She denies HA, sinus pressure, or sore throat. She
denies sick contacts, recent long travel or swelling in her legs
or PND. She does report that she cannot breathe as easily when
laying flat.
.
In the ED, initial vs were: T 97.3 P 99 BP 160/84 R 18 O2 sat 92
on room air. Patient was given albuterol and ipratropium nebs,
methylpred 125mg and azithromycin 500mg IV x1. Her CXR was
negative for infiltrates or pulm edema. Her O2 sats decrease to
85% occasionally on 3.5L and then O2 sats increase without
intervention.
Her current VS are 93 153/63 18 95% on 3.5L.
.
On the floor, she is not in any respiratory distress and is able
to speak in full sentences. She reports that she feels well
currently.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, or congestion. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
#1 COPD - last PFTs [**3-9**] FVC/FEV1 68, FVC 82% pred, FEV1 81%
pred. stage I, mild COPD. She reports being on Home O2 for a
period of [**4-2**] months in the past. Her last COPD flare requiring
steroids and admission was 1.5 years ago.
#2 current tobacco use
#3 DM II - hgb A1c 6.9, on oral agents
#4 Obesity
#5 Hyperlipidemia
#6 Diverticulosis
#7 h/o adrenal adenoma
#8 herpes simplex
#9 hx PE in setting of OCPs 30+ years ago
#10 Chronic kidney diease - baseline Cr 1.5-2.0
Social History:
She reports smoking 2PPD x 60 years. She has quit in the past
for 6 months at a time and she has been smoking [**2-1**] ppd
recently. She denies EtOH or drugs. She lives alone and reports
that she is able to complete all of her ADLs. She is able to
walk for 15 min to and from the grocery store without getting
SOB.
Family History:
father died in 60's - EtOH
mother died @ 36 - MI. obese, smoked
sister - DM, renal failure
brother - mentally retarded
had 4 children, 1 son died @ 42 - EtOH, hemochromatosis, seizure
father died in 60's - EtOH
mother died @ 36 - MI. obese, smoked
sister - DM, renal failure
brother - mentally retarded
had 4 children, 1 son died @ 42 - EtOH, hemochromatosis, seizure
1 son
2 daughters
9 grandchildren
5 great-grandchildren
Physical Exam:
ADMISSION:
Vitals: afebrile BP: 117/49 P: 92 R: 20 18 O2: 94% on 3L NC
General: Alert & oriented x3, no acute distress, no accessory
muscle use.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP @ 7cm, no LAD
Lungs: poor airflow, + inspiratory and expiratory wheezes
diffusely, no rales, ronchi. no dullness to percussion
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE:
General: Alert & oriented x3, NAD, appears comfortable, no
accessory muscle use. Speaking full sentences without
difficulty.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: good airflow, CTAB, no wheezes, rales or rhonchi.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on admission:
[**2160-10-7**] 07:05PM GLUCOSE-120* UREA N-27* CREAT-1.8* SODIUM-143
POTASSIUM-4.7 CHLORIDE-104 TOTAL CO2-29 ANION GAP-15
[**2160-10-7**] 07:05PM WBC-9.2 RBC-4.33 HGB-12.8 HCT-38.7 MCV-89
MCH-29.5 MCHC-33.0 RDW-13.0
[**2160-10-7**] 07:05PM PLT COUNT-300
[**2160-10-7**] 07:05PM NEUTS-72.1* LYMPHS-21.2 MONOS-4.7 EOS-1.4
BASOS-0.6
[**2160-10-7**] 05:12PM GLUCOSE-145*
[**2160-10-7**] 05:12PM ALT(SGPT)-17 AST(SGOT)-23
[**2160-10-7**] 05:12PM CHOLEST-154
[**2160-10-7**] 05:12PM TRIGLYCER-180* HDL CHOL-43 CHOL/HDL-3.6
LDL(CALC)-75
Micro:
MRSA swab PENDING
1/2 bottles blood culture with gram positive cocci in clusters.
Imaging:
CXR FINDINGS: The cardiomediastinal silhouette appears
unchanged. The hilum appears unremarkable bilaterally. There is
flattening of the diaphragm and irregular distribution of
pulmonary vessels consistent with COPD. No lobar consolidation
is noted. No pleural abnormalities are seen. The osseous
structures appear unremarkable.
IMPRESSION: COPD with no acute cardiopulmonary process.
LABS AT DISCHARGE:
[**2160-10-11**] 06:45AM BLOOD WBC-9.5 RBC-3.84* Hgb-11.5* Hct-35.0*
MCV-91 MCH-30.0 MCHC-32.9 RDW-12.9 Plt Ct-277
[**2160-10-11**] 06:45AM BLOOD Glucose-160* UreaN-51* Creat-2.0* Na-144
K-4.8 Cl-106 HCO3-33* AnGap-10
[**2160-10-11**] 06:45AM BLOOD Calcium-9.2 Phos-4.8* Mg-2.3
[**2160-10-7**] 05:12PM BLOOD %HbA1c-6.9*
Brief Hospital Course:
MICU COURSE:
This 71 yo female patient with history of mild COPD and current
tobacco use presented with a cough and hypoxia, and admitted for
COPD exacerbation. She was observed for 48 hours in the MICU.
She did not require intubation; her vital signs were closely
monitored. She received albuterol and ipratropium nebs Q2, as
well as advair inhaler. Prednisone 60mg daily for COPD
exacerbation was also started. She received azithromycin 250mg x
4 days. She was advised to stop smoking but refused a nicotine
patch. Her symptoms improved with this treatment. The patient's
symptoms were most likely secondary to a COPD exacerbation in
setting of URI in a patient with current tobacco use and
untreated COPD. She was transferred to the medicine wards in
stable condition.
MEDICINE [**Hospital1 **] COURSE:
On the wards, the patient was slowly weaned off of nebulizer
treatments of albuterol and ipratropium and changed to inhalers.
Her Advair inhaler was continued. She was continued on
azithromycin to complete a 5 day course, she was also continued
on prednisone 60 mg po x 5 days and discharged on a prednisone
taper. Her blood pressure remained wnl during admission, and
her home medications were continued. She was found to have
acute on chronic renal failure, with Cr elevated from her
baseline of 1.5 to 1.8 on admission. As a result of her bump in
creatinine, the patient's home Metformin was discontinued
*******ADD LISINOPRIL IF D/Cd*****. These will be restarted as
an outpatient only if advised by her primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 410**].
On prednisone, the patient was found to have a leukocytosis and
elevated serum glucose levels, as expected. Her high serum
glucose levels were treated on a regular insulin sliding scale.
Her glyburide, which was temporarily held in the MICU, was
restarted on the medical wards.
The patient was evaluated by PT and deemed stable for discharge
to home with services on [**2160-10-11**]. Her oxygen was found to
desaturate to less than 88% with ambulation and no oxygen on.
As a result, she was sent home with VNA and continuous home
oxygen. In addition, blood glucose levels were found to be
elevated due to prednisone. We started 5 units of NPH nightly
on [**2160-10-10**], and the patient was discharged on this medication,
after having teaching by nursing in the hospital. She will have
VNA services at home for teaching regarding her new medications
and home oxygen. She will also be evaluated for home physical
therapy.
It was recommended that she follow-up with her primary care
physician within one week of discharge from the hospital.
Medications on Admission:
1.Albuterol 90 mcg HFA 2 puffs(s) INH q4-6 hrs PRN - not taking
2.Fluticasone-Salmeterol 250 mcg-50 mcg 2 discs once daily - not
taking
3.Furosemide 20 mg PO daily
4.Glipizide 15 mg PO q AM and 10mg PO qPM
5.Lisinopril 20 mg by mouth once a day
6.Metformin 1,000 mg Tablet by mouth twice a day
7.Nifedipine 30 mg by mouth once a day
8.Simvastatin 80 mg Tablet by mouth once a day
9.Aspirin 81 mg Tablet by mouth once a day
Discharge Medications:
1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days.
2. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
Disp:*14 Tablet Sustained Release(s)* Refills:*0*
3. Nifedipine 30 mg Tablet Extended Rel 24 hr (b) Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Glipizide 5 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
7. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO Q PM ().
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 11 days: Six (6) Tablets daily for 2 days, then Four (4)
Tablets daily for 3 days, then Two (2) Tablets daily for 3 days,
then One (1) Tablet daily for 3 days.
Disp:*33 Tablet(s)* Refills:*0*
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation every eight (8) hours as needed for shortness
of breath or wheezing.
11. Home oxygen
Patient required continuous home oxygen, 2-3 liters nasal
cannula. Off oxygen, desaturates to less than 88% RA.
12. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
13. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
shortness of breath, wheezing.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Chronic Obstructive Pulmonary Disease Acute Exacerbation
Acute on Chronic Renal Failure
Discharge Condition:
Stable.
Discharge Instructions:
Mrs. [**Known lastname 13204**], you were admitted to the hospital because of an
exacerbation, or worsening of your COPD. Your primary care
doctor had noticed your oxygenation to be very low during your
last visit. In addition, you had new symptoms of cough,
increased shortness of breath, and trouble breathing. We think
that this occurred because you had not been taking all of your
COPD medications, and also caught a cold that caused
inflammation in your airway and affected your breathing. At
first, you were observed and treated in the medical intensive
care unit. Your course in the medical intensive care unit was
uncomplicated, shortly after you were transferred to a regular
medical [**Hospital1 **] for further management.
During this admission, you were treated with COPD medications
like albuterol, Advair, and ipratropium inhalers. You were also
started on oral prednisone and an antibiotic called
azithromycin. You were also kept on oxygen during your hospital
stay. Your symptoms improved with this regimen, you were
evaluated by physical therapy, were found to be stable and fit
for discharge to home with visiting nursing services to monitor
your oxygen levels and blood sugars.
During this admission, you were also found to have slightly
higher kidney blood tests than normal, also called acute on
chronic renal failure. This likely occurred at first because you
were dehydrated as a result of decreased fluid intake prior to
admission. Your Metformin and Furosemide were stopped while you
were in the hospital, because of the elevation of the kidney
blood tests. Dr. [**Last Name (STitle) 410**] will decide whether or not you should
restart this medication when you see her in follow-up. You may
notice that your blood sugars are a bit higher when you leave
the hospital. This is due to the prednisone that you are taking
and should resolve once this medication course is completed. We
started you on 5 units of NPH in the hospital twice daily, which
you were taught to give yourself in the hospital, and should
take this before breakfast and at night while you are on the
prednisone. You should continue the insulin while on the
prednisone and then follow up with you PCP about further blood
sugar control as your blood sugars will be lower once you stop
the steroids.
You are also going home on continuous oxygen. The reason for
this is that we found that your oxygen in your blood got to very
low levels when walking when you did not have the oxygen on. It
is VERY IMPORTANT that you do not smoke while you have the
oxygen on as this is a fire [**Doctor Last Name 13205**] and can be VERY dangerous.
It is very important that you adhere to the medication regimen
that is prescribed for you. Please make a follow-up appointment
with Dr. [**Last Name (STitle) 410**] within ONE WEEK OF DISCHARGE by calling her
office at: [**Telephone/Fax (1) 1144**]. Should you experience any fevers,
shortness of breath, lightheadedness, or other concerning
symptom, you should report these symptoms to a health care
provider immediately or go to an emergency room immediately.
There have been several changes to your medications during this
hospital stay as outlined below:
MEDICATIONS THAT HAVE BEEN STOPPED:
Metformin 1000 mg po twice daily
Furosemide 20 mg PO daily
These medications should be re-started only if advised by Dr.
[**Last Name (STitle) 410**].
NEW MEDICATIONS:
Prednisone 60mg PO once daily for 2 days, then 40 mg po once
daily for 3 days, then 20 mg once daily for 3 days, then 10 mg
once daily for three days then stop
Mucomyst 600mg PO twice daily
Fluticasone nasal spray, 2 sprays per nostril twice per day as
needed for nasal congestion
Ipratropium inhaler, 2 puffs every 8 hours as needed for
shortness of breath or wheezing
5 units NPH insulin injected subcutaneously before breakfast and
at night
CHANGED MEDICATIONS:
Fluticasone-Salmeterol 500mcg-50 mcg 2 puffs once daily changed
to two puffs twice daily.
It was a pleasure caring for you and we wish you the best!
Followup Instructions:
Please make a follow-up appointment with Dr. [**Last Name (STitle) 410**] within ONE
WEEK OF DISCHARGE by calling her office at: [**Telephone/Fax (1) 1144**].
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2160-10-12**]
|
[
"5849",
"40390",
"5859",
"2724",
"3051"
] |
Admission Date: [**2178-3-8**] Discharge Date: [**2178-3-20**]
Date of Birth: [**2129-10-27**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Penicillins
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
48yoW with h/o ESLD [**3-6**] EtOH cirrhosis, Crohn's disease, chronic
kidney disease, transfered from [**Hospital3 **] on [**3-8**] for persistent
MRSA bacteremia
Major Surgical or Invasive Procedure:
Admitted with PICC
Femoral HD catheter placement
History of Present Illness:
48yoW with h/o ESLD [**3-6**] EtOH cirrhosis, Crohn's disease,
chronic kidney disease, who was admitted to [**Hospital3 417**]
Hospital [**2178-2-18**] with liver failure, acute renal failure and
hyponatremia, and is transferred now to [**Hospital1 18**] with persistant
MRSA bacteremia.
.
The patient was initially referred to [**Hospital3 417**] ED [**2178-2-18**]
from her primary care physician's office for evaluation of
elevated LFTs, confusion, ARF (Cr 3.4), and hyponatremia (Na+
124). At that time she complained of SOB and productive cough.
She was transferred to the ICU [**2178-3-3**] with hypotension (BP
65/40) and treated for urosepsis after E.coli grew in her urine.
She was treated with initially ceftriaxone and then aztreonam.
Hypotension was treated initially with Neosynephrine, and then
levophed. Baseline SBP 80s. Hospital course also complicated by
LLL pneumonia. She then developed a MRSA bacteremia. Exam was
significant for pericardial rub, and echo showed a
small-moderate effusion. No vegetations were seen on TTE
[**2178-3-1**], but she was treated for endocarditis with
vancomycin/gentamicin. A TEE was not done due to concern for
causing a variceal bleed. EF was 60-65%. On the gentamicin her
creatinine rose from 1.0 to 3.8. On [**2178-3-2**] she had a single
burst of non-sustained Afib. Hospital course was also
complicated by hypokalemia requiring repletion. Surveillance
blood cultures were persistantly positive for MRSA, most
recently [**2178-3-5**], despite therapeutic doses of vancomycin.
Additionally the LLL infiltrate enlarged on CXR. Abdominal U/S
on [**2178-3-2**] showed hepatosplenomegaly, ascites, and reversed flow
in the portal vein. On [**2178-3-4**] she had a urine culture that grew
enterococcus. She was transferred on Levophed via PICC line in
left A/C vein.
.
Hospital course also complicated by indecision regarding code
status. She was initially DNR/DNI, then full code, then reverted
to DNR/DNI status prior to transfer.
.
On presentation now she complains of chest pain when coughing,
and cough productive of brown sputum. She denies SOB. She c/o
midepigastric abdominal pain and low back pain, which is her
baseline. She denies headache, dizziness, confusion, vision
changes, nausea, vomiting, diarrhea, constipation.
Past Medical History:
COPD
Crohn's disease
Liver failure d/t alcoholic cirrhosis c/b portal HTN, esophageal
varices
Sciatica
Osteoarthritis
Chronic kidney disease
Social History:
lives with her son. daughter serves as her HCP. on disability
+Tob use; +EtOH use; denies illicit drug use
Most recent drink was the day prior to hospitalization. she
denies having a h/o withdrawals. drinks 1pint vodka daily.
Family History:
Father - h/o EtOH abuse, d. Alzheimer' dz at 64yrs
Mother - alive, had stroke at 67yrs
Brother - EtOH abuse
MGM - EtOH abuse
Physical Exam:
T 97.2 HR 69 BP 93/36 RR 33 95%3Lnc Wt 94kg pulsus <10
GEN: alert, speaking full sentences, appropriate, NAD
HEENT: icteric sclera, PERRL (2->1mm), conjunctiva pale, OP
clear, MMdry
Neck: supple, no LAD, JVP 11cm
CV: PMI nondisplaced, regular rate, murmer vs rub, II/VI supine,
III/VI sitting
Resp: left basilar crackles, no rhonchi, no wheeze. no egophany.
Abd: +BS, soft, ttp RUQ, +fluid wave, +caput
Ext: 3+pitting edema BLE to thigh, 2+ DPs and radial pulses, no
splinter hemorrhage, [**Last Name (un) 1003**] or Osler lesions, fingers clubbed
Neuro: A&Ox3, CN II-XII intact, no asterixis, strength 5/5
throughout, sensation intact to touch, coordination intact FTN
Skin: jaundiced
Pertinent Results:
Admission Labs:
[**2178-3-8**] 09:57PM GLUCOSE-143* UREA N-59* CREAT-3.6*
SODIUM-130* POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-18* ANION GAP-16
[**2178-3-8**] 09:57PM estGFR-Using this
[**2178-3-8**] 09:57PM ALT(SGPT)-31 AST(SGOT)-75* LD(LDH)-225 ALK
PHOS-214* AMYLASE-78 TOT BILI-28.1* DIR BILI-21.0* INDIR BIL-7.1
[**2178-3-8**] 09:57PM LIPASE-100*
[**2178-3-8**] 09:57PM ALBUMIN-2.2* CALCIUM-8.0* PHOSPHATE-5.1*
MAGNESIUM-2.3
[**2178-3-8**] 09:57PM URINE HOURS-RANDOM UREA N-424 CREAT-61
SODIUM-18 TOT PROT-33 PROT/CREA-0.5*
[**2178-3-8**] 09:57PM URINE OSMOLAL-316
[**2178-3-8**] 09:57PM WBC-16.1*# RBC-3.04* HGB-11.1* HCT-30.8*
MCV-101*# MCH-36.5*# MCHC-36.0*# RDW-16.7*
[**2178-3-8**] 09:57PM NEUTS-82.7* LYMPHS-8.6* MONOS-3.7 EOS-4.6*
BASOS-0.4
[**2178-3-8**] 09:57PM ANISOCYT-1+ MACROCYT-3+
[**2178-3-8**] 09:57PM PLT COUNT-115*#
[**2178-3-8**] 09:57PM PT-15.7* PTT-37.9* INR(PT)-1.4*
[**2178-3-8**] 09:57PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.008
[**2178-3-8**] 09:57PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2178-3-8**] 09:57PM URINE RBC-[**4-6**]* WBC-[**12-22**]* BACTERIA-FEW
YEAST-MOD EPI-[**4-6**]
[**2178-3-8**] 09:57PM URINE EOS-NEGATIVE
.
Labs closest to time of Death:
[**2178-3-16**] 03:45AM BLOOD WBC-14.8* RBC-2.34* Hgb-8.5* Hct-24.6*
MCV-105* MCH-36.3* MCHC-34.5 RDW-17.9* Plt Ct-106*
[**2178-3-16**] 09:46AM BLOOD Glucose-342* UreaN-22* Creat-1.6* Na-128*
K-3.9 Cl-95* HCO3-20* AnGap-17
[**2178-3-16**] 09:46AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2178-3-16**] 09:46AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.2
[**2178-3-16**] 03:58AM BLOOD Type-[**Last Name (un) **] pO2-48* pCO2-44 pH-7.38
calTCO2-27 Base XS-0
.
MICRO:
Urine culture with yeast.
Blood cultures Negative
.
IMAGING:
CXR:
AP UPRIGHT PORTABLE CHEST X-RAY: There is a ill-defined opacity
within the left lower lobe consistent with patient's known
pneumonia in this region. The cardiac silhouette is difficult to
evaluate. The mediastinal and hilar contours appear within
normal limits. There is a small right pleural effusion. A left
PICC catheter terminates in the upper SVC. Cholecystectomy clips
in the right upper quadrant.
IMPRESSION: Left lower lobe consolidation consistent with
patient's known pneumonia. Small right pleural effusion.
.
Abd Ultrasound:
FINDINGS: This was a technically difficult examination and was
performed portably. The liver is heterogenous in echotexture and
is of increased echogenicity. It is shrunken and the appearances
are consistent with cirrhosis. There is evidence of ascites. The
flow in the main portal vein is reversed and is centrifugal. The
flow in the main hepatic artery reaches velocities of 80 cm/sec,
but there is a normal waveform and the resistive index is 0.77.
The flow in the right anterior portal vein is centripetal and
the flow in the right posterior portal vein is centrifugal. The
left portal vein is not well visualized. Normal waveforms are
seen in the right and left hepatic arteries. The flow in the
left hepatic vein, right hepatic vein and middle hepatic vein is
normal. No intrahepatic bile duct dilatation. The CBD measures
0.48 cm.
IMPRESSION: Technically difficult examination in a patient with
cirrhotic liver with ascites with reversed flow seen in the
portal veins. Ascites
.
ECHO:
Conclusions:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is moderate
aortic valve stenosis (area 0.8-1.19cm2) Mild to moderate ([**2-3**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
a small pericardial effusion.
.
MRI Abdomen:
FINDINGS: The liver is shrunken and nodular, consistent with the
given history of cirrhosis. Within the limits of the
examination, no focal mass lesion is seen. A mild-moderate
amount of ascites fluid is seen, primarily adjacent to the
liver. The pancreas is diffusely atrophic. Adrenal glands are
unremarkable. The spleen and kidneys also appear unremarkable.
A serpiginous structure showing flow voids is seen in the right
paraaortic/retroperitoneal region, with suggestion of
communication between the superior mesenteric vein and the renal
vein, probably representing a porto-systemic shunt.
IMPRESSION: Right-sided vascular structure, probably
representing a porto- systemic shunt between the SMV and the
right renal vein. No renal mass seen within the limits of this
noncontrast examination.
Brief Hospital Course:
48 y/o female with h/o end stage liver disease, EtOH abuse,
COPD, Crohn's disease, and chronic kidney disease, transferred
from OSH with MRSA bacteremia, liver failure, acute renal
failure, LLL pneumonia, enterococcus UTI, and hypotension. Her
hospital course is as follows:
.
Cirrhosis w/acute hepatitis: Patient was admitted with likely
EtOH cirrhosis given her known history and lab data
(discriminate score >32). Liver service cwas consulted. She
remained coagulopathic with elevated LFTs and
hyperbilirubinemia. She was also encephalopathic. We treated
her supportively with lactulose, rifamixin. We held her
propranolol given her hypotnesion requiring pressors. US was
negative for PV thrombosis, though there was reversal of flow.
A diagnostic paracentesis was unsuccessfully attempted. She was
also started on pentoxyfylline for presumed EtOH hepatitis, as
well as octreotide and midodrine for possible HRS.
Nevertheless, given her multiple issues, she continued to
decompensate. She was [**Hospital 22626**] transferred to the liver
service after a final decision was made to make her comfort
measures only.
.
ARF on CKD: Her baseline creatinine was unknown but per report
creatinine was 1.0 prior to initiation of gentamicin. She had
no h/o large volume paracentesis. She had been hypotensive
requiring pressors, including vasopressin, raising the concern
for pre-renal azotemia vs ATN. HRS was also considered given
her decompensated liver failure. Renal was consulted and
initiated CVVH after placing a femoral HD cath. However, after
she was made CMO all interventions were withdrawn.
.
MRSA bacteremia: Her source was unknown but was being treated
for endocarditis given persistant bacteremia despite therapeutic
doses of vancomycin at OSH. ID was consulted. She was started
on gent in addition to vanco. There were no positive cultures
here. TEE was not done given concern for causing variceal bleed;
however, EGD did not demonstrate varices. Worsening LLL
pneumonia on CXR at OSH could have been source of infection.
There was also a concern that her pericardial effusion might be
infected/purulent pericarditis. Spinal abscess or
thrombophlebitis was also considered. Multiple imaging studies
were performed without clear source of infection (see above).
Her antibiotics were stopped once the patient was made CMO.
.
Hypotension: It was unclear what degree of hypotension this
represented as patient's baseline SBP reported to be in the 80s.
However she was clearly septic at OSH. Sepsis, severe
infection, ESLD were thought involved. She was maintained on
levophed, neosynephrine, and vasopressin during her MICU stay.
Octreotide and midodrine were also started (see above).
However, these interventions were stopped once she was made CMO.
.
Tachycardia/chest pain: Patient had an episode of A fib w/ RVR
[**2178-3-15**]; likely [**3-6**] to fluid shifts w/ CVVHD and cardiac
irritation from levophed. Echo at OSH showed normal EF, LA
slightly enlarged. She was asymptomatic during event, cardiac
enzymes were flat. Levophed was changed to neo and pt bolused
fluid. She converted to NSR after 1-2hrs. She remained
tachycardic but looked to be in MAT.
.
MS changes: Patient was not oriented, and she was unclear that
she understood who made decisions for her. Psych evaluated her
and determined that she did not have capacity to make her own
decisions. There were multiple family meetings to discuss goals
of care. Palliative care also helped faciliate this decision
making process. She remained disoriented, likely secondary to
hepatic encephalopathy, infection, hyponatremia, and ARF.
.
Hyponatremia: It was thought to be hypervolemic hyponatremia
given her ESLD. It improved with fluid restriction
.
Code/End of Life Issues: Her code status continually fluctuated
during her admission, between full code and DNR/DNI. However,
after extensive family meetings and palliative care involvement,
the decision was made to make her CMO
.
Once the patient was CMO, she was transferred to the
[**Doctor Last Name 3271**]-[**Doctor Last Name **] service. There were no lab draws. She was put on
a morphine drip and appeared comfortable. She was pronounced
dead at 7AM on [**2178-3-20**]. Cause of death likely end stage liver
disease and infection. The family was notified. They did not
request an autopsy.
Medications on Admission:
Percocet 1-2tabs Q4hr prn
Protonix 40mg [**Hospital1 **]
Loratadine 10mg daily
Singulair 10mg dialy
Vistaril 25mg TID prn
Lomotil 2mg TID prn
Actos 15mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest
End Stage Liver Disease
Crohn's Disease
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"5845",
"496",
"5990",
"486",
"42731",
"2761",
"99592",
"40390",
"3051"
] |
Admission Date: [**2146-2-28**] Discharge Date: [**2146-3-8**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
conventional angiogram
History of Present Illness:
Pt. is a 84 y/o with a hx of HTN, MVP, who is transferred from
OSH after a fall with SAH and SDH found on Head CT.
Daughter reports that she was not present when her mother
fell,but heard the events from her friend, who was with her.
She was told (and OSH ED records corroborate) that pt was out at
lunch when she tripped and fell, and hit the back of her head.
Afterwards she was confused, and her friend called EMS, and she
was transported to [**Hospital3 1443**].
At [**Hospital1 487**] on initial exam she is described as confused, and
slow to respond, with no memory of the fall. She was oriented x
1, but moved all 4 extremities with full power. No other neuro
exam documented. Head CT was performed and showed diffuse SAH,
and a small L frontal SDH, as well as subgaleal hematoma.
Radiology there was concerned that the SAH could be concerning
for aneurysm, so she was transferred here for evaluation. She
was intubated for a deterioration on MS prior to transfer, and
given Dilantin 1 g IV.
Head CT repeated here and showed a 1.7 x 0.9 cm frontal
contusion in addition to the SAH and SDH seen on the prior
study. Pt. was evaluated by Neurosurgery who felt that no
intervention was warranted.
Past Medical History:
HTN
GERD
MVP
Palpitations (since she was a young woman)
Social History:
Lives alone, family in the area (daughter [**Telephone/Fax (1) 77807**])
Family History:
NC
Physical Exam:
T- 97.8 BP- 129/71 HR- 67 RR- 16 O2Sat- 100% on vent
Gen: Lying in bed, intubated
HEENT: hematoma R occiput, moist oral mucosa
Neck: in C collar
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: intubated and sedated. Frowns, restless in bed,
opens eyes to voice, does not follow commands.
Cranial Nerves:
R pupil irregular, surgical, non-reactive. L pupil 3 -> 2 mm.
+
corneal bilaterally. + gag on ETT. No obvious facial assymetry
(though eval limited by ETT)
Motor:
Diminished bulk throughout. Tone normal. No observed myoclonus
or
tremor. Moves both arms purposefully in bed (+ anti-gravity),
tries to pull at ETT when not restrained. Withdraws both arms
purposefully to pain. Withdraws both legs purposefully to pain.
Sensation: grimaces to pain all 4 ext
Reflexes:
+2 and symmetric throughout.
Toes upgoing bilaterally
Coordination: not assessed
Gait: not assessed
Pertinent Results:
[**2146-2-28**] - CT head w/o contrast
IMPRESSION:
1. Left frontal lobe parenchymal hemorrhagic contusion.
2. Diffuse bilateral subarachnoid hemorrhage within the sylvian
fissures,
parietal, and frontal sulci.
3. Severe white matter hypoattenuation most consistent with
chronic
microvascular ischemia.
4. Small right occipital scalp hematoma.
5. Small left convexity subdural hematoma without significant
gyral
effacement or shift.
[**2146-2-28**] - CTA head
IMPRESSION: No short interval change in the pattern of
subarachnoid
hemorrhage, left subdural hematoma, and left frontal
intraparenchymal
hemorrhage. No definite aneurysm is seen. The left transverse
sinus is not
clearly visualized and the left internal jugular vein appears
slightly small at the level of the skull base, likely congenital
in nature. These findings were communicated by Dr. [**Last Name (STitle) 2026**] to Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
[**2146-3-1**] - CT head w/o contrast
IMPRESSION:
1. In comparison with the prior study, there is evidence of mild
decrease in size of the left frontal parenchymal hemorrhagic
contusion.
2. Persistent and unchanged bilateral subarachnoid hemorrhage
within the
sylvian fissures, parietal, and frontal sulci.
3. Unchanged small left convexity subdural hematoma, there is no
evidence of midline shifting.
[**2146-3-2**] - CT c-spine
IMPRESSION:
No cervical spinal fractures.
[**2146-3-3**] - CT head w/o contrast
IMPRESSION:
1. New tiny amounts of intraventricular blood within the
occipital horns
bilaterally.
2. Stable left frontal lobe parenchymal hemorrhagic contusion.
3. Evolving bilateral subarachnoid hemorrhage within the sylvian
fissures,
parietal and frontal sulci.
4. Decrease in size of small left SDH.
[**2146-3-6**] - CXR
PA and lateral views of the chest are obtained on [**2146-3-6**] and
compared with the most recent study performed on [**2146-3-1**]. The
patient has been extubated and the nasogastric tube has been
removed. Cardiomediastinal silhouette is unchanged. The lungs
show no evidence of acute consolidation or large pleural
effusion. There is, however, minimal left costophrenic angle
blunting which may represent a tiny left pleural effusion
Brief Hospital Course:
Pt. is an 84 y/o with a hx of HTN who presents after a fall
today. She was confused and disoriented at the OSH, and when
she was found to have diffuse frontal and parietal SAH she was
intubated because of concern for deterioration of MS (not clear
what exactly this deterioration was) On initial examination she
was still sedated, but opened her eyes to voice and grimaces,
and moves both arms and legs purposefully to pain. Cranial
nerve exam was intact (though R pupil is surgical).
1) Traumatic Subarachnoid Hemorrhage-
On repeat CT at presentation she was found to also have a small
L frontal intraparenchymal hemorrhage- most likely consistent
with traumatic hemorrhage from contrecoup injury. Although the
SAH is also most likely traumatic, given how diffuse the
hemorrhage was and aneurysm was ruled out by both CTA head and
neck and conventional cerebral angiogram. The patient was
admitted to the neuro ICU and extubated following angiogram
without difficulty. Her dilantin was discontinued and she was
followed clinically for evidence of seizure activity. CT-C spine
was obtained revealed cervical spondylosis without cervical
fracture, and her spine was clinically cleared to remove hard
C-collar. Given large volume of blood present in the
subarachnoid space she was monitored in the ICU for frequent
neuro checks and then transferred to neurology step down unit.
She was started on nimodipine. In the neuro step down unit she
was monitored for evidence of cerebral vasospasm clinically.
She remained clinically stable and was then transferred to the
regular bed on the floor. Repeat head CT demonstrated
significant clearance of the subarachnoid hemorrhage so we felt
that it was safe to titrate her off of the nimodipine.
2) She was started on Cipro on [**2146-3-5**] due to evidence of a UTI.
This demonstrated x2 species of bacteria - 1 - EColi; 2-
Enterococcus. The sensitivities of the enterococcus came back
and due to definite sensitivity of these 2 organisms to
amoxicillin, amoxicillin 500mg PO Q8 was started (despite having
completed a 3 day course of cipro), and she is to continue on
this for a full 7 day course. A repeat urine sample should be
obtained at the rehab facility in order to make sure that she
has cleared the infection.
3) Baseline mental status exam during this admission: waxes and
wanes. She has never been oriented to place (can pick hospital
from a list); she is occasionally oriented to person. She has a
slight degree of abulia.
4) Hypertension: blood pressure running 150s-160s SBP, so
metoprolol dose increased to 25mg PO BID.
Medications on Admission:
Atenolol
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Amoxicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours) for 7 days.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain for 7 days.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, T > 100.4.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **] Green Nursing & Rehab Center - [**Hospital1 **]
Discharge Diagnosis:
diffuse frontal and parietal SAH
Discharge Condition:
stable.
Discharge Instructions:
(1) please monitor mental status and neurologic exam
(2) 7day course of amoxicillin started today due to
sensitivities of a second bacteria species that were just
revealed and likely resistant to cipro (s/p 3 day course)
(3) obtain f/u urinalysis in order to make sure that the UTI has
cleared.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1693**] once you are discharged from
the Rehab facility. Call [**Telephone/Fax (1) **] in order to schedule an
appointment.
Completed by:[**2146-3-8**]
|
[
"5990",
"4240",
"4019",
"53081"
] |
Admission Date: [**2159-10-22**] Discharge Date: [**2159-10-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
subdural hematoma, s/p fall
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
This is an 89 yo female with afib on coumadin, HT, CHF, history
of C.diff, who presents s/p fall at home. Per her granddaughter,
who lives upstairs, she heard a thud and found her grandmother
had fallen and hit her head, no apparent LOC. She was taken to
an OSH, where head CT showed bilateral subdural hematoms. Her
C-spine was cleared, and EKG was reportedly normal. She received
2 units of FFP, 10mg of IV vitamin K, and 1g of fosphenytoin.
Her SBP dropped to the 80s with respiratory distress an her
mental status worsened en route to [**Hospital1 18**] (from alert and
oriented at OSH). She received benadryl for possible allergic
reaction.
.
On arrival to [**Hospital1 18**], she was in respiratory distress, unable to
get a good SpO2, so she was intubated and started on propofol.
The propofol was stopped for hypotension, but low BPs persisted.
She was started empirically on vanc/zosyn/flagyl. EKG showed ST
depressions laterally, felt to be demand ischemia by cards. Not
clinically felt to be cardiogenic shock. FAST scan was performed
and negative. Her sats dropped to the high 70s, and she was
started on versed and vecuronium. CXR was done and consistent
with ARDS. Current vent settings include PEEP 12, and FiO2 of
100%, now satting 93-95%. 2 units of FFP were given. The
patient's SBP improved to 142, and she had never received
pressors (were going to do peripheral dopamine).
.
In the MICU, patient satting mid 80s on FiO2 1 and PEEP 12.
Overbreathing vent but responsive to fent/versed.
.
Review of systems: unable to perform
Past Medical History:
Afib - on coumadin
HTN
CHF - unknown details
Gout
History of C diff
Social History:
Lives in an apartment downstairs from her grand-daughter. [**Name (NI) **]
[**Name2 (NI) 16429**] on wheels, and a housekeeper who comes 1x/week, but is
reportedly independent in all other ADLs, and 'sharp as a tack.'
No EtOH, smoking or illicits.
Family History:
noncontributory
Physical Exam:
Vitals: T 99.3, HR 103, 103/53, R31, 75% on AC TV 400 rate 22
FiO2 1 PEEP 12.
General: Intubated, sedated, marked facial trauma
HEENT: Bilateral periorbital ecchymoses, hematoma above R eye.
Sclera anicteric, PERRL 3->2, ETT in place
Neck: hard collar in place, no gross deformities
Lungs: Bilateral rhonchi and coarse crackles, ?pleural rub on
right.
CV: Diminished beneath breath sounds, regular, [**1-5**] SM at apex.
Abdomen: soft, appears non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: cool UEs, warm LEs, 2+ DP pulses, minimal edema. R hand
with significant ecchymosis.
Neuro: sedated, not responsive.
Pertinent Results:
[**2159-10-22**]
WBC-26.2* Hgb-12.3 Hct-37.8 MCV-93 RDW-14.0 Plt Ct-245
Neuts-84* Bands-5 Lymphs-4* Monos-6 Eos-1 Baso-0
PT-17.4* PTT-25.0 INR(PT)-1.6*
Glucose-321* UreaN-16 Creat-1.1 Na-138 K-3.9 Cl-96 HCO3-26
AnGap-20
CK-MB-5 cTropnT-0.01
.
ART pO2-63* pCO2-67* pH-7.21* calTCO2-28 Base XS--2 AADO2-612
REQ O2-96
Lactate-5.7*
.
CT head [**10-22**]: (prelim) Unchanged tiny right frontal SDH and
parafalcine SDH. No new foci of intracranial hemorrhage. No
hydrocephalus.
.
Plain films pelvis [**10-22**]: (prelim) suboptimal eval of sacrum due
to overlying bowel gas. linear density projecting over left
sacrum may = bowel content although fx can not be excluded. rec
clin correlation and additional imaging as indicated.
.
CXR [**10-22**]: Diffuse bilateral infiltrates - ARDS vs. multifocal
pneumonia, less likely cardiogenic pulmonary edema. ETT in place
4 cm above carina.
.
EKG: sinus at 86, [**Last Name (LF) **], [**First Name3 (LF) **] depressions V4-V6 ST depressions.
diffuse limb lead TWF.
Brief Hospital Course:
Assessment and Plan:
89F with Afib on coumadin, presents s/p fall with subdural
hematoma with interval development of severe hypoxemia and ARDS.
.
# Hypoxemia/ARDS. Severe refractory hypoxemia. Differential
included aspiration pneumonia/pneumonitis (feel most likely),
CAP, pulmonary contusion from fall, ARDS from extrapulmonary
infection or trauma. Less likely cardiogenic pulm edema given
appearance of CXR. Bilateral infiltrates go against PE. Some
improvement with increases in sedation, but short lasting. Grave
situation discussed with family. Patient continued to actively
desat to low 70s. Felt that even aggressive intervention (CVL,
ALine, pressors, paralytics) may not be enough to get patient
through night. Family expressed understanding and wish to focus
on comfort care. Morphine gtt and versed gtt were started.
With increases in sedation, there were improvements in O2 sats,
however she became very hypotensive. The trade-off between
hypotension and sedation/vent compliance were discussed with the
family, and the collective feeling was to continue to make her
comfortable without other aggressive interventions. She died at
3:31 am, in the presence of her family. Autopsy was declined by
family, but case accepted by medical examiner.
Medications on Admission:
Medications: dosages unavailable
Lasix 40mg [**Hospital1 **]
Lisinopril
Atenolol
Norvasc
Zoloft
Coumadin
Potassium
Aspirin 81mg daily
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Hypoxic respiratory failure
Acute respiratory distress syndrome
.
Hypotension
Subdural hematoma
Leukocytosis
Lactic acidosis
Discharge Condition:
Expired
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"5070",
"42731",
"V5861",
"4280",
"4019"
] |
Admission Date: [**2107-1-5**] Discharge Date: [**2107-1-30**]
Service: VSU
PRINCIPAL DIAGNOSIS: Right foot ischemia and right great toe
ulcer, left third toe ulcer.
PRINCIPAL PROCEDURE: Right below knee popliteal with DP
bypass graft, left vein patch angioplasty graft to PT.
PAST MEDICAL HISTORY: Significant for diabetes,
hypertension, coronary artery disease, congestive heart
failure, end stage renal disease, neuropathy, Paget's
disease,
HOSPITAL COURSE: Mr. [**Known lastname 61975**] is an 83-year-old gentleman who
was admitted on [**2107-1-5**], with right foot ischemia
and right toe ulcer as well as left third toe ulcer. He was
started on IV antibiotics including Cipro and Flagyl and
Vancomycin preoperatively. On [**2107-1-5**], he had an
angio which showed an occluded right fem [**Doctor Last Name **] and left fem
[**Doctor Last Name **], but PDA was patent, as well as stenosis in his left PT.
On [**1-6**] he got a CT angiogram that showed bilateral
pleural effusions however no signs of PE. On [**1-7**] he
had vein mapping as well as PVRs as part of his preoperative
work up. He also had a cardiology evaluation. He was taken to
the operating room on [**2107-1-14**], for a right double
below knee popliteal to DP bypass graft with a left vein
patch angioplasty. Postoperatively he did well.
On postoperative day 1, he underwent dialysis. He was in the
vascular intensive care unit for monitoring. After dialysis
he was noted to be somewhat hypotensive. The health officer
was called to evaluate him and noted that he had some mental
status changes as well as hypotension. He was immediately
transferred to the intensive care unit where upon evaluation
of the blood gases and mental status changes, he was
electively intubated and started on Neo-Synephrine and
Levophed for his blood pressure. At this point a cardiology
evaluation was obtained in order to help evaluate the
etiology for his hypotension. He was empirically started on a
heparin drip and per cardiology there are no plans for
catheterization. His pressures stabilized on Neo-Synephrine
and Levophed. He self extubated himself that evening and was
stable on nasal cannula. His mental status improved and he
was alert, oriented and following commands. On [**1-17**],
he got an echocardiogram which showed dilated left atrium,
low to normal left ventricular function and elevated right
ventricular pressure with systolic hypertension. Cardiology
continued to follow him during this time. He continued to
have increased pressor requirement without any clear
etiology.
He had a full set of blood cultures which were all negative.
He was empirically started on broad spectrum antibiotics.
There was some concern because of his right ventricular
increased filling pressure of pulmonary embolus. He had a CT
of the chest on [**1-19**] that confirmed no sign of any
sort of pulmonary embolus. At this point his heparin drip was
stopped. He continued to be sort of stable on pressors,
however we were unable to wean his pressors. We were treating
him as if he was having a septic physiology as well as
possible congestive heart failure. He remained stable on
pressors and alert and oriented, however on the evening of
[**1-26**] he complained of some back pain and discomfort
and some increased shortness of breath. At that morning he
was intubated for increased work of breathing. He had CTA of
his chest and abdomen. CT of his chest showed new pulmonary
infiltrate and CT of his abdomen showed some abdominal
ascites, however there were no signs of any intraabdominal
process that would be concerning.
He had a repeat echocardiogram on [**1-27**] that did not
show any significant change since his previous echo on
[**1-17**], however he did continue over the course of next
few days to have increasing pressor requirement and was
intermittently started on a vasopressor, maxing on his
Levophed and Neo-Synephrine. On the morning of [**1-29**],
he was maxed out on both Neo-Synephrine, vasopressor and
Levophed with hypotension, systolic pressures in the 70s.
No secrecy concern that he had not been improving without any
clear etiology. It was determined to repeat his accuracy with
some changes in his cardiac function however at this time. It
was noted the enzymes had not been continuously cycled and
his troponins remained stable, however elevated likely
secondary to his renal failure. A repeat echo that afternoon
showed significant left ventricular dysfunction consistent
with possible myocardial infarction. Cardiology was consulted
and felt that he was not a candidate for a balloon pump, or
catheterization, or sort of intervention at this time, and
recommended medical management.
We switched his pressors over to milrinone and attempted the
[**Hospital1 **] without success. He continued to do poorly with
pressures in the 70s. We had a lengthy discussion with the
family and went over his echocardiogram with the family and
cardiology to explain this new finding in that his overall
condition had continued to deteriorate over this period. The
family at this point wished to continue with full medical
support. He started to have worsening metabolic acidosis and
we attempted to try some CVAs, however his pressures would
not tolerate this, so he received bicarbonate for his
acidosis. We continued to increase milrinone while he was
maxed out on Neo-Synephrine, vasopressor and Levophed. His
pressures remained in the 70s but stable. On the evening of
[**1-29**], his pressures started to decrease below 70s, and
then systolic pressures in the 60s. He was maxed out on all
of his pressors.
At this point the family was concerned and felt that if
situation got worse they did not want to resuscitate him or
proceed with any cardioversion or chest compressions. He was
made DNR on [**2107-1-29**], at 11:30 p.m. At this point
his pressures maxed out on 4 pressors and continued to
dwindle into the 50s. Family again called at [**1-30**] at 1
a.m. with concern that he was not getting better and wished
to make him CMO and felt that he would not wish to have any
further intervention and that it would be within his wishes
to make him CMO.
At 1 a.m. to [**2107-1-30**], he was made CMO and his
pressors were all weaned off. He expired at 1:36 a.m. on
[**2107-1-30**]. It was discussed with family for
postmortem and the family declined and they also declined for
any autopsy. They felt that they were happy with his overall
care and felt that the intensive care unit was quite
supportive during his entire course. Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26687**] were informed of both his DNR and CMO
status when they occurred.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], M.D. [**MD Number(1) 4417**]
Dictated By:[**Name8 (MD) 57264**]
MEDQUIST36
D: [**2107-1-30**] 05:50:23
T: [**2107-1-30**] 13:47:04
Job#: [**Job Number 61976**]
|
[
"9971",
"41071",
"40391",
"0389",
"42731",
"4280",
"486",
"2761",
"V4581"
] |
Admission Date: [**2123-6-23**] Discharge Date: [**2123-6-25**]
Date of Birth: [**2070-10-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Transfer from OSH after being found unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 78337**] is a 52M with a PMH s/f OSA, HTN, and dyslipidemia
who was transferred to the [**Hospital Unit Name 153**] from an OSH on [**2123-6-23**] for
management of a PEA arrest. History is taken from the patients
family, as the patient is unconscious. The patient was found
sleeping in his home after heavy alcohol and drug use by his
family members. When his breathing seemed to stop, EMS was
called, and on arrival was found to be asystolic. He was
intubated in the field, and received CPR, epinephrine, and
atropine. Upon arrival to the OSH he regained a pulse after 20
minutes of CPR, with a HR of 20 BPM. He was started on
dopamine. Initial labs were notable for an alcohol level of
300; a salicylate level of 4.1; and a urine tox positive for
marijuana and opiates. A neurology consult was called, and
found the patient to have absent brainstem reflexes, consistent
with anoxic brain injury. CT scan of the head confrimed a
diffuse loss of [**Doctor Last Name 352**]-white differentiation.
Past Medical History:
HTN
Hyperlipidemia
Gout
OSA
Anxiety
Asthma
Seasonal allergies
Social History:
Notable for ETOH and marijuana abuse. No tobacco use.
Family History:
NC
Pertinent Results:
CT head:
Markedly abnormal head CT, with diffuse cerebral edema and basal
ganglial hypodensity concerning for global ischemia. There is
also suggestion of possible downward tonsillar herniation. MRI
would be helpful for further evaluation. This was discussed with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24692**] immediately following completion of the
study. Marked paranasal sinus oapciifcation
.
[**2123-6-23**] 10:32PM PT-14.1* PTT-27.4 INR(PT)-1.2*
[**2123-6-23**] 10:32PM PLT COUNT-218
[**2123-6-23**] 10:32PM NEUTS-86.2* LYMPHS-7.6* MONOS-6.0 EOS-0.1
BASOS-0.1
[**2123-6-23**] 10:32PM WBC-22.1* RBC-5.05 HGB-14.9 HCT-44.6 MCV-88
MCH-29.4 MCHC-33.3 RDW-13.8
[**2123-6-23**] 10:32PM OSMOLAL-305
[**2123-6-23**] 10:32PM ALBUMIN-3.8 CALCIUM-7.3* PHOSPHATE-3.7
MAGNESIUM-1.5*
[**2123-6-23**] 10:32PM ALT(SGPT)-346* AST(SGOT)-394* ALK PHOS-105
TOT BILI-0.3
[**2123-6-23**] 10:32PM estGFR-Using this
[**2123-6-23**] 10:32PM GLUCOSE-151* UREA N-35* CREAT-3.6* SODIUM-143
POTASSIUM-3.9 CHLORIDE-111* TOTAL CO2-18* ANION GAP-18
[**2123-6-23**] 11:07PM LACTATE-1.7
[**2123-6-23**] 11:07PM TYPE-ART TEMP-37.8 RATES-25/32 TIDAL VOL-500
PEEP-5 O2-60 PO2-285* PCO2-39 PH-7.31* TOTAL CO2-21 BASE XS--6
-ASSIST/CON INTUBATED-INTUBATED
Brief Hospital Course:
Upon arrival to the [**Hospital Unit Name 153**] the patient was found to be
unresponsive. A neurology consult was called, and the patient
was found to have absent brain stem reflexes including cold
calorics, doll's eye, corneals, gag, and cough. He had fixed
dilated pupils, areflexia, and was unresponsive to noxious
stimuli. A head CT was consistent with anoxic brain injury with
impending tonsillar herniation. The patient was initially
managed with HOB elevation and mannitol, however given his grim
prognosis, and lack of response to treatment at 48hrs, the
family decided to withdrawl care.
Medications on Admission:
-Temazepam
-Advil
-Zyrtec
-Lorazepam
-Colchicine
-Nadolol
-Protonix
-Nifedipine
-Simvastatin
-HCTZ
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
|
[
"51881",
"5849",
"32723",
"4019",
"2720",
"2724"
] |
Admission Date: [**2147-6-10**] Discharge Date: [**2147-6-16**]
Date of Birth: [**2068-2-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
acute on chronic systolic heart failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
78M with a medical history of CAD s/p CABG ([**2139**] LIMA->diag,
SVG->OM1, SVG->LAD), s/p stent to LAD, [**Year (4 digits) **] to RCA ([**2146**]),
systolic heart failure secondary to ischemic cardiomyopathy (EF
20-30% [**2141**]), history of NSVT s/p ICD implantation ([**2141**])
transferred from [**Hospital6 17032**] for further
management of acute on chronic systolic heart failure,
hypotension in setting of diuresis, and worsening acute on
chronic renal insufficiency.
.
The patient has a history of multiple admissions to [**Hospital **] for CHF and COPD exacerbation and was recently
discharged to [**Hospital 25576**] Rehabilitation Center on [**2147-5-30**]
after hospitalization for one such episode. At the rehab
facility he was noted to have progressively worsening dyspnea,
lower extremity edema, and orthopnea/paroxysmal nocturnal
dyspnea. He was able to ambulate 10 steps but w/ dyspnea. Denies
chest pain. He was transferred to [**Location (un) **] for further evaluation
on [**2147-6-6**].
.
On admission, vitals 110/60, 86, 20 100%RA. The initial exam was
notable for bibasilar crackles and severe bilateral LE edema
with BNP of 2620 (unclear baseline), felt to be c/w CHF
exacerbation, for which he was given IV lasix boluses. With
diuresis he developed asymptomatic hypotension (SBP 50s to 90s)
and was transferred to the ICU. The diuretics were held (has not
gotten lasix in >48 hours) and he was given IV fluid boluses
(volume unclear). His renal function deteriorated over the
course of his hospitalization from admission creatinine of 2.5
(baseline 1.5-1.8) to 4.2 today. Urine output reported to be
800cc in the past 24 hours. He developed hyperkalemia, with a
peak of 6.6 for which he was given kayexcelate, and this AM was
5.5. He had evidence of a UTI on admission UA so was started on
ceftriaxone. Chest X-ray reported possible right base infiltrate
with effusion so this was broadened to levaquin and ceftriaxone.
Liver function tests have worsened from AST/ALT of 179/64 on
admission to 2600/1853 today.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS:
-Coronary Artery Disease (s/p MI x2)
-Diabetes (Type 2 insulin-dependant)
-Dyslipidemia
-Hypertension
2. CARDIAC HISTORY:
-CABG:
-s/p CABG in [**2139**] (LIMA->diag, SVG->OM1, SVG->LAD)
-PERCUTANEOUS CORONARY INTERVENTIONS:
-s/p prior LAD stent and PTCA of diag
-s/p [**Year (4 digits) **] to RCA in [**2146**]
-PPM/ICD:
- Ischemic cardiomyopathy, s/p ICD implantation [**2141-7-14**]
- PPM (unclear when placed)
-OTHER CARDIAC HISTORY:
- Paroxysmal atrial fibrillation
- Nonsustained ventricular tachycardia
- Chronic systolic CHF [**2-14**] ischemic cardiomyopathy(last EF
20%)
- Mitral regurgitation
- Pulmonary Hypertension
3. OTHER PAST MEDICAL HISTORY:
-Chronic Obstructive Pulmonary Disease on 3L home O2 since [**2146**]
-Chronic Renal Insufficiency (baseline creatinine 1.5-1.8)
-s/p right renal artery stent
-Severe Peripheral Vascular Disease, s/p left fem-[**Doctor Last Name **] bypass
[**2137**]
-Obstructive sleep apnea intolerant to CPAP
-GERD
-Anxiety
-Depression
-Post Traumatic Stress Disorder
Social History:
Married and lives with his wife. Retired from
Army. Most recently worked as a cook at the [**Hospital **] [**Hospital6 28623**]. He used to drink alcohol heavily, but has had none in
40
years. 40+ pack year h/o smoking, quit 40 years ago.
Family History:
Father died of an MI at age 48. Brother died of
an MI at age 64.
Physical Exam:
VS:: Afebrile, 99/76, 74, 22 99%3L
GEN: WDWN in NAD. Oriented to self, year,location. Mood
appropriate.
HEENT: Anicteric, moist mucus membranes, PERRL
NECK: JVP difficult to assess, at least 6cm at 30 degrees
CARDIAC: S1, S2 regular rhythm, normal rate, II/VI systolic
murmur LLSP radiate to axilla
LUNGS: respirations slightly labored, no accessory muscle use,
crackles right base, rhonchi left base, no wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 3+ pitting edema dependent areas and shins
SKIN: cool, venous stasis changes RLE, bilateral UE ecchymosis,
right ankle dressed C/D/I, Stage II decubitus and right heel
ulcer
MSK: left ankle no point tenderness navicular, medial/lateral
ankle
Dopplerable distal pulses
Pertinent Results:
2D-[**Hospital6 **] ([**1-/2147**] OSH)
Right sided structures are normal in size and function
w/borderline right atrail enlargement. Pacing wires on RV. LA is
dialted. MV exhibits tethering to both anterior and posterior
leaflets with calcification of posterior mitral annulus noted.
LV is dilated and globally hypokinetic with severe hypokinesis
involving septum and inferobase. Overall LV fx is severely
impaired and estimated 20-25%. Aortic valve is tricuspid,
sclerotic and adequate excursions. Aortic root is normal. Severe
MR w/ [**3-16**]+ with jet that extends to base of LA. Moderate severe
TR. Mild AI. Pulse doppler reveals increased E/A ratio w/
elevated E/E prime with grade III diastolic dysfunction.
pulmonary HTN with estimated pulmonary systolic of 50-60.
Conclusions:
1. LV dilation w/ global hypokinesis most prominent involving
the left ventricular apex, anterobase, and inferobase. Overall
LV function is severely impaired with EF of 20-25%.
2. Tethering of anterior and posterior mitral valve leaflets
with mitral valve calcifications and severe MR.
3. Moderate to severe tricuspid regurgitation and pulmonary
hypertension, with pulmonary systolic 50mm to 60mm
4. Mild aortic insufficiency
5. Grade III diastolic dysfunction
6. Pacing wire, RV
7. Biatrial enlargement
.
CARDIAC CATH: 6/ [**2146**]
Cardiac cath ([**5-13**]): 1. Coronary angiography of this right
dominant system revealed native three vessel coronary artery
disease. The LMCA had a distal 50% stenosis. The LAD was
occluded in the mid-vessel. The major diagonal branch had an
ostial 60% stenosis. The LCx had a long 60% lesion in OM1. The
RCA had a 90% stenosis just beyond the origin of the PDA. 2.
Arterial conduit angiography demonstrated patent LIMA-D1 and
SVG-OM grafts. The SVG-OM was occluded proximally. 3. Resting
hemodynamics revealed elevated right and left sided filling
pressures (RVEDP 16 mm Hg, PCWP mean 28 mm Hg). There was
moderate to severe pulmonary arterial hypertension (PASP 61 mm
Hg). The systemic arterial blood pressure was normal (SBP 122 mm
Hg). The cardiac index was normal at 2.7 l/min/m2. The systemic
vascular resistance was normal (911 dynes-sec/cm5). The
pulmonary vascular resistance was normal (PVR 135
dynes-sec/cm5). 4. Successful PTCA and stenting of the distal
RCA jailing the right PDA with a Xience (3x18mm) drug eluting
stent postdilated with a 3.25mm balloon. Final angiography
demonstrated no angiographically apparent dissection, no
residual stenosis and TIMI III flow throughout the vessel (See
PTCA comments). 5. Successful closure of the right femoral
arteriotomy site with a Mynx closure device.
FINAL DIAGNOSIS:
1. Native three vessel coronary artery disease.
2. Patent LIMA-D1 and SVG-LAD grafts.
3. Occluded SVG-OM graft.
4. Moderate biventricular diastolic dysfunction.
5. Moderate pulmonary hypertension.
6. Successful PTCA and stenting of the distal RCA with a Xience
drug eluting stent.
7. Successful closure of the right femoral arteriotomy site with
a Mynx closure device.
.
CHEST (PORTABLE AP) Study Date of [**2147-6-10**] 8:40 PM
FINDINGS:
Comparison is made to the prior study from [**2146-5-12**]. There
is mild
bibasilar atelectasis. Heart is mildly enlarged. Dual-lead pacer
is present. There is increased bibasilar atelectasis since the
prior study.
CBC
[**2147-6-11**] 04:23AM BLOOD WBC-13.3* RBC-4.68 Hgb-13.5* Hct-43.9
MCV-94 MCH-28.9 MCHC-30.9* RDW-17.0* Plt Ct-186
[**2147-6-10**] 04:38PM BLOOD WBC-14.7*# RBC-4.51* Hgb-13.4* Hct-41.7
MCV-93 MCH-29.7 MCHC-32.1 RDW-17.0* Plt Ct-191
Coags
[**2147-6-11**] 04:23AM BLOOD PT-19.9* PTT-29.5 INR(PT)-1.8*
[**2147-6-10**] 04:38PM BLOOD PT-22.1* PTT-29.3 INR(PT)-2.1*
Chemistry
[**2147-6-11**] 02:52PM BLOOD Glucose-341* UreaN-88* Creat-3.2* Na-132*
K-4.1 Cl-91* HCO3-30 AnGap-15
[**2147-6-11**] 04:23AM BLOOD Glucose-300* UreaN-92* Creat-3.5* Na-132*
K-4.8 Cl-89* HCO3-24 AnGap-24*
[**2147-6-10**] 04:38PM BLOOD Glucose-196* UreaN-97* Creat-3.9*#
Na-132* K-5.3* Cl-90* HCO3-27 AnGap-20
[**2147-6-11**] 02:52PM BLOOD Calcium-8.5 Phos-4.4 Mg-2.5
[**2147-6-11**] 04:23AM BLOOD Albumin-3.6 Calcium-8.7 Phos-5.3* Mg-2.7*
[**2147-6-10**] 04:38PM BLOOD Albumin-3.9 Calcium-8.6 Phos-6.3*#
Mg-3.0*
LFTs
[**2147-6-11**] 04:23AM BLOOD ALT-1765* AST-2200* LD(LDH)-575*
AlkPhos-92 TotBili-1.9*
[**2147-6-10**] 04:38PM BLOOD ALT-2221* AST-4086* LD(LDH)-1418*
AlkPhos-98 TotBili-2.1*
Brief Hospital Course:
78M with a medical history of CAD s/p CABG ([**2139**] LIMA->diag,
SVG->OM1, SVG->LAD), s/p stent to LAD, [**Year (4 digits) **] to RCA ([**2146**]),
systolic heart failure secondary to ischemic cardiomyopathy (EF
20-30% [**2141**]), history of NSVT s/p ICD implantation ([**2141**])
transferred from [**Hospital6 17032**] with acute on
chronic systolic heart failure, hypotension limiting diuresis,
worsening acute on chronic renal insufficiency, and worsening
liver function.
.
#Acute on Chronic systolic Heart failure/Dyspnea: Patient was
initally treated for HCAP at OSH but this was stopped given his
CXR was without evidence of infiltrates. Patient volume
overloaded on exam with elevated BNP. He was diuresed for acute
on chronic systolic heart failure with lasix gtt. An echo was
done that showed dilated LA, RA, RV and LV; LV systolic function
depressed with EF 20-25%. His outpatient cardiologist was
contact[**Name (NI) **] who confirmed that patient was on diovan, aldactone,
and coumadin as an outpatient. Ultimately, his lasix gtt was
switched to torsemide. Valsartan was and metoprolol were
restarted. EP was also consulted for possible biv upgrade of
patient's ICD as he was 90% RV pacing with widened QRS.
Patient's ICD was interogated and revealed underlying sinus
rhythm with 1:1 AV conduction. His ICD was reprogrammed to
allow native conduction. Patient was discharged with plans for
follow up with EP as an outpatient.
.
#. Atrial Fibrillation: Confirmed with outpatient cardiologist
that patient had been on coumadin and was in favor of restarting
this. Patient wsa restarted on coumadin with lovenox bridge.
Amiodarone was continued. EP consulted as stated above, pacer
interrogated showing underlying sinus with 1:1 AV conduction.
.
#Hypotention: No infectious etiology identified. Patient
diuresed cautiously; sbp ranged from 70s-110s but mentating
well. His [**Last Name (un) **] and beta blocker were started slowly as blood
pressure tolerated.
.
# Acute on Chronic Renal Insufficiency: Creatine improved with
diuresis; diovan restarted later on his hospital course.
.
# Elevated LFTs: Improved with diuresis, likely hepatic
congestion secondary to acute on chronic heart failure.
.
#. CAD: Patient was continued on aspirin, zocor, and [**Last Name (un) **]/bb were
restarted at later date. Plavix was stopped as patient was over
a year out from his catheterization.
.
# Diabetes: Continued NPH and sliding scale.
.
#Hyperlipidemia: continued zocor and tricor
.
#STAGE II HEEL/DECUBITUS: wound care consulted. Patient was set
up with an appoitnment to follow up with vascular surgery as
outpatient.
.
#SUBCLINICAL HYPOTHYROIDISM: Noted to have elevated TSH w/
normal T4 at OSH. Outpatient follow up.
.
GERD: Ranitidine renally dosed at 150mg daily
.
DEPRESSION: continued home dose Effexor XR and Trazadone.
Medications on Admission:
- Humalog 50/50 16u [**Hospital1 **]
- Aldactone 12.5mg [**Hospital1 **]
- Duoneb INH QID
- Amiodarone 100mg daily
- ASA 81mg daily
- plavix 75mg daily
- colase 100mg [**Hospital1 **]
- tricor 145mg daily
- advair 250/50 [**Hospital1 **]
- flonase 1 spray daily
- lasix 80mg [**Hospital1 **]
- zestril 2.5mg [**Hospital1 **]
- MVI daily
- Nystatin S/S QID
- Miralax 1 tblsp daily
- zantac 150mg [**Hospital1 **]
- zocor 10mg daily
- trazadone 50mg QHS
- Effexor XR 112.5mg daily
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Venlafaxine 75 mg Tablet Sig: 1.5 Capsule, Sust. Release 24
hrs PO DAILY (Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) as needed for constipation.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-14**]
Puffs Inhalation Q6H (every 6 hours).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Torsemide 100 mg Tablet Sig: One (1) Tablet PO once a day.
13. Miralax 17 gram Powder in Packet Sig: One (1) packet PO once
a day.
14. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
15. Humalog Mix 50-50 100 unit/mL (50-50) Suspension Sig: Ten
(10) units Subcutaneous twice a day.
16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM for 2 days: Then continue Warfarin according to INR, goal
2.0-3.0.
17. Enoxaparin 100 mg/mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours): continue until INR > 2.0,
then d/c. .
18. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
19. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous three times a day: before meals.
20. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
21. Outpatient Lab Work
Please check chem7 and INR on [**First Name8 (NamePattern2) 1017**] [**6-18**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]
Discharge Diagnosis:
Acute on Chronic Systolic Congestive Heart Failure
Coronary Artery Disease
Diabetes Mellitus Type 2
Paroxysmal Atrial Fibrillation
Acute on chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had another episode of congestive heart failure and needed
to be transferred to [**Hospital1 18**] for low blood pressure. Your kidneys
were not working well initially but have improved now. You did
not have a urinary tract infection here. You will return to see
Dr. [**Last Name (STitle) **] next month to discuss a revision of your pacemaker
that may help with the congestive heart failure. We started you
on coumadin to prevent blood clots and stroke with your
irregular heart beat. You will need to take this medicine every
day and follow your blood levels closely. Information about
coumadin was given to you here.
Medication changes:
1. Discontinue Zestril, furosemide, flonase, Plavix and
spironolactone
2. Start Diovan 40 mg to lower blood pressure and help your
heart work better
3. Start Torsemide to prevent fluid overload
4. Start senna to help with constipation
5. Start Lovenox to prevent blood clots until the coumadin level
is > 2.0. Then d/c Lovenox
6. Start coumadin at 5mg daily for 2 days, check INR on [**First Name8 (NamePattern2) 1017**]
[**6-18**] and adjust coumadin accordingly. Goal INR is 2.0-3.0.
7. Start Troprol to lower your heart rate and help your heart
pump better.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Cardiology: Electrophysiology
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2147-7-20**] 9:00
.
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] Phone: [**Telephone/Fax (1) 11650**] Date/time: [**6-22**] at 2:00pm
.
Primary Care:
[**Month (only) **],[**Female First Name (un) **] Phone: [**Telephone/Fax (1) 24306**] Date/Time: Pls make an appt to
see Dr. [**Last Name (STitle) 24305**] when you get out of rehabilitation
Completed by:[**2147-6-16**]
|
[
"5849",
"4280",
"41401",
"5859",
"2767",
"496",
"42731",
"V4582",
"4168",
"412",
"32723",
"4240",
"4241",
"53081"
] |
Admission Date: [**2149-3-1**] Discharge Date: [**2149-3-7**]
Date of Birth: [**2073-4-5**] Sex: F
Service: MEDICINE
Allergies:
Ceftriaxone / Propofol
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Endotracheal intubation.
Bronchoscopy on [**2149-3-1**]
Bronchoscopy on [**2149-3-3**]
Central line placement (RIJ) [**2149-3-3**]
Central line pull out and tip culture [**2149-3-6**]
History of Present Illness:
Pt is a 75F h/o OSA with multiple intubations secondary to
tracheobronchomalacia s/p recent stenting in [**2149-2-14**] by Dr.
[**Last Name (STitle) **] who presented today with subjective feeling of SOB,
although sats initially at baseline (98-99 2L). She was also
noted to have have yellow sputum and increased facial edema.
.
In the ED, initial vs were: 98.8 80 145/90 20 100 4L. She was
initially thought by ED to have a mild COPD exacerbation and
received nebs, solumedrol 125 X 1, and levaquin 750 X 1. She did
not receive IVFs. She was about to be moved to a floor bed when
her respirations became more labored, RR increased to 45, and HR
increased to sinus tachycardia in 130's. She was evaluated by IP
in ED, had a trial of bipap with minimal improvement. CXR
unchanged from prior. She also received 2mg IV ativan for
anxiety. She was intubated in ED, IP bronched her and saw no
mucous plug, clear and patent stent, and distal airways.
.
She arrived to ICU intubated and sedated with propofol. Of note,
her last spirometry showed no obstructive pattern. No clear
etiology for resp decline.
Review of sytems: not possible as patient intubated and sedated.
Past Medical History:
# Panick attacks with respiratory compromise
# Tracheobronchomalacia s/p recent Y silicone stenting
# Obesity
# Diabetes Mellitus type 2
# Hypertension
# Obstructive Sleep Apnea
# Anxiety Disorder
Social History:
Patient originally form Conecticcut, used to live with his
daughter who is the priamry care taker. She was at Rehab ([**Hospital1 599**]
[**Last Name (un) **]) due to her respiratory therapy and streght as well as
frequent pulmonologist visits. She denies any current or prior
history of smoking or alcohol. She denies any illegal drug use.
Family History:
Denies any history of premature coronary artery disease, DM,
HTN.
Physical Exam:
VITAL SIGNS - Temp 98.6 F, BP 135/78 mmHg, HR 84 BPM, RR 16 X',
O2-sat 98% RA
<br>
GENERAL - well-appearing womman in NAD, appropriate, speaking in
short sentences [**2-24**] SOB, but comfortably at baseline.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - bilateral ronchi without any appreciable wheezes, 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
[**5-27**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait.
Pertinent Results:
On Admission:
[**2149-3-1**] 10:40AM WBC-4.0 RBC-3.38* HGB-10.6* HCT-32.4* MCV-96
MCH-31.4 MCHC-32.8# RDW-13.8
[**2149-3-1**] 10:40AM NEUTS-57.2 LYMPHS-32.0 MONOS-4.8 EOS-5.7*
BASOS-0.3
[**2149-3-1**] 10:40AM PLT COUNT-319#
[**2149-3-1**] 10:40AM GLUCOSE-153* UREA N-6 CREAT-0.7 SODIUM-140
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-30 ANION GAP-11
[**2149-3-1**] 10:40AM PT-12.8 PTT-28.6 INR(PT)-1.1
[**2149-3-1**] 10:40AM CK-MB-6
[**2149-3-1**] 10:40AM cTropnT-0.03*
[**2149-3-1**] 10:40AM CK(CPK)-130
[**2149-3-1**] 10:57AM LACTATE-1.3
[**2149-3-1**] 02:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2149-3-1**] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2149-3-1**] 02:30PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-10
.
CTA [**2149-3-1**]:
IMPRESSION:
1. No evidence of central or segmental pulmonary embolism. The
subsegmental branches are not fully evaluated due to contrast
bolus timing and respiratory motion artifact.
2. No focal pulmonary consolidation to suggest pneumonia.
Aerosolized secretions are noted within the indwelling tracheal
Y stent in the proximal right and left main stem bronchus in
conjunction with bronchial wall thickening and regions of
bronchiectasis within the right lower lobe which may suggest
superimposed infectious bronchitis.
3. Bilateral pulmonary nodules as described above. Based on
[**Last Name (un) 8773**] guidelines, if patient is at low risk, a dedicated
one-year followup CT would be recommended, if high risk, a
dedicated followup in [**7-4**] months would be recommended. If the
patient has outside CT imaging, comparison should be made to
assess for stability.
4. Atherosclerotic disease involving the aorta and coronary
circulation.
5. Bilateral pleural effusions with regions of adjacent
compression atelectasis.
6. Left hepatic cyst with calcification
.
CXR [**2149-3-1**]:
There is moderate cardiomegaly, unchanged. Small bilateral
pleural effusions and bibasilar atelectasis are noted. There is
no definite consolidation or pneumothorax identified. Tracheal
stent is not clearly seen on this limited view. Extensive
calcifications of the aortic arch are noted.IMPRESSION: Tiny
bilateral pleural effusions and bibasilar atelectasis. No
definite consolidation identified.
.
On Discharge [**2149-3-7**]:
[**2149-3-6**] 05:59AM BLOOD WBC-8.2 RBC-3.27* Hgb-10.5* Hct-30.5*
MCV-93 MCH-32.0 MCHC-34.4 RDW-13.0 Plt Ct-315
[**2149-3-6**] 05:59AM BLOOD Plt Ct-315
[**2149-3-6**] 05:59AM BLOOD UreaN-8 Creat-0.6 Na-145 K-3.3 HCO3-35*
.
SPIROMETRY [**2149-2-12**]:
1:43 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 1.42 2.01 71
FEV1 1.41 1.37 102
MMF 1.41 1.96 72
FEV1/FVC 99 68 145
LUNG VOLUMES 1:43 PM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 3.18 3.48 91
FRC 1.75 2.05 85
RV 1.73 1.47 118
VC 1.45 2.01 72
IC 1.43 1.43 100
ERV 0.01 0.58 2
RV/TLC 54 42 129
He Mix Time 3.00
NOTES:
Dx: COPD Spirometry: Fair test quality and reproducibility,
results are a
composite of 2 different efforts. Lung Volumes: only one
reportable effort,
good test quality. DLCO: unable to get reportable results due
to pt.
difficulty performing test. BMI: 41.9
Mechanics: The FVC is mildly reduced. The FEV1 is normal. The
FEV1/FVC
ratio is elevated.
Flow-Volume Loop: mild restrictive pattern with an early
termination of
exhalation.
Lung Volumes: The TLC, FRC and RV are normal. The RV/TLC ratio
is elevated.
Impression:
Normal lung volumes with probably normal spirometry. The FVC
may be
underestimated due to early termination of exhalation. There
are no prior
studies available for comparison.
Echocardiogram [**2149-2-7**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF 60-70%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is moderately dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
IMPRESSION: elevated right atrial pressure with normal left and
right ventricular contractile function
Brief Hospital Course:
This is a 75 y/o F with tacheobronchomalacia s/p stenting, OSA,
who now presents with SOB.
.
# SOB: Based on history, she may have initially presented with
reactive airway disease / asthma exacerbation with no compromise
of her oxygenation. Unfortunately we do not have ABGs. Patient's
lungs were without crackles. Patient's NT-proBNP was 679 and she
had a normal echocardiogram 3 weeks prior to presentation. Off
note, she had normal PFTs at that time as well (see reports
section). She suddenly decompensated in the ER with increased
labor breathing and respiratory distress and had a bronchoscopy
looking for mucus plug and/or stent obstruction. However, the
bronchoscopy showed patent stent and no mucus. Nothing was sent
to microbiology. Patient was emergently intubated had a PE-CT
that showed normal lung parenchyma and no evidence of pulmonary
embolus. Pt was transferred to the ICU and the first ABG on
12/500/40/12 was 7.35/58/179. She was started on
methylprednisolone 60 mg Daily and slowly weaned off the vent.
On [**2149-3-3**] she was extubated and started with respiratory
distress afterwards with SpO2 of 100% on 4 L NC. She underwent a
bronchoscopy and there was paradoxical movement of the vocal
cords with edematous cords and with patent airways and stent and
distal malacia without any evidence of secretions or mucus plug.
Patient received racemic epinephrin and salbutamol nebs and
improved within an hour. She was transferred to the medicine
floor, where she was weaned off the oxygen slowly until she was
breathing comfortably in room air. She was able to go upstairs
with an SpO2 of 92-99% on RA. In the medical floor there was no
clear precipitant of the crisis, so viral panel was sent and
negative. Patient was afebrile and without a white count.
Steroids started to be tappered and nebs were continued. The
most likely diagnosis after extensive work up was panic attack
with paradoxical vocal cord movement. ENT was consulted in house
and patient refused examination. They recommended video swallow
that showed mild delay without other abnormalities. Patient can
have full liquids and soft solids, but stated that she prefered
thickened fluids. Benzodiazepines were not recommended since she
will need very high-dose in case of the repeating episode and
will need very close monitor. She was arranged for follow up
with ENT for vocal cord training to avoid another episode. She
has follow up arranged with PFTs with Dr. [**Last Name (STitle) **] in 3 weeks.
.
# Volume status - Pt had low urine output first day of
admission, FeNA consistent with volume depletion and prerenal
state. Patient was hydrated and urine output improved.
.
# Hypertension - Patient is diabetic and currently BP not on
started according to JNC-7 guidelines. She will benefit of ACEI,
but did not start them in the setting of respiratory distress in
case she were to get cough as an adverese reaction. She was
started on Nifedipine, which was titrated up to 90 mg Daily. She
will need further titration as outpatient and may be able to
switch to an ACEI once breathing stable.
.
# DM - Patient was given ISS. She is being discharge on lantus
plus sliding scale.
.
# Anemia ?????? stable hematocrit of ~30 with guaiac negative stools
and MCV 93, MCH 32, MCHC 34.4 and normal PLT count. Will need
outpatient work up.
.
# Anxiety - Patient with low threshold for anxiety with medical
issues and family situation. She was reassured and explained her
diagnoses. No role of benzodiazepines at this time (see above).
.
# Mental stauts - patient showed signs of poor recent memory.
She will need close PCP follow up to evaluate for progressive
cognitive decline.
.
# FEN: No IVF, replete electrolytes, diet as tolerated.
.
# Prophylaxis: Subcutaneous heparin, PPI, Colace/Senna.
.
# Access: PIV.
.
# Code: Full code.
.
# Communication: Patient, pt's son [**Name (NI) 1663**]([**Telephone/Fax (1) 81658**]) and
daughter [**Name (NI) 81659**] [**Telephone/Fax (1) 81660**] and [**2149**].
Medications on Admission:
Colace/Senna
Escitalopram 10 mg daily
Simvastatin 40 mg daily
Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **], mix w/albuterol.
Ferrous Sulfate 325 mg daily
Famotidine 20 mg daily
SQ Hep
Ipratropium
Albuterol
Mucinex 1,200 mg Tab, Multiphasic Release PO BID
Saline Nebulizers: 3cc Saline nebs tid for Y stent patency
Acetaminophen 325 mg as needed for pain.
NPH 5 Subcutaneous QAM & HS.
HISS
Discharge Medications:
1. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*1 Inhaler* Refills:*2*
5. Omeprazole 40 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*
6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 Inhaler* Refills:*2*
8. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation Inhalation twice a day.
Disp:*1 Disk* Refills:*2*
9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for
8 days: Day 1: 4 tablets, Day 2: 4 tablets, Day 3: 2 tablets,
Day 4: 2 tablet, Day 5: 1 tablet, Day 6: 1 tablet, Day 7: [**1-24**]
tablet, Day 8: [**1-24**] tablet.
Disp:*15 Tablet(s)* Refills:*0*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
12. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q4H (every 4
hours) as needed for cough.
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) Units
Subcutaneous at bedtime.
14. Humagol Insulin
Please resume your prior sliding scale.
15. Saline Mist 0.65 % Aerosol, Spray Sig: One (1) Nasal four
times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnsosis:
Anxiety with panic attacks associated with respiratory distress
Tracheobronchomalacia
Possible reactive airway disease / asthma
.
Secondary Diagnsosis:
Obesity
Diabetes Mellitus
Hypertension
Obstructive Sleep Apnea
Discharge Condition:
Stable, breathing comfortably on room air, tolerating diet,
walking by herself.
Discharge Instructions:
You were seen at the [**Hospital1 18**] for shortness of breath. The doctors
in the [**Name5 (PTitle) **] thought you were having a COPD exacebration and were
going to admit you for medical management when you suddenly
started with sever shortness of breath and respiratory distress.
You had an emergent bronchoscopy to take a look at your airways
for the concern of mucus plug in your stent. It was patent and
functioning adequately. Then, to help you breathe they intubated
you. You had a CT scan of your chest that showed normal lungs,
patentn stent and no clots in your arteries. You were slowly
extubated. Immediately after extubation you had another episode
of respiratory distress and had another bronchoscopy that was
normal again. You received nebulized medication and improved. In
the medical floor you were slowly weaned of the oxygen as you
were tolerating until you were breathing comfortably on room
air.
.
Your medications were changed (see attached sheet).
.
If you have sudden worsening of your breathing, fever, chills,
rigors, production of green sputum or anything else that
concerns you please come back to our ER.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-3-18**] 8:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2149-4-1**] 9:00
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2149-4-1**] 9:00
.
MD: [**First Name8 (NamePattern2) **] [**Doctor Last Name **]
Specialty: Pulmonology
Date and time: [**2149-4-1**] at 9am
Location: [**Hospital Ward Name 517**], [**Hospital1 **] 116
Phone number: [**Telephone/Fax (1) 3020**]
Special instructions if applicable: Scheduled for a pulmonary
function test with 6min walk at 9am, then a follow up with Dr
[**Last Name (STitle) **] at 10:30am and then a brochoscopy at 11:30 which lasts
around 90 mins. All in same location.
.
MD: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1837**]
Specialty: Otolaryngology (ENT)
Date and time: [**2149-4-1**] at 3pm
Location: [**Hospital Ward Name 517**],[**Last Name (NamePattern1) 439**], [**Hospital Ward Name **] Bldg, Floor 6,
Suite 6E
Phone number: [**Telephone/Fax (1) 41**]
|
[
"51881",
"4280",
"49390",
"25000",
"4019",
"32723",
"2859",
"311"
] |
Admission Date: [**2190-11-21**] Discharge Date: [**2190-11-27**]
Date of Birth: [**2120-2-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Abdomenal pain
Major Surgical or Invasive Procedure:
1. Laparoscopy.
2. Open cholecystectomy.
History of Present Illness:
This was a 70 year-old woman who
entered the hospital 36 hours earlier with abdominal
discomfort and mild emesis. Her preoperative liver function
tests were normal. An ultrasound of the gallbladder
demonstrated thickening of the wall with some inflammatory
changes and a normal common bile duct. A CT scan also
demonstrated edema of the gallbladder wall. She appeared to
potentially have a stone impacted in the neck. She had a
prior history of type II diabetes mellitus. She was placed on
broad-spectrum antibiotics and plans were made for removal of
the gallbladder.
Past Medical History:
s/p CVA
HTN
DM
A fib
Neurogenic bladder
Obesity
Physical Exam:
At presentation, the patient was in no acute distress. Hear was
regular rate rhythm. Lungs were clear to ascultation. Her
abdomen was soft, with RUQ tenderness, without rebound or
guardin.
Brief Hospital Course:
Upon admission, the patient was made NPO, given IVF, as well as
broad sprecturm antibiotics. She was given IV pain medication
for comfort. She was taken to the operating room the next day
to have an open (converted from laprascopic) cholecystectomy.
She tolerated the procedure well. Post-operatively, she had
bouts of afib, but eventually stabilized on a beta-blocker and a
calcium-[**Last Name (un) 21766**] blocker. She also had poor PO intake. However,
she has increased her intake to an acceptable level over the
last 2 days. She now also reports of being hunger. Since the
operation, she has been afrible with stable vital, with the
exception of several bouts of Afib. She has been tolerating a
regular diet. She will be discharged to day back to her
previous rehab in fair/stable condition.
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Albuterol Sulfate 0.083 % Solution Sig: [**12-27**] Inhalation Q6H
(every 6 hours) as needed.
4. Ipratropium Bromide 0.02 % Solution Sig: [**12-27**] Inhalation Q6H
(every 6 hours).
5. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
6. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
7. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day).
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day. Tablet, Delayed
Release (E.C.)(s)
9. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
10. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day:
**Please check INR** medication restarted [**2190-11-27**].
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed. Capsule(s)
13. Compazine 10 mg Tablet Sig: One (1) Tablet PO every [**3-31**]
hours as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Fair/Stable
Discharge Instructions:
Please take medications as prescribed and read warning labels
carefully. If previous symtoms recur, such as fever/chills,
nausea/vomiting, please go to the emergency room immediately.
If signs of infections such as purulent discharge from wound,
increase pain and redness at wound, please call or go to the
emergency room. Remember to call for a follow up appointment
(bellow). Light activities until seen in clinic. [**Month (only) 116**] eat
regular food. [**Month (only) 116**] shower but no baths. Pat incision wounds
dry, do not scrub wound when showering. Absolutely no smoking.
Followup Instructions:
Please call Dr.[**Name (NI) 1745**]([**Telephone/Fax (1) 5323**] office to be seen in [**12-27**]
weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2190-11-27**]
|
[
"42731",
"25000",
"4019"
] |
Admission Date: [**2191-1-9**] Discharge Date: [**2191-1-20**]
Date of Birth: [**2113-6-22**] Sex: F
Service: KENARD-ICU
CHIEF COMPLAINT: Fever and confusion.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 97956**] is a pleasant
77-year-old female who was recently diagnosed with nonsmall
cell lung cancer in [**2190-11-17**], and is status post four
treatments consisting of Taxol, carboplatin and XRT to the
right pretracheal mediastinal area, who presents to the
Emergency Department with fever and decreased blood pressure
along with some confusion. The patient was recently
discharged on [**2190-12-16**] with the new diagnosis of her
nonsmall cell lung cancer and was sent to [**Hospital1 **] for
conditioning while receiving her chemotherapy.
The patient had been tolerating the treatments well until the
night before admission when she started complaining of
fatigue, and her O2 sat dropped to 93% on room air. Later
on, the patient became very hypoxic with an oxygen saturation
of 87% on room air, and started experiencing lethargy along
with increased confusion. The patient received percocet for
her pain, and her temperature spiked to 101.8, and O2 sats
continued to drop to 86% on 4 liters of nasal cannula. The
patient also had decreased urine output, and her blood
pressure on arrival to the ED was 100/60, with a pulse of
110, and a respiratory rate of 30. The patient also started
to experience some diaphoresis along with accessory muscle
use, and was sent to the ED of [**Hospital6 2018**].
On admission, the patient denied any headache, neck
stiffness, rash, cough, shortness of breath, chest pain,
abdominal pain, dysuria, frequency, urgency of her urine.
The patient was started on Zosyn and transferred to the
Kenard-ICU on the MUS ....... protocol for a working
diagnosis of septic shock secondary to pneumonia.
PAST MEDICAL HISTORY:
1. Nonsmall cell lung cancer.
2. COPD.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She was a retired psychologist at [**Hospital6 1760**]. She lives alone in
[**Location (un) 3307**], [**State 350**]. She used to smoke but quit 15
years ago, but occasionally has 1 or 2 cigarettes a week.
Denies any IV drug use, but is an occasional alcohol drinker.
MEDICATIONS ON ADMISSION:
1. Colace 100 mg [**Hospital1 **].
2. Protonix 40 mg qd.
3. Trazodone 25 mg q hs prn.
4. Tylenol prn.
5. Percocet prn.
6. Calcitonin 200 U intranasal qd.
7. Albuterol-Atrovent inhalers.
8. Lasix 20 mg [**Hospital1 **].
9. Lactulose.
10.Fluoxetine 20 mg qd.
11.Dexamethasone 4 mg po qid.
PHYSICAL EXAM ON ADMISSION - VITAL SIGNS: Temperature 95,
pulse 107, blood pressure 132/68, respiratory rate 20, O2 sat
95% on 4 liters.
GENERAL: Pleasant, elderly female who appeared to be in no
acute distress on admission.
HEENT: PERRLA.
NECK: Supple, dry mucosal membranes.
HEART: S1, S2, tachycardic.
LUNGS: Diffuse expiratory wheezing with no accessory muscle
use at the time of admission. No paradoxical breathing.
ABDOMEN: Soft, nondistended, nontender, positive bowel
sounds.
EXTREMITIES: Warm, no edema, 2+ pulses.
NEURO: Alert, awake, oriented x 3, [**6-21**] motor strength in
upper and lower extremities.
LABS AT ADMISSION: White count 0.2, ANC 170, crit 33.2,
platelets 85, PT 12.4, PTT 29.1, INR 1.0, sodium 124,
potassium 4.7, chloride 93, bicarb 23, BUN 19, creatinine
0.2, glucose 84, mag 1.6, phosphorus 2.7, ALT 30, AST 26,
amylase 37, lipase 9, alk phos 109, total bili 0.8, albumin
2.8, lactate 1.8. Urinalysis was negative with no signs of
infection. ABGs 7.43, PCO2 35, PO2 77 on 100% nonrebreather.
RADIOGRAPHIC IMAGES: Chest x-ray showed a large spiculated
density in the right hilum, 7.0 x 5.2 cm, along with
adenopathy. Pulmonary vasculature was slightly prominent
with Kerley B lines consistent with CHF. Improved bilateral
pleural effusions as compared to prior x-rays.
EKG: Showed 100 beats per minute, rate sinus rhythm, normal
axis, normal intervals, delayed R wave progression, and there
was some T wave inversions in V2-V4.
HOSPITAL COURSE - 1) SEPSIS/ID: The patient presented to the
hospital with hypotension, fever, lethargy, and had a white
count of 0.2 most likely secondary to her most recent
chemotherapy. Although initially there were no clear
presenting symptoms, or signs of patient infection, the
patient was started on broad coverage of Zosyn, Zithromax and
vancomycin. Blood cultures, urine cultures, sputum cultures
were sent, and throughout the hospital course the patient's
blood culture grew back [**5-21**] positive for Strep pneumoniae,
and so the patient was tailored accordingly to the
sensitivities, and was started on ceftriaxone 1 gm qd. In
addition, the Zithromax and the Zosyn were stopped, since the
urine Legionella was negative. The patient was also started
on stress dose steroids of hydrocortisone 100 mg IV tid which
the patient continued for 7 days. Throughout the hospital
course, the patient's white blood count slowly began to rise
without requiring any Neupogen. A surveillance set of blood
cultures was sent on [**1-12**], and another one on [**1-17**] which showed no further growth in the blood. The patient
completed a 7-day course of IV ceftriaxone.
2) RESPIRATORY: When the patient initially presented, the
patient did not appear to be in respiratory distress.
However, throughout the hospital course a CAT scan was
obtained that showed significant right middle lobe and right
lower lobe pneumonia, although the patient not producing much
sputum. The patient was continued on the ceftriaxone, and on
[**1-16**] the patient was intubated secondary to
respiratory failure. The patient began to retain carbon
dioxide and became confused and less responsive. The patient
was extubated on [**2191-1-19**] in anticipation for comfort
measures only since the patient's condition continued to
deteriorate with a very poor prognosis.
3) CARDIOLOGY: The patient has no known coronary artery
disease, and throughout the hospital course the patient was
in sinus rhythm with occasional PACs and ectopy. The patient
was tachycardic which was thought to be a combination from
her being in sepsis, volume overload due to resuscitation,
respiratory distress. In addition, after intubating, the
patient became very hypotensive and had decreased urine
output, and so required a significant amount of fluid
resuscitation along with Levophed to help maintain her blood
pressure. Her Levophed was slowly weaned off a day or two
prior to her extubation, since she was able to maintain an
adequate amount of blood pressure.
4) HEME/ONC: The patient completed chemotherapy consisting
of Taxol, carboplatin and XRT for nonsmall cell lung cancer.
Dr. [**Last Name (STitle) **] who is her primary oncologist was involved
during the care of this patient in the ICU who recommended
that there was no need for Neupogen, as her white count would
slowly increase. Dr. [**Last Name (STitle) **] also had an extensive
discussion with the family that despite her aggressive
treatment, her prognosis is very poor, and so at that time it
was decided that she would be extubated for goals of comfort
measures only.
5) LINES/ACCESS: The patient will have a right subclavian
line to help get her medications to make her comfortable
consisting of morphine and ativan.
6) CODE: The patient is DNR/DNI.
7) COMMUNICATION: The [**Hospital 228**] healthcare proxy is her
brother, [**Name (NI) **] [**Name (NI) 97956**], and their family consisting of
Mr. [**First Name8 (NamePattern2) **] [**Known lastname 97956**], [**First Name8 (NamePattern2) 2270**] [**Known lastname 97956**], and Ms. [**First Name4 (NamePattern1) 31250**]
[**Last Name (NamePattern1) **] were very involved in her care.
DISCHARGE STATUS: The patient is being discharged to either
inpatient hospice versus home hospice with comfort measure
goals.
DISCHARGE CONDITION: The patient is comfortable at this
time.
DISCHARGE MEDICATIONS: Morphine prn.
DISCHARGE DIAGNOSES:
1. Nonsmall cell lung cancer.
2. Pneumococcal pneumonia.
3. Chronic obstructive pulmonary disease.
4. Depression.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Name8 (MD) 14914**]
MEDQUIST36
D: [**2191-1-20**] 11:29
T: [**2191-1-20**] 11:33
JOB#: [**Job Number 97960**]
|
[
"78552",
"51881",
"4280",
"496"
] |
Admission Date: [**2111-5-21**] Discharge Date: [**2111-6-5**]
Date of Birth: [**2053-2-13**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 58 year old white female
has a history of diabetes, hypertension, hypercholesterolemia
and had upper respiratory infection symptoms for four days
prior to admission. She then presented to [**Hospital3 20445**] with mental status changes and had a low glucose.
Her CPK and troponins were checked and her CPK was 238 with a
troponin of 12.8 and the EKG revealed 1.5 mm ST segment
depressions in 1 and AVL with T wave inversions in 3 and AVF.
She was treated with aspirin and transferred to the [**Hospital1 1444**] where she was treated with
Lopressor, heparin and Integrilin.
PAST MEDICAL HISTORY: Significant for a history of insulin
dependent diabetes mellitus. History of hypertension.
History of hyperlipidemia. History of hiatal hernia.
History of gout. History of depression. History of
nephropathy with a baseline creatinine of 3.5. History of
Charcot foot. History of asthma and status post bilateral
cataract surgery.
MEDICATIONS ON ADMISSION: Lopressor 25 mg P.O. B.I.D,
Lipitor 80 mg P.O. q day. NPH 60 units in the morning, 40
units at night, regular 10 units in the morning, 10 at night,
aspirin 325 mg P.O. q day, Atrovent p.r.n., Neurontin 300 mg
P.O. q day, Prilosec 30 mg P.O. q day, amitriptyline 50 mg
P.O. q.h.s., Zaroxolyn , Lasix and Cozaar and Glucophage.
She is allergic to sulfa.
SOCIAL HISTORY: She does not smoke cigarettes. She does not
drink alcohol. She works in Medical Records at an outside
hospital and lives with her son.
FAMILY HISTORY: Is significant for coronary artery disease.
REVIEW OF SYSTEMS: As above.
PHYSICAL EXAMINATION: She is a morbidly obese white female
in no apparent distress. Temperature was 96.9, heart rate
94, blood pressure 104/79, respiratory rate 12. 95 percent
saturation on room air. Head, eyes, ears, nose and throat
examination: Normocephalic, atraumatic, bilateral surgically
repaired pupils, extraocular movements intact. Oropharynx
was benign. Neck is supple, full range of motion, no
lymphadenopathy or thyromegaly. Carotids 2+ and equal
bilaterally without bruits. Lungs were clear to auscultation
and percussion. Cardiovascular examination: Regular rate
and rhythm, normal S1, S2 with no murmurs, rubs or gallops.
Abdomen was obese, soft, nontender with positive bowel
sounds. No masses or hepatosplenomegaly. Extremities were
without clubbing or cyanosis. He had 1+ bilateral pedal
edema and her pulses were 2+ throughout with the exception of
dorsalis pedis which were 1+ bilaterally.
LABORATORY DATA: On admission hematocrit 32, white count
21,000, platelets 398,000, sodium 133, potassium 5.2,
chloride 90, CO2 27, BUN 83, creatinine 3.3.
HOSPITAL COURSE: She was given intravenous hydration and her
catheterization was postponed due to her increased
creatinine. She did not have any further symptoms and she
underwent an echocardiogram which 1+ mitral regurgitation and
an ejection fraction of 35 to 40 percent. She had a cardiac
catheterization on [**5-25**] which revealed her left main coronary
artery was normal. LAD had diffuse 60 percent proximal
lesion with a 90 percent mid lesion. Left circumflex had a
90 percent OM lesion before the bifurcation. The RCA had a
99 percent mid lesion. Her left ventriculogram was not
performed.
Cardiac surgery was consulted. The patient was continued on
Integrilin and heparin and on [**5-28**] the patient underwent
coronary artery bypass graft times two with LIMA to the LAD
and reverse saphenous vein graft to the OM. Crossclamp time
was 32 minutes, total bypass time 43 minutes. She was
transferred to the CSRU on dobutamine and Levophed in stable
condition. She was extubated her postoperative night. She
remained on dobutamine on postoperative day one and was
started on Lopressor. On postoperative day two her chest
tubes were discontinued and she was started on Lasix and her
dobutamine had been weaned off. She required aggressive
pulmonary toilet. Postoperative day three her [**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**]
drain from her leg was discontinued. She continued to
progress and on postoperative day five she was transferred to
the floor in stable condition. Her epicardial pacing wires
were discontinued. She continued to progress and continued
to be diuresed and worked aggressively with Physical Therapy.
On postoperative day number eight she was discharged to home
in stable condition.
Her laboratories on discharge were hematocrit 30.3, white
count 13,900, platelets 441,000, sodium 142, potassium 4.3,
chloride 29. BUN 26, creatinine 1.3, blood sugar 94.
MEDICATIONS ON DISCHARGE: Lasix 40 mg P.O. B.I.D for two
weeks, potassium 40 mEq P.O. B.I.D for two weeks, Colace 100
mg P.O. B.I.D, Ecotrin 325 mg P.O. q day, Plavix 75 mg P.O. q
day, Percocet 1 to 2 P.O. q 4 to 6 hours p.r.n. pain,
Glucophage 500 mg P.O. B.I.D, Lipitor 0 mg P.O. q. Day,
amitriptyline 50 mg P.O. q.h.s., Neurontin 300 mg P.O.
q.h.s., Combivent MDI p.r.n., Lopressor 25 mg P.O. B.I.D,
Darvocet 30 mg P.O. q day, insulin 40 units subcutaneous at
10 P.M. and a regular insulin sliding scale.
She will be followed by Dr. [**Last Name (STitle) 52995**] in one to two weeks and
Dr. [**Last Name (STitle) **] in three to four weeks.
DISCHARGE DIAGNOSES: Coronary artery disease.
Insulin dependent diabetes mellitus.
Hypertension.
Hyperlipemia.
Depression.
Nephropathy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], MD 2229
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2111-6-5**] 16:06:44
T: [**2111-6-5**] 21:41:42
Job#: [**Job Number **]
|
[
"41071",
"41401",
"5849",
"2851",
"4019",
"49390"
] |
Admission Date: [**2170-7-24**] Discharge Date: [**2170-7-29**]
Date of Birth: [**2096-8-13**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: On [**2170-7-12**] the patient
exercised for five minutes [**First Name8 (NamePattern2) **] [**Doctor First Name **] protocol and achieved 88
percent of his age-predicted heart rate. An
electrocardiogram was significant for 6-mm ST segment
depressions in leads II, III, aVF, V1, and V4 through V6.
Frequent premature ventricular contractions were noted.
Nuclear imaging revealed a dilated left ventricular cavity
with stress and mild inferoapical reversible defects. The
ejection fraction was 59 percent with no wall motion
abnormalities.
As a result of this, the patient was referred to the Cardiac
Surgery Service for a coronary artery bypass grafting.
PAST MEDICAL HISTORY: A cerebrovascular accident in [**2156**]-
[**2157**] with residual left hand swelling.
A myocardial infarction in [**2157**]; status post PPCA of the
right coronary artery in [**2153**].
Mitral regurgitation.
Carotid artery disease.
SOCIAL HISTORY: Right carotid endarterectomy and
appendectomy.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS AT HOME:
1. Lisinopril/hydrochlorothiazide 20/25 mg by mouth every day
2. Atenolol 100 mg by mouth once per day.
3. Lipitor 20 mg by mouth once per day.
4. Aspirin 81 mg by mouth once per day.
PHYSICAL EXAMINATION ON PRESENTATION: The patient is a 73-
year-old gentleman in no acute distress. Head, eyes, ears,
nose, and throat examination revealed the pupils were equal,
round, and reactive to light and accommodation. The
extraocular movements were intact. The oropharynx was
benign. Neck examination revealed the trachea was midline.
Pulmonary examination revealed the lungs were clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. The abdomen was soft,
nontender, and nondistended. There were no masses.
Extremities revealed no cyanosis and no edema.
Neurologically, the patient was alert and oriented times
three.
SUMMARY OF HOSPITAL COURSE: The patient was admitted on [**2170-7-24**] and taken to the operating room where he underwent
coronary artery bypass grafting times two. The patient
tolerated the procedure well and received Novolin products in
the Operating Room and was admitted the Cardiac Surgery
Recovery Room after his procedure.
The patient was extubated the following day and transferred
to the floor. On [**2170-7-27**] his pacemaker wires were
discontinued.
DISCHARGE DISPOSITION: He was seen by Physical Therapy who
cleared him to go home.
CONDITION ON DISCHARGE: He was discharged on [**2170-7-29**]
in good condition.
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting on [**2170-7-24**].
Status post cerebrovascular accident.
Status post myocardial infarction.
Mitral regurgitation.
Carotid disease.
Status post right carotid endarterectomy.
Status post appendectomy.
MEDICATIONS ON DISCHARGE:
1. Aspirin 81-mg tablets one tablet by mouth once per day.
2. Acetaminophen 325-mg tablets two tablets by mouth q.4h. as
needed (for pain).
3. Clopidogrel bisulfate 75-mg tablet by mouth once per day
(for three months).
4. Atorvastatin calcium 20-mg tablets one tablet by mouth
once per day.
5. Furosemide 20-mg tablets one tablet by mouth once per day
(for five days).
6. Atenolol 100-mg tablets one tablet by mouth once per day.
DISCHARGE FOLLOW-UP PLANS: The patient was instructed to
make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in five to six
weeks. The patient was also instructed to make a follow-up
appointment with is cardiologist.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 32536**]
MEDQUIST36
D: [**2170-7-29**] 17:52:20
T: [**2170-7-29**] 18:31:00
Job#: [**Job Number **]
|
[
"41401",
"4240",
"412",
"V4582"
] |
Admission Date: [**2155-3-31**] Discharge Date: [**2155-4-17**]
Date of Birth: [**2132-4-8**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Keflex
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Shortness of breath, cough
Major Surgical or Invasive Procedure:
ICU monitoring
[**2155-4-15**] Flexible bronchoscopy
[**2155-4-9**] Flexible bronchoscopy with bronchoalveolar lavage,
right VATS total pulmonary decortication.
[**2155-4-8**] Transthoracic ultrasound. Tube thoracostomy 14-French
pigtail on the right side.
History of Present Illness:
Ms. [**Known lastname 5730**] is a 22 yo F with a history of asthma who presents
with worsening shortness of breath, cough, and R-sided pleuritic
chest pain since awakening early this morning. She reports that
she has had URI symptoms of rhinorrhea, sore throat, and cough
for the past couple of days, which dramatically worsened this
morning. Her cough is productive of yellow/tan sputum, denies
bloody sputum. She also reports that she in unable to take a
deep breath because "[my lungs] just won't let me". She reports
that she has been taking her Advair daily and has also been
using her rescue inhaler regularly for the past couple of days.
The pt denies any history of blood clots or recent air travel,
prolonged car travel, trauma to the LEs, or swelling in the
legs, but does report that she has been taking OCPs for the past
couple of months. Pt denies myalgias, arthralgias, and
nausea/vomiting.
In the ED, VS: T 98.8, HR 98, BP 148/77, RR 16, O2sat 100%RA.
Physical exam without wheezing, no accessory muscle use. Pt
given prednisone 60 mg, as well as combivent & albuterol nebs,
for presumed asthma exacerbation, and ibuprofen for R-sided
chest pain. However, CXR was indicative of RLL pneumonia for
which pt was started on 750 mg of levofloxacin. Pt developed
fever to 102.2 following nebs, and also developed worsening
tachypnea to 24, with O2 sat 95% on RA (99% on 2L NC). Pt was
admitted due to worsening respiratory condition.
Currently, pt is with considerable shortness of breath as well
as persistent right-sided chest pain. She reports that her
dyspnea is worse than when she presented to the ED this morning.
ROS: Denies headache, vision changes, rhinorrhea, congestion,
sore throat, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
Asthma (hospitalized as child, no history of intubation;
symptoms recently well-controlled with current regimen)
Social History:
Works in administration in the [**Hospital3 1810**] recovery
room, accompanied by boyfriend to hospital. Denies tobacco use,
endorses recent EtOH use (one drink last night), denies illicit
drug use.
Family History:
Denies history of blood clots.
Physical Exam:
Vitals - T: 99.8 BP: 142/80 HR: 109 RR: 26 02 sat: 94%RA
GENERAL: Young woman sitting up in bed in apparent discomfort
with difficulty breathing.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. EOMI. MMM. OP clear. Neck supple, no LAD, no
thyromegaly.
CARDIAC: Tachycardia, regular rhythm. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP not elevated.
LUNG: Tachypneic, coarse breath sounds bilaterally with mild
expiratory wheezing. Dullness to percussion at base of right
lung, no change fremitus appreciated. Increased work of
breathing with nasal flairing and mild accessory muscle use.
ABDOMEN: BS+, soft, NT/ND. No masses palpated.
EXT: No edema or calf pain, 2+ dorsalis pedis pulses
bilaterally.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation and strength throughout.
DERM: No rashes/lesions, ecchymoses.
Pertinent Results:
[**2155-3-31**] 11:26PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.023
[**2155-3-31**] 11:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2155-3-31**] 11:00PM URINE HOURS-RANDOM
[**2155-3-31**] 11:00PM URINE GR HOLD-HOLD
[**2155-3-31**] 04:41PM LACTATE-2.0
[**2155-3-31**] 04:30PM GLUCOSE-133* UREA N-10 CREAT-0.7 SODIUM-139
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-21* ANION GAP-17
[**2155-3-31**] 04:30PM estGFR-Using this
[**2155-3-31**] 04:30PM WBC-11.0 RBC-4.73 HGB-14.0 HCT-40.0 MCV-85
MCH-29.5 MCHC-34.9 RDW-13.3
[**2155-3-31**] 04:30PM NEUTS-70 BANDS-18* LYMPHS-9* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2155-3-31**] 04:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2155-3-31**] 04:30PM PLT SMR-NORMAL PLT COUNT-225
Chest x-ray ([**3-31**]): Right lower lobe pneumonia.
ECG ([**4-1**]): Sinus tachycardia. ST-T wave abnormalities. RSR'
pattern in lead V1. Clinical correlation is suggested. No
previous tracing available for comparison.
Chest x-ray ([**4-1**]) #1: Increasing pneumonia and pleural effusion
at the right base.
Chest x-ray ([**4-1**]) #2: There is interval increase in right
pleural effusion and ajacent lung consolidation. There is also
increase in left pleural effusion with left retrocardiac
consolidation.
Chest x-ray ([**4-2**]): No short-term interval change was
demonstrated in the bibasilar right significantly more than left
consolidations and bilateral pleural effusions also right more
than left.
Chest x-ray ([**4-3**]): No significant interval change of the
bibasilar opacities, right greater than left.
Chest CT [**4-7**] - Severe multifocal pneumonia, with complete
heterogenous consolidation of the right middle lobe and right
lower lobe, associated with necrotizing component in right lower
lobe. Obstruction of the bronchus intermedius with peribronchial
nodal tissue could be due to mucous plugging and less likely
inflammatory reaction to a foreign body.
Chest CT [**4-14**] -Overall improvement. Improvement in right lower
lobe collapse and
consolidation, left lower lobe consolidation and collapse, and
aeration of
multiple bronchi as described above. Improvement of bilateral
pleural
effusion, especially on the right.
[**2155-4-9**] 05:14AM BLOOD WBC-16.1* RBC-3.30* Hgb-9.7* Hct-28.0*
MCV-85 MCH-29.6 MCHC-34.8 RDW-13.3 Plt Ct-454*
[**2155-4-10**] 05:04AM BLOOD WBC-41.5*# RBC-3.50* Hgb-10.3* Hct-30.2*
MCV-86 MCH-29.5 MCHC-34.2 RDW-13.4 Plt Ct-556*
[**2155-4-11**] 06:15AM BLOOD WBC-19.0*# RBC-3.38* Hgb-9.8* Hct-28.9*
MCV-85 MCH-28.9 MCHC-33.9 RDW-13.1 Plt Ct-540*
[**2155-4-13**] 03:38AM BLOOD WBC-11.8* RBC-3.02* Hgb-8.7* Hct-25.6*
MCV-85 MCH-29.0 MCHC-34.1 RDW-13.4 Plt Ct-605*
[**2155-4-16**] 05:44AM BLOOD WBC-9.7 RBC-3.24* Hgb-9.4* Hct-27.6*
MCV-85 MCH-29.1 MCHC-34.2 RDW-14.1 Plt Ct-641*
[**2155-4-15**] 05:41PM BLOOD Vanco-18.1
RESPIRATORY CULTURE (Final [**2155-4-14**]): OROPHARYNGEAL FLORA
ABSENT. STAPH AUREUS COAG +.
Brief Hospital Course:
Ms. [**Known lastname 5730**] is a 22 yo F with a hx of asthma found to have severe
community-acquired pneumonia, transferred to MICU on HD#1 with
increasing dyspnea and O2 requirement, with slow improvement on
empiric vancomycin/levofloxacin; transferred to medicine floor
on HD#3.
1) Severe community-acquired pneumonia: Pt was initiated on
levofloxacin for CAP, but continued to progress during hospital
day #1 with worsening tachypnea, new O2 requirement, and
splinting due to severe right-sided pleuritic chest pain. She
was transferred to the MICU where she required high-flow O2 and
vancomycin was empirically added to her antibiotic regimen to
cover a post-viral pneumonia. Initial ABGs in the MICU
demonstrated respiratory alkalosis, but lactate was elevated as
well indicating a superimposed metabolic acidosis in the setting
of sepsis. Sputum samples with no definitive microbiology, but
rather moderate oropharyngeal flora, for which broad-spectrum
antibiotics were continued. Respiratory viral panel as well as
urine legionalla were negative, and BCx were with no growth to
date. Serial chest x-rays demonstrated rapid progression of
right lower lobe consolidation from HD #1- HD #2, but no
interval change following that time period. U/S in the MICU was
negative for a loculated or drainable pleural effusion. Pt
slowly improved clinically on antibiotics with morphine PRN for
right-sided pleuritic chest pain, and was transferred to the
medicine floor on 4L O2 on HD #3.
On [**4-8**] a right pigtail catheter was placed in an attempt to
drain the large effusion, CT scan showed significant loculations
as well as a thick pleural rind, the decision was made to take
the patient to the operating room for a formal decortication and
drainge. On [**4-9**] the patient was taken to the operating room, a
right pulmonary decortication, bronchoscopy with BAL, and
drainage with placement of chest tubes x3 was performed.
Post-operatively the patient was admitted to the floor on
telemetry, antibiotics were continued pain was controlled with a
PCA, all 3 chest tubes were left to sution. CXR were checked
daily to evaluate for recurrence of effusion, pneumothorax as
well as appropriate chest tube position. Diet and activity were
advanced, although the patient did have difficulty with nausea
and vomiting early in her post-operative course, this was
managed with anti-emetics, and resolved. Intra-operative
cultures became positive for MRSA, Vancomycin and levaquin were
continued as abx coverage. Given the need for long term
antibiotic therapy a PICC line was placed. On POD 4 patient
noted some swelling in her right arm a venous duplex was
performed to evaluate for DVT given her PICC line, the study was
negative for thrombosis. On POD 5 repeat CT scan was performed,
showing; " Overall improvement. Improvement in right lower lobe
collapse and consolidation, left lower lobe consolidation and
collapse, and aeration of multiple bronchi as described above.
Improvement of bilateral pleural effusion, especially on the
right." The patient also began to have vision changes,
opthamology was consulted, and commented this was likely
secondary to the anti-cholinergic effects of her anti-emetics.
On POD #6 repeat bronchoscopy was performed, this demonstrated
improvement of edema in RML/RLL, with no evidence of
obstruction. The anterior-apical tube was d/c'd, the
post-apical and basilar tubes were both backed out 2cm and
resecured. On POD #8 the patient was deemed fit for discharge,
with visiting nursing services for home Vancomycin therapy as
well as monitoring of the wounds. At the time of discharge, pt
pain was controlled with PO meds, she was ambulating without
assistance, her oxygen saturations were in the high 90's on room
air, her WBC had normalized, and she was tolerating a regular
diet.
2) Asthma: Pt demonstrated no physical exam evidence of
wheezing, suggestive against an acute asthma exacerbation.
Continued pt on fluticasone-salmeterol and albuterol nebulizers
given difficulty of taking home inhalers with dyspnea. Systemic
steroids, which were given in ED, were not continued given known
infection and no evidence of asthma exacerbation.
3) Sinus tachycardia: Heart rate 110 bpm at admission; most
likely secondary to fever and pleuritic chest pain, as well as
s/p albuterol nebulizers, both of which can produce tachycardia.
Heart rate only mildly elevated at admission, and improved with
defervescence and improved respiratory function.
4) Normocytic anemia: Hct dropped to 32-34 during
hospitalization, Hct 40 at admission. Baseline unknown, likely
component of hemodilution given IVFs. No clinical evidence of
bleeding.
5) PPX: Heparin SQ, bowel regimen
6) CODE: Full
Medications on Admission:
Advair
Proair PRN
OCPs
Discharge Medications:
1. Oral contraceptive pills [**Month/Day (4) **]: One (1) once a day: Continue
to take, as directed.
2. Advair HFA 115-21 mcg/Actuation Aerosol [**Month/Day (4) **]: Two (2)
Inhalation twice a day.
3. Docusate Sodium 100 mg Capsule [**Month/Day (4) **]: One (1) Capsule PO BID (2
times a day).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*70 Tablet(s)* Refills:*0*
6. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*qs ML(s)* Refills:*0*
7. Sodium Chloride 0.9 % 0.9 % Solution [**Last Name (STitle) **]: Three (3) ML
Injection Q8H (every 8 hours) as needed for line flush.
Disp:*qs ML(s)* Refills:*0*
8. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: 2.5 Recon Solns Intravenous
Q 8H (Every 8 Hours) for 5 weeks.
Disp:*qs Recon Soln(s)* Refills:*0*
9. Levaquin 750 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO every
twenty-four(24) hours for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing for 2 weeks.
Disp:*30 nebs* Refills:*0*
11. Nebulizer/compressor with supplies
Indication - necrotizing pneumonia
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Severe Right middle and lower lobe pneumonia with necrosis
Discharge Condition:
Stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Incision develops drainage
-Chest tube site place clean dressing daily. Drain pneumostat
daily
-No driving while taking narcotics. Take stool softners with
narcotics
-You may shower. No tub bathing or swimming until all incisions
healed
-Go directly to the ED if you experiene any of the following;
acute onset chest pain, shortness of breath, intractable
nausea/vomiting, severe pain not relieved by medication, or any
other concerning symptoms.
-Take all new medications as prescribed; a visiting nurse has
been arranged for your antibiotic infusions. They will also
assist with the care of your wounds, as well as the PICC line.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 1533**] [**Telephone/Fax (1) 2348**] Date/Time:[**2155-4-22**]
11:30pm in the [**Hospital Ward Name 121**] Building [**Hospital1 **] I Chest Disease Center
Completed by:[**2155-4-18**]
|
[
"5119",
"49390",
"2859"
] |
Admission Date: [**2171-7-16**] Discharge Date: [**2171-7-25**]
Date of Birth: [**2120-6-20**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
African American female with severe morbid obesity,
obstructive sleep apnea on BIPAP and bilateral pedal edema
who presents to the Emergency Department on the day of
admission for further evaluation of left breast tenderness
she initially presented to the [**Hospital1 2177**] surgical service for
evaluation in [**2171-4-26**]. At that time, the patient had an
ultrasound done which was negative for abscess. She was
started on intravenous nafcillin with significant
improvement. She was noted at that time to have significant
bilateral pedal edema which was felt to be dependent because
of intravenous fluids and sodium in the antibiotics. She was
Augmentin, also started on atenolol. The patient came to the
Emergency Department day of admission because she noted
increasing puckering of her left breast erythema and foul
smell covering the breast over the past two weeks. She has
had a discharge from a wound in her back, but none from her
breast. She has noted increased bilateral lower extremity
edema to the thighs over the last two weeks. She has
occasional shortness of breath and has been having increasing
orthopnea. She chronically uses two to three pillows and
denies increased paroxysmal nocturnal dyspnea. She has
obstructive sleep apnea and has been on BIPAP for the last
two years. According to her daughter, the BIPAP machine has
not been functioning well over the last several weeks and she
feels that the patient has been somewhat more lethargic
because of that. She has not had a cardiac echocardiogram
recently. The patient denies any fevers, chills or cough.
Denies chest pain or palpitations. She denies any previous
history of deep venous thrombosis or pulmonary embolus and
denies history of lung disease.
In the Emergency Department, she was slightly tachycardic to
103 to 112 initially. Blood pressure was stable at 90 to 110
over 66 to 73. She was breathing at 24. On admission to the
Emergency Department, she was noted to be hypoxic at 73% on
room air which increased to 90% on 60% face mask. Arterial
blood gas was checked on 40% Venti mask and was 7.27, 90 and
60. She was given nebulizers and started on BIPAP. Chest
x-ray showed a question of cardiac enlargement and congestive
heart failure. The patient was given 20 of Lasix
intravenous, diuresed 1200 cc in the Emergency Department.
Also started on heparin empirically for question of pulmonary
embolism. ............. showed on the left lower extremity
suboptimal study without evidence of deep venous thrombosis.
Heparin was discontinued, also given Ancef for cellulitis in
the Emergency Department. Mental status and O2 saturations
improved on BIPAP in the Emergency Department. Room air
still saturating at 84%. She was admitted to the Intensive
Care Unit for close observation for hypoxia and hypercapnia.
PAST MEDICAL HISTORY:
1. Morbid obesity
2. Status post incision and drainage of back wound in [**2171-4-26**]
3. History of left breast cellulitis previously treated at
[**Hospital6 **]
4. Obstructive sleep apnea on BIPAP at night
5. Osteoarthritis of knee
PAST SURGICAL HISTORY:
1. Status post cesarean section
MEDICATION:
1. Aspirin 325 mg po qd
ALLERGIES: NOVOCAINE, REACTION IS NOT CLEAR
SOCIAL HISTORY: Tobacco one pack per day x35 years, no
alcohol. The patient is unemployed, lives in [**Location 16174**] with
her children.
FAMILY HISTORY: Mother with hypertension and question of
heart disease. No family history of cancer or diabetes.
PHYSICAL EXAM:
GENERAL: She is a morbidly obese African American female who
is alert and oriented x3 in no apparent distress.
VITAL SIGNS: Temperature 98.6??????, heart rate 84 to 90, blood
pressure 119/70, respiratory rate 23, O2 saturation 91% on 3
liters.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light. Extraocular muscles are intact. Oral
mucosa dry. Tongue coated, no oral lesions, positive
macrognathia was noted.
NECK: Short, supple, no lymphadenopathy appreciable, jugular
venous distention.
CHEST: Poor inspiratory effort transmitted, upper
respiratory sound, no crackles, rales, rhonchi or wheezing.
HEART: Regular rate and rhythm, normal S1 and S2, no
murmurs, rubs or gallops, no appreciated right sided S3.
BREASTS: Large area of firm peau d'orange extending to back
with slight erythema and increased warmth. No drainage, no
nipple discharge.
ABDOMEN: Severely obese, soft, nontender, nondistended,
positive bowel sounds. Indurated pannus was noted across
left side.
EXTREMITIES: Bilateral 2+ lower edema to the sides
bilaterally and no palpable pulses bilaterally. No cyanosis,
clubbing or lesions appreciated.
NEUROLOGIC: Nonfocal neurologic exam.
ADMISSION LABORATORIES: White blood cell count 4.5,
hematocrit 50.9, hemoglobin 14.7, platelets 192. Sodium 140,
potassium 3.6, chloride 96, bicarbonate 32, BUN 6, creatinine
0.5, glucose 106. Urinalysis: Specific gravity 1.031.
Urine was [**Location (un) 2452**], positive nitrites, no glucose. Trace
ketones, moderate bilirubin, 30 red blood cells, 14 white
blood cells, occasional bacteria. Urine culture was
negative. Arterial blood gases on the [**5-16**] on 40%
face mask 7.27, 90 and 60. Also, later that day, 7.29, 81
and 60. On [**7-17**], first arterial blood gas 7.24, 102
and 96. Second arterial blood gas 7.30, 83, 37 on room air.
There was a question of this arterial blood gas being a
venous blood gas.
IMAGING: Chest x-ray on the 21st showed congestive heart
failure, ill defined density of the left base which may
represent early pneumonia. Portable on [**7-17**] following
Lasix showed a limited radiograph due to position and body
habitus with apparent elevation of the left hemidiaphragm,
the left upper extremity ultrasound limited bilateral lower
extremity duplex venous exam without evidence of deep venous
thrombosis. Electrocardiogram showed tachycardia at 103,
normal intervals, R-axis deviation, diffuse low voltage, S in
1, Q in 3, no T-wave inversion in 3, Q in AVF, Q-wave
flattening in AVL. There was a question of precordial lead
reversal of V2 and V3 with V4 and V5. No acute ischemic ST-T
wave changes were noted. No right atrial enlargement, no
evidence of right ventricular hypertrophy.
HOSPITAL COURSE: The patient was transferred from the
Emergency Department to the MICU because of hypoxia and
hypercapnia. While in the MICU, she was maintained on oxygen
during the day, either nasal cannula or face mask. She was
placed on BIPAP overnight. On [**7-19**], she refused
BIPAP. Her oxygen saturations were in the high 80s to low
90s while in the MICU. This likely represents her baseline.
Blood gases were stable with PCO2s ranging in the 70s to
100s. The patient tolerated this well and denied symptoms of
shortness of breath or chest pain. VQ scan was done to
address the question of pulmonary embolus. It was also
suboptimal. It showed no evidence of perfusion defects. The
patient was treated for three days with ciprofloxacin for
urinary tract infection in addition to her Ancef for the
breast cellulitis.
Left breast ultrasound demonstrated soft tissue edema along
the left lateral chest wall, fluid tracking along the fascial
planes. Several small fluid pockets, the largest of which
was 2.8 x 1.2 x 0.8 cm. Echocardiogram showed a dilated
right ventricle, hypokinetic right ventricular free wall,
left ventricular wall thickness cavity and abnormal septal
wall motion position consistent with right ventricular
pressure volume overload, tricuspid and mitral regurgitation
which could not be quantitated. Pulmonary artery pressure
could not be determined.
The patient remained stable while in the Intensive Care Unit.
Her blood gases continued to remain with PCO2s in the 70s to
100s. Her O2 saturations were high 80s to low 90s. Her
cardiovascular function was not an active issue during this
admission. The patient remained afebrile on Ancef and was
switched to Keflex on [**2171-7-24**]. The patient was
transferred to the regular medical floor 12 [**Hospital Ward Name 1827**] on [**2171-7-21**]. She continued to refuse BIPAP. No repeat blood
gases were performed. The patient remained stable from a
pulmonary point of view. The patient had a mammogram while
on the regular medical floor. It was technically inadequate
secondary to the patient's body habitus and motion artifact
and the patient's inability to stand straight. There were no
lesions suspicious for neoplasm noted, however. A repeat
mammogram should probably be scheduled in the future for this
patient. This patient was seen by the nutrition consult who
recommended and 1800 kilocalorie diabetic diet, even though
the patient is not diabetic. She would definitely benefit
from weight loss which would improve her functional status
and her pulmonary status. The patient was seen by physical
therapy who recommended continued rehabilitation. The
patient is being discharged to [**Hospital3 35555**] for continued rehabilitation on [**2171-7-25**].
DISCHARGE MEDICATIONS:
1. Colace 100 mg po tid
2. Saline nasal spray 0.4 1 to 3 sprays each nostril qid prn
3. Lactulose 30 cc po bid
4. Debrox otic 6.5% 10 drops left ear [**Hospital1 **]
5. Keflex 500 mg po qid until [**2171-7-31**] for
treatment of left breast cellulitis
6. Milk of Magnesia 30 cc po qid
7. Motrin 800 mg po q6h prn
8. Lasix 20 mg po qd
9. Heparin 5000 units subcutaneous [**Hospital1 **]
10. Aspirin 325 mg po qd
DISCHARGE DIAGNOSES:
1. Obstructive sleep apnea
2. Obesity hypoventilation syndrome
3. Left breast cellulitis
4. Right heart failure
DISCHARGE INSTRUCTIONS: The patient has been instructed to
follow up with Dr. [**Last Name (STitle) **] at [**Hospital **] Community Health Center,
telephone ([**Telephone/Fax (1) 35556**]/pager [**Telephone/Fax (1) 35557**]. If the patient is
unable to reach
this physician, [**Name10 (NameIs) **] will follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at
[**Hospital6 256**] [**Company 191**], telephone
([**Telephone/Fax (1) 1921**]. The patient should follow up within one week
to 10 days of discharge for evaluation for left breast
cellulitis.The patient was informed that she needs a f/u
ultrasound of her left breast after her course of antibiotics.
Dr. [**Last Name (STitle) **] was called and a message was left on her voicemail and
with her staff informing her of the necessity of this f/u
examination of the patient's breast. Dr.[**Name (NI) 2804**] phone number and
pager number were also left with Dr. [**Last Name (STitle) **] and she was asked to
call if she had any questions.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2171-7-25**] 13:43
T: [**2171-7-25**] 13:47
JOB#: [**Job Number 35558**]
|
[
"4280",
"5990",
"4240",
"2762"
] |
Admission Date: [**2191-3-5**] Discharge Date: [**2191-3-24**]
Date of Birth: [**2111-9-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7455**]
Chief Complaint:
SOB, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 72408**] is a 79 yo female with COPD,CHF, dementia who was
transferred from [**Hospital 100**] Rehab due to increasing SOB and
abdominal pain. Per PCP note, pt has had increasing "moans",
SOB, and abd pain/distension over past week, which is a change
from baseline. She was seen by psychiatry at NH, who questioned
psychotic depression and started Seroquel and Paxil. Pt also had
non-contrast Abd CT at [**Hospital1 882**] on [**3-1**], which reportedly showed
"no acute process." She had CXR on [**3-1**] which showed "interval
improvement" of bilateral opacities. Per the pt's daughter, pt
had pneumonia in [**1-9**] and has had gradually decreasing function
since then. The daughter also reports pt's mental status has
decreased significantly over the past week. She has had frequent
"panic attacks." R arm contracture has also occurred over the
past several weeks, however the daughter is unsure of the cause.
In the [**Name (NI) **], pt was found to have a PNA on CXR and was started on
BiPAP for hypercarbic resp failure. Her BP initially was up to
206/88, but this decreased without antihypertensive therapy.
Temp was up to 100.6, with O2 sat 92% on 4L NC (increased to
100% on BiPAP). Her code status was reportedly reversed from
DNR/DNI to only DNR (but intubatable). She was given Solumedrol
125mg IV, 2L NS, Levofloxacin 500mg IV, and Morphine 2mg IV.
She currently is not able to converse due to resp distress,
agitation, and BiPAP machine, however she nods "yes" to almost
every question.
Past Medical History:
1)Primary intermedullary ependymoma/astrocytoma, spinal cord
tumor (in the process of being worked up per daughter, s/p XRT
and steroid taper at [**Hospital1 2025**], oncologist Dr. [**Last Name (STitle) **]
2)Remote hx of brain tumor s/p VP shunt placement
3)h/o thoracic aneurysm
4)s/p recent PNA
5)COPD
6)CHF (unknown EF)
7)MVR (bioprosthetic MV)
8)Atrial fibrillation (on coumadin)
9)dementia
10)h/o urinary retention (had foley cath at rehab)
Social History:
Lives at [**Hospital 100**] Rehab. Pt needs total care with ADL's. Other
social hx not obtained.
Family History:
Fam hx of depression.
Physical Exam:
Vitals: T 99.5 BP 147/110 HR 87 RR 17 O2sat 100% on BiPAP
10/4/40%
Gen: pt in resp distress, using accessory muscles, on BiPAP,
awake, alert, moaning
HEENT: OP slightly dry, but not fully examined due to BiPAP
machine
Neck: Supple. JVD approximately to earlobe
Cardio: irregularly irregular, 2/6 SEM @ apex
Resp: diffuse exp wheezes bilaterally (although difficult to
discern from pt making "squeeking" noises while exhaling)
Abd: soft, nt, mildly distended, +BS, no rebound/guarding
Ext: trace BL LE edema. LUE ecchymoses
Neuro: awake, alert, R arm with contracture. Knows she is in
"hospital", but unable to speak further due to agitation and
BiPAP machine. Asked her to squeeze my fingers, and she nodded
"no".
Pertinent Results:
Laboratory Results:
[**2191-3-4**] 06:00PM BLOOD WBC-10.6 RBC-3.89* Hgb-12.5 Hct-36.6
MCV-94 MCH-32.0 MCHC-34.0 RDW-15.9* Plt Ct-506*
[**2191-3-13**] 06:10AM BLOOD WBC-12.7* RBC-3.08* Hgb-10.1* Hct-31.2*
MCV-101* MCH-32.8* MCHC-32.4 RDW-15.8* Plt Ct-411
[**2191-3-20**] 05:27AM BLOOD WBC-8.1 RBC-2.89* Hgb-9.2* Hct-28.1*
MCV-97 MCH-31.8 MCHC-32.7 RDW-16.1* Plt Ct-398
[**2191-3-5**] 03:25AM BLOOD PT-25.9* PTT-24.2 INR(PT)-2.6*
[**2191-3-20**] 05:27AM BLOOD PT-20.4* PTT-27.2 INR(PT)-2.0*
[**2191-3-4**] 06:00PM BLOOD Glucose-121* UreaN-19 Creat-0.7 Na-135
K-4.6 Cl-92* HCO3-31 AnGap-17
[**2191-3-4**] 06:00PM BLOOD ALT-21 AST-39 LD(LDH)-536* CK(CPK)-128
AlkPhos-70 Amylase-68 TotBili-0.4
[**2191-3-13**] 06:10AM BLOOD ALT-41* AST-26 LD(LDH)-373* AlkPhos-51
TotBili-0.4
[**2191-3-4**] 06:00PM BLOOD CK-MB-4 cTropnT-0.09*
[**2191-3-15**] 11:29AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2191-3-16**] 06:19AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2191-3-17**] 06:00AM BLOOD proBNP-1752*
[**2191-3-5**] 01:00AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.9
[**2191-3-14**] 04:40AM BLOOD VitB12-1446* Folate-14.8
[**2191-3-5**] 03:12PM BLOOD Lactate-1.2
Relevant Imaging:
1)Cxray ([**3-4**]): Retrocardiac opacity, possibly representing
atelectasis versus focal consolidation. Likely small bilateral
pleural effusions.
2)CT abdomen/pelvis ([**3-4**]): 1. No evidence of pulmonary embolism.
2. Bibasilar consolidation, likely atelectasis, although
evolving infection cannot be entirely excluded. Moderate right
and small left pleural effusion. 3. Coronary artery
calcifications. 4. Multiple hepatic cysts. 5. Sigmoid
diverticula without evidence of diverticulitis
3)CT Head ([**3-6**]): Limited study due to motion. No acute
intracranial hemorrhage. No mass effect. No evidence of
dilatation of the ventricles.
4)Abdomen xray ([**3-10**]): No evidence of obstruction.
5)ECHO ([**3-17**]): Symmetric LVH with preserved global and regional
biventricular systolic function. Minimal aortic stenosis with
mild regurgitation. Normally-functioning mitral bioprosthesis.
Moderate tricuspid regurgitation. EF 70-80%.
.
6) CT abdomen/pelvis [**3-17**]:
IMPRESSION:
1. Airspace opacity of the dependent bilateral lower lobes is
thought more likely to represent atelectasis; however,
underlying infection cannot be definitively excluded.
2. Small right pleural effusion and minimal left pleural
effusion.
3. Multiple well-defined hypodense foci scattered throughout the
liver, the larger of which are consistent with cysts. Several
smaller lesions are too small to definitively characterize.
4. Numerous sigmoid diverticula without evidence of acute
diverticulitis.
.
7) CXR [**3-16**]:
Feeding tube present, with distal tip directed cephalad in the
fundus. Right PICC line remains in place in the superior vena
cava. Cardiac and mediastinal contours are widened but without
change from the prior radiograph. Previously reported pulmonary
edema has slightly progressed with increased perihilar haziness.
Bilateral pleural effusions are present, best visualized on the
lateral view, small in size.
.
Discharge labs:
[**2191-3-23**] 08:21AM BLOOD WBC-8.4 RBC-2.89* Hgb-9.2* Hct-28.2*
MCV-98 MCH-31.9 MCHC-32.7 RDW-15.9* Plt Ct-377
[**2191-3-24**] 05:28AM BLOOD PT-16.0* PTT-29.5 INR(PT)-1.5*
[**2191-3-23**] 08:21AM BLOOD Glucose-107* UreaN-14 Creat-0.6 Na-141
K-3.7 Cl-104 HCO3-33* AnGap-8
Brief Hospital Course:
Ms. [**Known lastname 72408**] is a 79 yo female with COPD, dementia, here with PNA,
hypercarbic respiratory failure, abd pain, and abnormal EKG.
1) Respiratory failure: Patient presented with respiratory
acidosis and was admitted to the MICU for closer monitoring.
Respiratory decompensation likely occurred in the setting of
pneumonia seen on cxray, COPD, and CHF exacerbation. She was
placed on Levaquin, then vancomycin and zosyn. Zosyn and
Levaquin were stopped and she was continued on Vancomycin for 2
weeks since sputum cultures grew MRSA. Her oxygen saturations
improved with antibiotics and agressive diuresis. She also
completed a short Prednisone taper for her COPD. Per daughter,
she requires at least 2L at baseline at rehab. She was continued
on 2L NC with O2 sats in high 90s. She was continued on lasix
PO and this was progressively decreased to 20mg daily.
2)Abdominal pain: Patient presented with several week history of
diffuse abdominal pain. All imaging studies, including CT scan
abdomen/pelvis, were negative for acute pathology that could
explain her symptoms. It was thought that she was constipated.
She did have bowel movements that were extremely loose in
nature. Lactate was normal and guiac negative suggestive of
mesenteric ischemia being unlikely. GI was consulted and they
recommended a repeat CT abdomen/pelvis which was unchanged. She
was started on oxycodone standing and narcotics were tapered due
to effects on her bowels. Her bowel regimen was optimized with
Colace, senna, and Miralax. Her abdominal pain and distention
improved following bowel movements. She was decreased to
oxycodone 2.5mg q8hr prn pain.
3)Elevated troponins/EKG changes: Patient presented with mildly
elevated troponins and diffuse ST depressions in the
anterolateral leads. Likely demand ischemia given respiratory
distress and underlying infection. Given patient's persistent
abdominal pain, it was thought that this may be an anginal
equivalent. Cardiology was consulted and agreed with agressive
diuresis as well as change from CCB to b-blocker. There were no
new wall motion abnormalities on both ECHOs. She did have
significant LVH with hyperdynamic EF~70-80's. No further imaging
or studies were recommended.
4)Atrial fibrillation: Patient remained in afib throughout her
hospital stay. Her digoxin was d/c'ed in the MICU. She was
continued on Verapamil for rate control. Verapamil was changed
to Metoprolol, per cardiology recommendation, as a result of
increasing abdominal pain and distention. She was continued on
Coumadin with close monitoring of her INR. Her INR became
supratherapeutic to >6 at which point her coumadin was held for
one dose and she was given vitamin K. Her INR then became
subtherapeutic and her coumadin was continued. Her INR on the
day of discharge was 1.5
5)Hypertension: Patient presented with SBP in 200's on admission
but quickly returned to baseline. She was continued on
outpatient regimen of Verapamil, but this was changed to
Metoprolol during her hospital stay.
6) Delirium/Dementia/agitation: Per patient's daughter, she has
had an acute decline in her mental status over past several
weeks. The daughter and PCP denied any history of dementia. She
was initially started on Quetiapine and Lorazepam but given the
increased sedative effects of the quetiapine this medication was
stopped. She was continued on Ativan prn and her mental status
contineud to wax and wane throughout her hospital stay likely
from her comorbidities. She remained oriented to self but not
to time or place. The etiology of her delirium was thought to
be multifactorial with a prolonged hospital stay and significant
comorbitities contributing. She remained afebrile with a stable
WBC count so infection was thought not to be contributing. Her
electrolytes were wnl and her B12 and folate were also normal.
She was started on depakote for mood stabilization at 250mg [**Hospital1 **].
She was also started on paxil 30mg daily for her depression. She
was evaluated by psychiatry given her delirium and history of
depression and they recommended seroquel 12.5 mg tid prn for
anxiety/agitation. They also recommended decreasing her paxil
to 20mg daily. On the day of discharge the patient was more
alert and appropriate following these medication adjustments.
7) h/o brain/spinal tumors: Patient being followed closely at
[**Hospital1 2025**]. She received XRT in [**Month (only) 404**] and was supposed to undergo a
repeat MRI of her C-spine. This was attempted during this
admission but given her agitation this could not be done.
Further work-up will be deferred to as an outpatient. She will
likely need MRI c-spine as an outpatient at [**Hospital1 2025**].
.
8) FEN: NGT was initially placed since patient had poor mental
status. When her mental status improved the NGT was removed and
she tolerated PO intake appropriately. She was evalauted by
speech and swallow who determined that she could tolerate a
regular diet without signs of aspiration. She requires
significant encouragement to take PO.
.
9) Sacral decubitus ulcer: patient was evaluated by wound care
nurse who recommended dressing changes every 2-3 days with
following protocol: clean with commercial cleanser, pat dry,
apply protective barrier wipe to periwound tissue, apply duoderm
gel, cover with Allevyn Foam adhesive 5x5". This should be
continued at rehab. She also requires repositioning every 2
hours. There was no sign of infection at the site.
Medications on Admission:
coumadin 3.5 mg qd
flovent 110mcg 1 puff [**Hospital1 **]
gabapentin 300mg qhs
MOM 30ml qd prn
Verapamil 120mg qd
Amoxicillin 2g prn dental procedures
Klonopin 0.25mg [**Hospital1 **]
Doxycycline 100mg [**Hospital1 **] (started [**3-2**] to be completed [**3-9**])
Levaquin (started [**2-26**], finished [**3-1**])
Digoxin 0.125mg qd
Morphine (Roxanol) 2mg q2h prn
Morphine (Roxanol) 4mg q12h
Seroquel 25mg [**Hospital1 **]
Maalox 15ml q6h prn
Atrovent nebs q4h prn
Albuterol nebs q4h prn
Lasix 40mg qd
Sorbitol 15ml qd
Colace 250mg qd
Senna 2 tabs qhs
Paxil 20mg [**Hospital1 **]
Dulcolax 10mg qhs
Dexamethasone 0.125mg q12h (started [**3-2**])
Discharge Medications:
1. Fluticasone 110 mcg/Actuation Aerosol [**Month/Year (2) **]: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
4. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
5. Warfarin 3 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime).
6. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
7. Oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO every eight (8)
hours as needed for pain.
8. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation every four (4) hours as needed.
9. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
10. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. Paroxetine HCl 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
12. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO every six
(6) hours.
13. Maalox 200-200-20 mg/5 mL Suspension [**Last Name (STitle) **]: Five (5) ml PO
three times a day.
14. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
15. Polyethylene Glycol 3350 17 g (100%) Powder in Packet [**Last Name (STitle) **]:
One (1) Powder in Packet PO DAILY (Daily).
16. Quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times a
day) as needed for anxiety/agitation.
17. Divalproex 125 mg Capsule, Sprinkle [**Last Name (STitle) **]: Two (2) Capsule,
Sprinkle PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
MRSA pneumonia
COPD
Atrial fibrillation
Constipation
Sacral decubitus ulcer
CHF
Dementia/delirium
Discharge Condition:
Afebrile. Respiratory status stable. Tolerating PO. Moving
bowels.
Discharge Instructions:
Please take all of your medications as directed
.
If you experience difficulty breathing, chest pain, inability to
eat, high fevers or other concerning symptoms, please call your
doctor or come to the emergency room.
Followup Instructions:
|
[
"51881",
"42731",
"4280",
"2761",
"496",
"4019"
] |
Admission Date: [**2117-5-26**] Discharge Date: [**2117-5-29**]
Date of Birth: [**2059-2-7**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
R parietal mass
Major Surgical or Invasive Procedure:
[**2117-5-26**]: Right craniotomy for tumor resection
History of Present Illness:
This is a 58 year old gentleman with history of renal cell CA in
[**2115**] status post nephrectomy presented to [**Hospital 487**] Hospital on
[**5-21**] with complaints of headache,
fatigue and slight gait instability. CT head was performed and
revealed right temporal/parietal lesion with significant
edema/MLS. He was given decadron but left Against Medical Advice
because he wanted
to attend his son's rehearsal dinner instead of being
transferred
to the [**Hospital1 18**]. He presentd again on [**5-22**] to establish care,
receive
any necessary medications and make sure that he is safe to
attend
his son's wedding on the next day. He did not want to be
admitted but
agreed to perform necessary tests prior to leaving the Emergency
Department.
He states that he was recently evaluated by his nephrologist
last
week and a follow up CT of his kidneys was negative for
recurrance. He apparently also had a Chest XRay 4 months ago
that was
negative. Mr [**Known lastname **] did explain that he was offered an
experimental chemo after his nephrectomy but declined.
He returned for an elective resection on [**2117-5-26**].
Past Medical History:
Renal Cell CA status post nephrectomy in [**2115**]
Social History:
married, smokes approximately 1/2-1ppd since teens,
4-6 beers per day, denies drugs. Employed part time in
construction.
Family History:
non contributory
Physical Exam:
Pre-op:
PHYSICAL EXAM:
O: T:97.8 BP: 131/77 HR:92 R 20 O2Sats 98% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech 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 intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-1**] throughout. No pronator drift
Sensation: Intact to light touch
Coordination: left dysmetria. rapid alternating movements and
heel to shin intact
On the day of discharge [**2117-5-29**]- the patient was intact.
strength was [**4-1**]. the patient was oriented to person, place,
and time. EOMs were intact. face symetric. ambulating
independently
Pertinent Results:
MR HEAD W & W/O CONTRASt [**2117-5-28**]- patient unable to tolerate
due to anxiety.
Head CT [**2117-5-26**]:
IMPRESSION: Status post right parietal mass resection with small
amount of
blood and gas in the resection bed, surrounding vasogenic edema
Head CT [**2117-5-27**]:
IMPRESSION: Stable appearance of the brain compared with
[**2117-5-26**]. No new
area of hemorrhage or extension of edema seen or hydrocephalus
noted.
MR HEAD W/ CONTRAST Study Date of [**2117-5-26**] 10:36 AM IMPRESSION:
Right parietal enhancing lesion is identified for surgical
planning on this presurgical study (markers were placed on the
surface for
surgical planning). Overall, the appearances of the enhancing
lesion and
surrounding brain are unchanged compared to [**2117-5-22**]
Pathology Report Tissue: POSSIBLE METASTATIC TUMOR, Study Date
of [**2117-5-26**]
Report not finalized.
Assigned Pathologist [**Doctor Last Name **],HASINI
Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**]
PATHOLOGY # [**-9/2708**]
POSSIBLE METASTATIC TUMOR,
CHEST (PRE-OP PA & LAT) Study Date of [**2117-5-25**] 2:32 PM
IMPRESSION: No pneumonia, effusion, or edema.
Cardiology Report ECG Study Date of [**2117-5-25**] 1:59:34 PM
Sinus rhythm. Possible left atrial abnormality. No previous
tracing available for comparison.
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
75 126 92 [**Telephone/Fax (2) 89132**] 45
[**2117-5-26**] 05:23PM TYPE-ART PO2-235* PCO2-35 PH-7.41 TOTAL
CO2-23 BASE XS--1 INTUBATED-INTUBATED
[**2117-5-26**] 05:23PM GLUCOSE-117* LACTATE-2.6* NA+-133* K+-4.5
CL--102
[**2117-5-26**] 05:23PM HGB-13.7* calcHCT-41
[**2117-5-26**] 05:23PM freeCa-1.08*
[**2117-5-26**] 03:22PM TYPE-ART PO2-222* PCO2-40 PH-7.37 TOTAL
CO2-24 BASE XS--1
[**2117-5-26**] 03:22PM GLUCOSE-114* LACTATE-1.4 NA+-130* K+-4.0
CL--100
[**2117-5-26**] 03:22PM HGB-13.5* calcHCT-41
[**2117-5-26**] 03:22PM freeCa-1.09*
[**2117-5-25**] 02:05PM UREA N-21* CREAT-1.4*
[**2117-5-25**] 02:05PM WBC-9.4 RBC-4.63 HGB-14.6 HCT-43.3 MCV-94
MCH-31.6 MCHC-33.8 RDW-13.2
[**2117-5-25**] 02:05PM PLT COUNT-278
[**2117-5-29**] 09:15AM BLOOD WBC-10.8 RBC-4.27* Hgb-13.8* Hct-40.2
MCV-94 MCH-32.3* MCHC-34.3 RDW-12.9 Plt Ct-278
[**2117-5-29**] 09:15AM BLOOD Plt Ct-278
[**2117-5-29**] 09:15AM BLOOD PT-10.6 PTT-21.2* INR(PT)-0.9
[**2117-5-29**] 09:15AM BLOOD Glucose-97 UreaN-17 Na-138 K-3.8 Cl-100
HCO3-27 AnGap-15
[**2117-5-29**] 09:15AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.2
[**2117-5-29**] 09:15AM BLOOD Phenyto-9.5*
Brief Hospital Course:
This is a 58 year old male elective admission for Right crani
for tumor resection on [**2117-5-26**]. Intraoperatively, there were
no complications, a subdural drain was placed. Post-operatively
he was kept in the Neuro IntensiveCareUnit overnight for
observation. His post-operative head CT was stable. There were
no exam changes.
On [**5-27**], The patient was awake and alert. He was ready for floor
transfer but the patient became very agitated and aggressive. He
was trying to leave to have a cigarette. A code purple was
called and the patient was given Ativan and Haldol. A repeat
Head CT was stable and showed no acute hemorrhage. He was kept
in the ICU overnight. His Decadron was discontinued because of
the steroid induced psychosis.
On [**5-28**], he was oriented and his affect/behavior was at baseline.
His subdural drain was removed and staples were placed. He was
transferred to the floor. He went to MRI but was unable to
tolerate secondary to anxiety and chest tightness. His vitals
remained stable. A EKG was stable. He returned to the floor. The
patient ws tolerating a regular diet.
On [**2117-5-29**], the patient was alert and oriented to person place
and time. His strength was full. there was no pronator drift.
pupils were recative and extraocular movements were intact.
bowel sounds were present. The patient was not anxious or
aggitated. The patient was able to void on his own. It was
explained that since he was unable to tolerate the MRI post
operatively, that he will now need to have a MRI with and
without contrast prior to his follow up in the Brain [**Hospital 341**]
Clinic in 4 weeks.Physical Therapy evaluated the patient today
and found that while he is independent with ambulation , the he
would benefit from high level balance training on an out patient
basis with Physical Therapy.
Medications on Admission:
none
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Hospital **]:*60 Capsule(s)* Refills:*2*
2. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day for 4
weeks: hold for loose stools.
[**Hospital **]:*28 Capsule(s)* Refills:*0*
3. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day for 4
weeks: hold for loose stools.
[**Hospital **]:*28 Tablet(s)* Refills:*0*
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for Pain: do not drive while taking, hold for
lethargy.
[**Hospital **]:*60 Tablet(s)* Refills:*0*
5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 7 weeks: please have your level drawn
in one week at your PCP.
[**Name Initial (NameIs) **]:*90 Capsule(s)* Refills:*2*
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Outpatient Lab Work
dilantin level in one week please fax result to [**Telephone/Fax (1) 87**]
9. Outpatient Physical Therapy
for high level balance trainaing- please call to make an
appointment this week
Discharge Disposition:
Home
Discharge Diagnosis:
Right parietal brain mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. physical therapy has
seen the patient and discharged him with recommendation for high
level balance training on a outpatient basis.
Discharge Instructions:
General Instructions/Information
?????? 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 staples 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 generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed until follow-up when we will
decide if this is still needed. You will need your level drawn
in one week with the result faxed to our office. The office fax
number is [**Telephone/Fax (1) 87**].
?????? 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:
You will need to be see at the Brain [**Hospital 341**] Clinic in [**3-3**] weeks
with a MRI of the Brain with and without contrast. Please call
the office on Tuesday [**2117-6-1**] to set up an apointemnt or if
your have and questions you may call them at [**Telephone/Fax (1) 1844**]. As we
were unable to get an MRI while you were inpatient, you will
need one for follow-up.
You will need to return to Dr [**Last Name (STitle) **] clinic for staple removal
10 days from surgery. Please call [**Telephone/Fax (1) 4296**]. Any questions or
concerns please call.
Completed by:[**2117-5-29**]
|
[
"3051"
] |
Admission Date: [**2123-6-10**] Discharge Date: [**2123-6-17**]
Date of Birth: [**2066-4-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr [**Known lastname 976**] is a 57-year-old gentleman with a CML s/p allogeneic
BMT in [**9-/2121**], course c/b chronic GVHD (affecting skin and
liver), who presented to the [**Hospital 3242**] clinic for routine follow up
when he was noted to be very SOB. His O2 sats were in low 80%
range; his other VS were normal and he was afebrile. He stated
that his symptoms began 2 days ago when he noticed some
congestion and a cough productive of green sputum. He states
that his SOB was markedly worse today upon waking up. He was
also complaining of nausea and a headache. He vomited x1 and
had tenesmus with loose stools x3 this morning. His brother
in-law (lives in same house) with a "bronchial thing" earlier
this week. The patient was put on 5L NC and his sats increased
to 94%. On exam in the clinic, his lungs with diffuse coarse
crackles. He was sent to the ED. Of note, the patient has been
on Coumadin for recent PE and continued immunosuppression for
GVHD.
.
In the ED, his vitals 98.9, 85, 105/61, 16, 100% on NRB. ABG
pO2 60s unclear on how much oxygen he was on at the time. In the
ED, he was given Azithromycin 500mg, Cefepime, Decadron 10 mg IV
for concern re: GVHD of lung, bactrim and a combivent neb.
Blood cultures were obtained. A cardiac consult was obtained
for concern re: MI and they felt that he was not having ACS.
Past Medical History:
PAST ONCOLOGICAL HISTORY
# CML diagnosed in 1/[**2120**]. During the [**2120-8-17**] the
patient first noticed some lower extremity swelling and began to
feel quite fatigued. However he did not have insurance at the
time and did not go to his physician for evaluation. In [**Month (only) 404**]
[**2120**] he presented to [**Hospital6 204**] with an acute onset
of dyspnea, lower extremity edema, and confusion. Workup was
consistent with pneumonia and anemia with a hematocrit of 23. He
had an elevated white count, elevated platelet count, increased
basophils, and splenomegaly at that time. Further workup and
bone marrow biopsy were consistent with CML. His peripheral
blood was [**Location (un) 5622**] chromosome positive. He was started on
Hydrea, allopurinol, and Gleevec. He initially required a
Gleevec dose of 800 mg daily but his disease was never fully
controlled on this medication. He has been noted several times
since [**2121-1-15**] to have a platelet count of 700,000- 1,000,000.
.
In [**2121-6-17**], his Gleevec was stopped and he was started on
Sprycel 70 mg twice a day with improved platelet response. His
Hydrea was also tapered and stopped at this time. He is now s/p
myeloablative allogeneic stem cell transplant for CML refractory
to bcr/abl targeted therapies. He tolerated this as above with
diarrhea, rash on upper torso, and abdominal pain. His diarrhea
is now well controlled with qmonthly photopheresis.
.
OTHER PAST MEDICAL HISTORY
# GVHD- chronic diarrhea and liver involvement (chronic
transaminitis)
# Chronic RUQ pain- since [**2113**] with extensive workup and pain
clinic evaluations. No cholecystectomy. No prior abd surgeries.
# GERD- [**Doctor Last Name **] esophagus, offered Nissen fundoplication but not
done, takes pantoprazole
# HTN
# Hx of recent PE [**4-25**] - on coumadin.
Social History:
Lives with his sister and brother-in-law. Used to work in
manufacturing but now out on disability. Denies EtOH. Long
smoking history - quit 14 years ago. Smoked 1 PPD for many
years.
Family History:
Father with diabetes mellitus, BPH, alive at 85yrs
Mother with h/o breast cancer; d. TIAs and CVD at 75yrs
Sister with h/o breast cancer in her 50s, atrial fibrillation
Two brothers with h/o melanoma
Physical Exam:
Vitals: T: 94.6 BP: 98/70 HR: 103 RR: 18 O2Sat: low 90s 5L NC
GEN: Well-appearing, well-nourished, no acute distress
HEENT: NCAT, EOMI, PERRL, sclera anicteric, pharynx with tachy
mucosa, no erythema
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 bilat
PULM: diffuse rhonchi bilat to mid->upper lung zones; diffuse
end-expiratory wheezes.
ABD: Soft, mildy distended, mild tenderness to palpation
diffusely, worse in RUQ +BS, no HSM, no masses
EXT: 2+ pitting edema to mid-tibia. No C/C
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
SKIN: No jaundice, cyanosis. large area of dermatitis on back
r/t GVHD. Purpura on arms bilat.
Pertinent Results:
# LABS ON ADMISSION:
.
HEMATOLOGY:
CBC: [**2123-6-10**] 11:00AM BLOOD WBC-5.1 RBC-3.11* Hgb-10.2*
Hct-31.5* MCV-101* MCH-32.8* MCHC-32.5 RDW-15.8* Plt Ct-291
Diff: [**2123-6-10**] 11:00AM BLOOD Neuts-78* Bands-16* Lymphs-2*
Monos-2 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
Coags: [**2123-6-10**] 11:00AM BLOOD PT-21.7* INR(PT)-2.1*
ANC: [**2123-6-10**] 11:00AM BLOOD Gran Ct-4794
.
CHEMISTRY:
[**2123-6-10**] 11:00AM BLOOD Glucose-143* UreaN-34* Creat-1.5* Na-140
K-4.9 Cl-101 HCO3-28 AnGap-16
[**2123-6-10**] 11:00AM BLOOD Albumin-4.0 Calcium-9.4 Phos-2.4* Mg-1.8
UricAcd-8.4*
.
LFTs:
[**2123-6-10**] 11:00AM BLOOD ALT-92* AST-69* LD(LDH)-327* AlkPhos-670*
TotBili-0.4
.
Cardiac enzymes:
[**2123-6-10**] 12:50PM BLOOD cTropnT-0.18* CK(CPK)-71
[**2123-6-10**] 04:25PM BLOOD cTropnT-0.12* CK(CPK)-29*
[**2123-6-10**] 10:45PM BLOOD CK-MB-4 cTropnT-0.07* CK(CPK)-34*
[**2123-6-11**] 05:27AM BLOOD CK-MB-4 cTropnT-0.06* CK(CPK)-31*
.
.
# LABS ON DISCHARGE:
.
HEMATOLOGY.
CBC: [**2123-6-17**] 06:20AM BLOOD WBC-3.5* RBC-2.89* Hgb-9.3*
Hct-28.0* MCV-97 MCH-32.3* MCHC-33.4 RDW-15.7* Plt Ct-314
DIFF: [**2123-6-17**] 06:20AM BLOOD Neuts-78.7* Lymphs-8.8* Monos-11.1*
Eos-1.3 Baso-0.1
COAGS: [**2123-6-17**] 11:00AM BLOOD PT-14.5* PTT-29.3 INR(PT)-1.2*
.
CHEMISTRY:
[**2123-6-17**] 06:20AM BLOOD Glucose-101 UreaN-19 Creat-1.1 Na-137
K-5.1 Cl-101 HCO3-31 AnGap-10
[**2123-6-17**] 06:20AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8
.
LFTs:
[**2123-6-17**] 06:20AM BLOOD ALT-64* AST-32 LD(LDH)-309* AlkPhos-554*
TotBili-0.3
.
.
# MICROBIOLOGY:
.
BLood culture negative
.
[**6-15**] - Nasopharyngeal aspirate --> Parainfluenza virus antigen
POSITIVE
.
.
# RADIOLOGY:
[**6-10**] IMPRESSION: No acute cardiopulmonary process.
.
.
.
CARDIOLOGY:
.
TTE [**6-11**] The left atrium is elongated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mildly dilated thoracic aorta. Mild aortic
regurgitation.
.
.
.
RADIOLOGY:
[**6-11**] CTA Chest
1) No evidence of pulmonary embolism.
2) Emphysema.
3) Indeterminate 4mm LLL nodule as above. Not seen on recent
priors. Given
underlying emphysema, patient requires a 12 month follow up CT
scan per
current guidelines.
.
[**6-12**] CT Sinus
MPRESSION: Opacification of the frontal, ethmoidal, maxillary
and mastoid
air cells as described above.
Brief Hospital Course:
57 year old male with CML s/p allo BMT [**9-23**] complicated by
chronic GVHD of skin and liver presented with hypoxia and
dyspnea for two days as well as loose stools. Patient was
admitted to [**Hospital Unit Name 153**] monitoring for desaturations to 80% on room
air, where he improved significantly no ABx and increased dose
of steroids. He was transferred to the floor for further care
on HD#2.
# Hypoxic respiratory distress: Given patient's history,
bandemia, bronchiectasis (predisposes to infection) and
immunosuppression, bacterial PNA was considered the most likely
cause of his hypoxia, SOB, however, no evidence of consolidation
on CT scan. Atypical bacterial PNA, viral PNA or bronchitis vs
underlying GVHD of lung (which can have neg CT/CXR finding,
requires High Resolution CT) that may make him more prone to a
pneumonitis when he has a respiratory infection were also
considered. PE was ruled out by CTA. Other causes include
cardiac ischemia but felt to be unlikely given lack of sx, EKG
changes and recent [**12-25**] nl echo. Pt ruled out for MI. Finally,
since patient was c/o nasal congestion, a set of nasal washings
and cultures revealed parainfluenza virus antigen positivity. ID
consult recommended conservative management. Pt's condition
improved on steroids and montelukast. Was discharged with
mid-90% O2sat on RA with pulmonary followup. Patient was
continued on ceftriaxone and azithromycin with plan for total of
7 and 5 days respectively. His steroid dose was increased to
10mg [**Hospital1 **] of prednisone. For occasional wheezing, patient was
placed on ipatropium/albuterol nebs Q6hr PRN.
.
# Bandemia: On admission it was felt that PNA was the most
likely etiology. Other possible sources considered included GI
given sx or urine. Sputum, blood cx, u/a and urine cx, stool cx
& c. diff toxin were all negative.
.
# CML and GVHD - no acute exacerbations noted during hospital
stay, but possibly contributing to respiratory distress.
Patient was continued on outpatient immunosuppressives and the
increased dose of prednisone.
.
# HTN: well controlled during hospital stay. Pt was continued on
metoprolol, lasix.
.
# Osteoporosis & compression fx - continued outpatient pain meds
and Ca and Vit D.
.
# GERD: asymptomatic during admission, continued PPI.
.
# Recent PE: Elevated INR of 2.1 was noted on HD#3, patient on
Warfarin for PE. Eleveated INR most likely [**12-19**] starting
azithromycin for pulmonary infection. Coumadin was held on HD#3
and INR on discharged was 1.2
# PPx: Hep SQ, PPI, Bowel regimen, acyclovir, posaconazole.
Patient was discharged from the hospital in stable condition on
HD# 8.
Medications on Admission:
1. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H
2. Pentamidine Inhalation Q month
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn
4. Pantoprazole 40 mg Tablet daily
5. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS
6. Cyclosporine Modified 50 mg Capsule Sig: Three (3) Capsule PO
Q12H (every 12 hours).
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS prn
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
9. Mycophenolate Mofetil 250 mg Tablet Sig: 1 PO BID
10. Posaconazole 200 mg/5 mL Suspension Sig: One (1) tablets PO
TID
11. Calcium Citrate- Vit D3 315-200 unit tab PO TID
12. Lasix 20 mg PO BID
13. Prednisone 5 mg Tablet Sig: One (1) Tablet [**Hospital1 **]
14. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
daily
15. Morphine 15 mg Tablet Sig: Three (3) Tablet PO Q4H prn
16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily
17. Morphine 60 mg Tablet Sustained Release Sig: Three (3)
Tablet Sustained Release PO twice a day: Take 3 pills in the
19. bisacodyl 10mg Supp PR [**Hospital1 **] PRN
20. Polyethylene glycol 17 g daily.
Discharge Medications:
1. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Morphine 30 mg Tablet Sustained Release Sig: Five (5) Tablet
Sustained Release PO Q12H (every 12 hours).
6. Morphine 15 mg Tablet Sig: 1-3 Tablets PO Q6H (every 6 hours)
as needed.
7. Cyclosporine Modified 25 mg Capsule Sig: Two (2) Capsule PO
Q12H (every 12 hours).
8. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
10. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours) for 2 doses.
Disp:*2 injection* Refills:*0*
11. Prednisone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Pentamidine 300 mg Recon Soln Sig: One (1) inh Inhalation
once a month.
14. Posaconazole 200 mg/5 mL Suspension Sig: One (1) tab PO TID
(3 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID:PRN as needed
for constipation.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
18. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
19. Outpatient Lab Work
Please have your INR checked and faxed to [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 3236**] @
[**Telephone/Fax (1) 30658**].
Discharge Disposition:
Home
Discharge Diagnosis:
CMPL
GVHD
Pulmonary embolism
Chronic right sided pain
Hypertension
Reflux
Discharge Condition:
afebrile, hemodynamically stable, good oxygenation on room air
Discharge Instructions:
You were admitted to [**Hospital1 18**] with symptoms of congestion and
productive cough that resulted in respiratory distress with low
oxygen values in your blood. You were started on antibiotics for
suspected infection, however, they were discontinued because we
did not find a bacterial infection. You were found to have a
parainfluenza virus infection for which supportive care is
recommended. We continued you on an increased dose of 10mg
prednisone [**Hospital1 **] and also started you on montelukast 10mg QD to
help your breathing.
.
You have successfully been weaned off oxygen. You were
discharged with normal oxygenation at room air.
Should you experience fevers, chills, nausea, vomiting,
lightheadedness, new diarrhea, cough, chills, shortness of
breath, chest pain, new or worsening abdominal pain, new rashes
in your skin, burning or pain with urination, or any other
symptom concerning to you, please call your primary care
provider or go to the nearest emergency room.
Followup Instructions:
Please check you INR regularly and take Coumadin as directed by
your physicians.
.
Please follow up with the following providers:
Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 11064**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2123-6-24**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2123-7-7**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2123-8-13**] 8:30
Completed by:[**2123-11-5**]
|
[
"5849",
"V5861",
"53081",
"4019",
"2859"
] |
Admission Date: [**2100-11-8**] Discharge Date: [**2100-11-14**]
Date of Birth: [**2021-9-7**] Sex: F
Service: CSU
Ms. [**Known lastname 174**] is a direct admission to the operating room for
aortic valve surgery. She was seen in preadmission testing
prior to her scheduled surgery. At the time of visit in
preadmission testing, the patient's physical exam is as
follows.
CHIEF COMPLAINT: Asymptomatic patient.
HISTORY OF PRESENT ILLNESS: A 79-year-old woman, with known
AS x 9 years followed by serial echoes, the last echo with
worsening aortic stenosis and a diminishing aortic valve
area, referred for cath and followed by aortic valve
replacement. The patient had an echo done in [**2100-8-29**]
that showed an EF of 60 percent with an aortic valve area of
0.9, and a peak gradient of 96, and a mean gradient of 60,
with mild LVH, 1 plus AI, and 1 plus TR. She had a cardiac
cath done [**10-5**] that showed an aortic valve gradient of
56, with an aortic valve area of 0.5 cm2, an EF of 56
percent, RCA 40 percent, left main 20 percent, and an LAD 30
percent lesion.
PAST MEDICAL HISTORY: Hypertension.
Aortic murmur.
Hiatal hernia.
GERD.
Diverticulosis.
Hernia repair in [**2034**].
Cataract surgery in [**2096**].
D and C in [**2071**].
Drainage of a thyroid cyst approximately 10 years ago.
MEDS AT ADMISSION:
1. Cardizem CD 240 once daily.
2. Hydrochlorothiazide 12.5 once daily
3. Lipitor 10 once daily.
4. Niferex 150 once daily.
5. Calcium.
6. Glucosamine.
7. Metamucil.
ALLERGIES: The patient states environmental allergies, as
well as codeine, although her reaction is simply confusion.
FAMILY HISTORY: Mother died of CAD in her 70s. Father died
of CAD late in life.
SOCIAL HISTORY: She lives with her husband. She denies
tobacco use. Occasional alcohol use. No other recreational
drug use.
REVIEW OF SYMPTOMS: Noncontributory.
PHYSICAL EXAM: VITAL SIGNS: Heart rate 86, blood pressure
124/80, respiratory rate 20, height 5 feet 0 inches, weight
138 pounds. GENERAL: Sitting up in chair, no acute
distress. SKIN: Warm, dry and intact. No lesions. HEENT:
Pupils equally round and reactive to light. Extraocular
movements intact. Neck is supple with no JVD and no bruits,
but she does have a radiated murmur. Chest is clear to
auscultation bilaterally. Heart regular rate and rhythm with
a IV/VI systolic ejection murmur. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are warm and well-perfused with 1-2 plus edema,
right greater than left. VARICOSITIES: None.
Neurologically alert and oriented x 3. Nonfocal exam.
PULSES: Femoral 2 plus bilaterally. Dorsalis pedis 1 plus
bilaterally. Posterior tibial 1 plus bilateral. Radial 2
plus bilaterally.
Carotid ultrasound showed less than 40 percent stenosis
bilaterally.
LABS: White count 4.5, hematocrit 32, platelets 234, PT
12.8, INR 1.0, sodium 139, potassium 3.2, chloride 100, CO2
28, BUN 16, creatinine 0.8, glucose 122, ALT 13, AST 22, alk
phos 82, amylase 78, total bili 0.5, albumin 4.0, hemoglobin
A1C 5.1. Chest x-ray showed no CHF or pneumonia.
HOSPITAL COURSE: On [**11-8**], the patient was directly
admitted to the operating room where she underwent an aortic
valve replacement with a number 23 mm [**Last Name (un) 3843**]-[**Doctor Last Name **]
tissue valve. Her bypass time was 142 minutes with a
crossclamp time of 102 minutes. She tolerated the operation
well and was transferred from the operating room to the
Cardiothoracic Intensive Care Unit. At the time of transfer,
the patient was in a normal sinus rhythm at 85 beats per
minute, with a mean arterial pressure of 67 and a CVP of 15.
She had propofol at 20 mcg/kg/min and Neo-Synephrine at 0.15
mcg/kg/min.
The patient did well in the immediate postoperative period.
Her anesthesia was reversed. She was weaned from the
ventilator and successfully extubated. Throughout that
period, she remained hemodynamically stable, as she did
throughout the operative day. However, she did require a
Nipride drip to maintain a blood pressure between 100 and
110.
On postoperative day 1, the patient continued to be
hemodynamically stable. She was begun on oral medications
and weaned off of her Nipride drip. Additionally, her chest
tubes were removed, and she was transferred to the floor for
continuing postoperative care and cardiac rehabilitation.
Once on the floor, the patient had an uneventful hospital
course. Her activity level was increased with the assistance
of the nursing staff, as well as physical therapy.
On postoperative day 3, her temporary pacing wires and her
Foley catheter were removed. Over the next 2 days, her
activity level was further advanced with nursing and physical
therapy assistance, and on postoperative day 6, it was
decided that the patient was stable and ready to be
discharged to home.
DISCHARGE VITALS: Temperature 98.3, heart rate 81--sinus
rhythm, blood pressure 128/66, respiratory rate 22, O2 sat 94
percent on room, weight preoperatively 63 kg, at discharge
60.1 kg.
LAB DATA: Hematocrit 29.4, sodium 142, potassium 3.5,
chloride 102, CO2 34, BUN 16, creatinine 0.8, glucose 98.
DISCHARGE PHYSICAL EXAM: NEURO: Alert and oriented x 3.
Moves all extremities. Follows commands. Nonfocal exam.
RESPIRATORY: Lungs clear to auscultation bilaterally.
CARDIAC: Regular rate and rhythm, S1, S2, with no murmur.
Sternum is stable. Incision with Steri-Strips, open to air,
clean and dry. Abdomen is soft, nontender, nondistended with
normoactive bowel sounds. Extremities are warm and well-
perfused with no edema.
Th[**Last Name (STitle) 1050**] is to be discharged to home with visiting nurses.
She is to have follow-up with Dr. [**Last Name (STitle) 6073**] in [**3-2**] weeks, and
follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks. Additionally, she
is to have follow-up with her primary care doctor [**First Name (Titles) **]
[**Last Name (Titles) 5887**] once she returns to [**State 5887**].
DISCHARGE DIAGNOSES: Status post aortic valve replacement
with a number 23 [**Last Name (un) 3843**]-[**Doctor Last Name **] tissue valve.
Hypertension.
Gastroesophageal reflux disease.
Diverticulosis.
Hernia repair.
Cataracts.
DISCHARGED MEDICATIONS:
1. Metoprolol 50 mg [**Hospital1 **].
2. Colace 100 mg [**Hospital1 **].
3. Aspirin 325 once daily.
4. Percocet 5/325, 1-2 tabs q 4-6 hr prn.
5.
Atorvastatin 10 mg once daily.
6. Niferex 150 mg once daily.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2100-11-15**] 17:55:55
T: [**2100-11-16**] 10:57:54
Job#: [**Job Number 6074**]
|
[
"4241",
"9971",
"42731",
"4019",
"53081"
] |
Admission Date: [**2136-9-26**] Discharge Date: [**2136-10-10**]
Date of Birth: [**2065-9-26**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Codeine / Ticlid / Atorvastatin
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
epigastric and chest pain, radiating to the back.
Major Surgical or Invasive Procedure:
Intubation
Cardioversion
Central line placement
History of Present Illness:
71 yo female with history of CAD, COPD, HTN, who was initially
admitted on [**2136-9-26**] to vascular service with mid upper back pain
that radiated to mid-epigastrium raising concern for an aortic
dissection. CT showed no dissection and no progression compared
with CT at the [**Hospital 4068**] hospital on [**2136-9-25**]. A CT scan revealed a
descending aortic ulcer. Vascular surgery recommended medical
management and she was then transferred to medicine.
Past Medical History:
CAD s/p CABG [**2117**], stents [**2128**] and [**2134**]
HTN
COPD
B/L Renal artery stenosis s/p right stent placed [**11-29**]- Last MRA
[**8-27**]
Anxiety
Possible Barretts seen on last egd [**2134**]- but not on bx
s/p CCY
s/p Appy
s/p Oophrectomy
renal artery stent placed as above
CABG and stent placements as above
Social History:
Patient has no h/o tabacco. She does not use alcohol. She has 7
children.
Family History:
Mother, grandmother died of liver cancer.
Physical Exam:
Exam at the time of transfer to medical floor from the MICU:
VS: 97.0 127/91 84 (70-84) 24 95% on 4L NC
GEN: Elderly female in no distress, eating lunch, alert, awake,
conversant
HEENT: PERRL, EOMI, CN II-XII otherwise intact, no palpable
cervical LAD, OP moist, no lesions
Neck: supple, no LAD, JVP
CV: regular, nl S1/S2, [**1-1**] syst murmur
PULM: soft bibasilar crackles
ABD: soft, nt, nd, NABS.
NEURO: A&O x3, answers questions appropriately, no gross motor
or sensory deficits
EXT: no peripheral edema, warm and well perfused, no clubbing,
DP pulses 2+, PT pulses 1+
Pertinent Results:
Labs on admission:
[**2136-9-26**] 05:45AM BLOOD WBC-16.2* RBC-4.45# Hgb-12.6# Hct-36.8
MCV-83 MCH-28.2 MCHC-34.1 RDW-14.1 Plt Ct-448*
[**2136-9-26**] 05:45AM BLOOD Neuts-79.1* Lymphs-15.7* Monos-3.6
Eos-1.4 Baso-0.3
[**2136-9-26**] 05:45AM BLOOD PT-12.7 PTT-25.0 INR(PT)-1.1
[**2136-9-26**] 05:45AM BLOOD Glucose-95 UreaN-14 Creat-0.9 Na-144
K-4.2 Cl-110* HCO3-25 AnGap-13
[**2136-9-27**] 02:15AM BLOOD Lipase-49
[**2136-9-26**] 01:40PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.9
[**2136-9-26**] 01:46PM BLOOD Lactate-1.1
[**2136-9-27**] 02:15AM BLOOD ALT-156* AST-131* CK(CPK)-96 AlkPhos-126*
Amylase-60 TotBili-0.6 DirBili-0.2 IndBili-0.4
________________
Cardiac Enzymes:
[**2136-9-26**] 10:43AM BLOOD CK-MB-2 cTropnT-<0.01
[**2136-9-27**] 02:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2136-9-29**] 01:37AM BLOOD CK-MB-24* MB Indx-5.4 cTropnT-0.86*
[**2136-9-29**] 05:41PM BLOOD CK-MB-10 MB Indx-3.9 cTropnT-0.92*
[**2136-10-4**] 01:10PM BLOOD CK-MB-NotDone cTropnT-0.98*
[**2136-10-5**] 03:54AM BLOOD CK-MB-NotDone cTropnT-0.89*
[**2136-10-7**] 05:45AM BLOOD CK-MB-NotDone cTropnT-0.17*
[**2136-10-8**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.07*
________________
Other pertinent lab results:
[**2136-10-9**] 05:50AM BLOOD calTIBC-273 Ferritn-122 TRF-210
[**2136-9-29**] 01:37AM BLOOD TSH-1.2
[**2136-10-8**] 06:00AM BLOOD TSH-3.9
[**2136-9-30**] 02:02AM BLOOD Cortsol-24.1*
[**2136-9-30**] 09:25AM BLOOD Cortsol-41.2*
________________
Labs at the time of discharge:
[**2136-10-10**] 05:45AM BLOOD WBC-19.6* RBC-3.64* Hgb-10.1* Hct-30.5*
MCV-84 MCH-27.8 MCHC-33.1 RDW-15.8* Plt Ct-553*
[**2136-10-10**] 05:45AM BLOOD Glucose-82 UreaN-24* Creat-1.1 Na-142
K-4.7 Cl-106 HCO3-26 AnGap-15
[**2136-10-10**] 05:45AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
[**2136-10-10**] 05:45AM BLOOD PT-18.3* PTT-36.0* INR(PT)-2.3
Microbiology:
RESPIRATORY CULTURE (Final [**2136-10-1**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
ENTEROBACTER AEROGENES. MODERATE GROWTH.
STAPH AUREUS COAG +. MODERATE GROWTH. (oxacilin
sensitive)
Pertinent Studies:
Echo [**2136-9-27**] Moderately dilated LA, left to right shunt at
rest, moderate ASD (4-6 mm in diameter)secundum, mild LVH, LVEF
60-70%,1+MR
RUQ US [**2136-9-27**]: Dilatation of extrahepatic common bile duct to
1 cm, which is an equivocal finding.
CT [**2136-9-27**] (c/w [**2136-9-25**] CT from [**Hospital 4068**] hospital): 1. No
evidence of pulmonary embolism. 2. Stable appearance of
penetrating descending thoracic aortic ulcer. No evidence of
aortic dissection or intramural hematoma. 3. Interval
development of dependent bilateral air space opacities, diffuse
interlobular septal thickening and small bilateral pleural
effusions. Findings are all consistent with pulmonary edema and
atelectasis.
Renal US [**2136-9-30**]: No hydronephrosis. Fluid is seen within the
bladder in the presence of a Foley catheter suggesting possible
catheter malfunction.
CXR [**2136-10-8**]: Improving right lower lobe consolidation but new
tiny left pleural effusion.
p-MIBI [**2136-10-9**]:
Uninterpretable EKG in the absence of anginal symptoms.
Nuclear report: 1. Mild transient ventricular dilitation. 2.
Moderately partial reversible defects in the distal anterior
wall and apex. 3. Enlarged left ventricular cavity size in
stress. Hypokinesis of distal a
anterior wall and apex.
Brief Hospital Course:
71 yo female admitted from the ED on [**9-26**] with mid upper back
pain that radiated to mid-epigastrium raising concern for an
aortic dissection. A CT scan revealed a descending aortic ulcer.
She was hypertensive to 213/98 on arrival and was found to have
mild epigastric tenderness on exam. She was evaluated by
vascular surgery and because CT scan showed no dissection, no
aneurysmal dilatation, and no changes from [**2136-9-25**] CT from
[**Hospital 4068**] Hospital the patient was transferred to medicine. Strict
blood pressure control was recommended. The patient was treated
aggressively with labetalol, Diltiazem, beta-blocker, Nipride
and essentially periods of sinus arrest with junctional escapes.
She then became hypotensive was given fluids and required ICU
transfer for respiratory distress, chest pain and hypotension in
the setting of afib with RVR. In the MICU, she was initially
treated a NTG gtt that was changed to a nitroprusside gtt,
labetalol gtt and intermittently required pressors after
becoming hypotensive. MICU course was complicated by PNA
requiring intubation on [**2136-9-30**].
1. Hypoxic respiratory failure. On [**9-28**] she was started on
levofloxacin for presumed pneumonia given increasing WBC, cough
and secretions. She has a neutrophilic predominance with 4
bands. The patient required intubation on [**2136-9-30**] in the
setting of aggressive volume resuscitation for hypotension and
progression pneumonia. Her sputum culture later grew
Methicillin-sensitive Staph aureus. The patient was treated
initially with CTX/azithromycin/Vanco then changed to Oxacillin
and then Levofloxacin. She improved with diuresis and
antibiotics and was successfully extubated on [**2136-10-2**]. The
patient was discharged to complete 4 more days of Levofloxacin
(organisms sensitive).
2. Atrial fibrillation. Early in her hospital course, the
patient was noted to have episodes of sinus arrest with
junctional escapes in the setting of all cardiovascular
medications she was receiving. The patient was later noted to be
in AFib with RVR during this admission. She has no prior history
of atrial fibrillation. She also had anginal symptoms during
most of the episodes of rapid ventricular response with chest
pain radiating into her neck and jaw. She was converted with
DCCV to SR at 80 on [**2136-9-30**]. Because of allergy to iodine, she
received was briefly on procainamide, but after more history
about her allergies was obtained, she was started on po
Amiodarone loading on [**2136-10-3**] (TSH normal). She continued to
have recurrent intermittent episodes of a fib with RVR some of
which were poorly tolerated. After she was transferred to the
floor, metoprolol dose was titrated up to 37.5 mg po tid which
appeared to keep her HR in 60's with BP tolerating this dose
well. The patient was started on heparin and then transitioned
to Coumadin during this admission. Her INR was therapeutic at
the time of discharge. Electophysiology consultants followed her
closely throughout this admission, and felt that low dose
digoxin may be an option if the patient continues to have
symptomatic episodes of a fib with RVR on beta-blockers and
metoprolol alone. She will have her INR's followed by her PCP's
office who were notified and follow up was arranged. Her
Amiodarone dose was decreased to 400 mg po daily starting
[**2136-10-11**].
3. Coronary artery disease. Patient has a history of CABG [**2117**],
PCIs in [**2128**] and [**2134**]. During this admission she ruled in for
NSTEMI in the setting of afib/RVR and pneumonia. Troponin has
peaked on [**2136-10-4**] at 0.98. She was continued on aspirin,
beta-blocker, Ace I, niacin and pravachol was added. Because she
had anginal symptoms when in rapid ventricular response,
cardiology consult was obtained and the decision was to further
risk stratify her with a p-MIBI which she had on [**2136-10-9**].
Nuclear images showed moderate size partially reversible defect
in distal ant/apex. Because the defect was relatively small, the
patient had no anginal symptoms with exertion, it was felt that
medical management and a fib management should be tried first.
This was discussed with her outpatient cardiologist, Dr.
[**Last Name (STitle) **], who was in agreement.
4. CHF/volume overload. EF 60-70%, secundum ASD with L to R
shunt, mild LVH, 1+ MR. The patient was diuresed with Lasix as
needed. Her oxygen requirements continued to decrease and she
was slowly weaned off oxygen. The patient is being discharged on
beta-blocker, ACE inhibitor. Her ambulatory oxygen saturations
were 90% at the time of discharge with very quick recovery when
at rest. The patient was seen by PT who cleared her for d/c
home. The patient was instructed to check daily weights. Her
weight at the time of discharge was 58 kg.
5. Aortic ulcer. Patient had evaluation as above. She will need
strict blood pressure control.
6. Transaminitis. The patient had mild transaminitis on
admission (alt 156, ast 131, ap 126) possibly from hepatic
congestion. For her abdominal pain she was evaluated on
admission by the GI service and started on Protonix for possible
gastritis. Her abdominal pain gradually resolved. RUQ US was
done to r/o cholecystitis and was negative. H. pylori serologies
and EGD was recommended and could be considered as part of
outpatient work up. Of note, the patient did report a recent 10
pound weight loss and early satiety.
7. COPD. She was continued on Montelukast and
fluticasone-salmeterol. She was asked to avoid albuterol if
possible given afib to prevent tachycardia. She will use
ipratropium instead of Combivent when possible.
8. Anxiety. Ativan prn was given.
The patient was discharged home with VNA and PT services after
inpatient PT evaluation/clearance. Close outpatient follow up
with PCP and Dr. [**Last Name (STitle) **] was arranged for the patient.
Medications on Admission:
Vasotec 40 mg [**Hospital1 **]
Cardiazem 240 mg daily
Toprol 50 mg daily
Loratadine
Ativan
Advair
ASA 325mg daily
Niacin 500mg daily
Singulair
HCTZ 12.5 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
2. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Niacin 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1)
Inhalation three times a day as needed for shortness of breath
or wheezing.
10. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days: then your dose should be decreased to 400 mg po
daily.
Disp:*14 Tablet(s)* Refills:*0*
12. Lansoprazole 30 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*
13. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*0*
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*0*
15. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes as needed for chest pain: may take up
to 3 pills under tongue.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
1. Staph aureus pnemonia
2. Atrial fibrillation
3. Coronary artery disease
4. Angina when in rapid ventricular response
5. Aortic ulceration
Secondary:
1. Hypertension
Discharge Condition:
Vital signs stable. Afebrile
Discharge Instructions:
Please take all medications as prescribed. It is very important
that you take your heart medications as scheduled. Please note
that we added several new medications to your list. You are
started on Coumadin, a blood thinner, and your levels (INR) need
to be closely monitored. Please go to Dr.[**Name (NI) 31083**] office for
INR check this Thursday, [**2136-10-11**], at 9:30 am.
Please follow up as listed below.
Please check your weight every morning. Please call your doctor
if you notice > 3lbs weight gain. Please call your doctor if you
have chest pain, more shortness of breath, develop fevers,
chills, increased cough, unable to tolerate po, bleeding that
does not stop after applying pressure for 5 minutes, or if you
have any other concerns.
Followup Instructions:
Please go to Dr.[**Name (NI) 31083**] office for INR check this Thursday,
[**2136-10-11**], at 9:30 am. Please call Dr. [**Last Name (STitle) **] to find out the
results and to adjust Coumadin dose.
Please follow up with Dr. [**Last Name (STitle) **] (covering for Dr. [**Last Name (STitle) **] this
week) on Friday, [**2136-10-12**], at 2:15 pm. Phone number is
[**Telephone/Fax (1) 6163**].
Please follow up with Dr. [**Last Name (STitle) **], on Tuesday, [**2136-10-23**] at
2:30 pm. Please call if you need to reschedule [**Telephone/Fax (1) 6163**].
Please follow up with your cardiologist, Dr. [**Last Name (STitle) **], on
Wednesday, [**2136-10-24**] at 11:00 am. ([**Telephone/Fax (1) 41856**]
Completed by:[**2136-10-10**]
|
[
"41071",
"4280",
"5180",
"51881",
"42731",
"2762",
"V4581",
"4019",
"V4582"
] |
Admission Date: [**2187-2-14**] Discharge Date: [**2187-2-21**]
Date of Birth: [**2111-8-11**] Sex: M
Service: VASCULAR
CHIEF COMPLAINT: Gangrene of left toes.
HISTORY OF PRESENT ILLNESS: This is a 75-year-old male with
multiple medical problems who was admitted in [**Name (NI) 404**] of this
year for ischemic right foot and gangrenous toes. He
underwent a right popliteal to dorsalis pedis bypass with
vein on [**2187-1-2**], which failed. He underwent a right
TMA which was done on [**2187-1-9**], which did not appear
viable.
He underwent with Dr. [**First Name (STitle) **] of Interventional Cardiology an
attempt to improve the distal circulation with an
angioplasty, but this was unsuccessful. The patient
underwent a right below-the-knee amputation on [**2187-1-19**].
During his hospitalization, wound cultures grew pansensitive
Staphylococcus aureus. He was treated with Kefzol.
Postoperatively he had a fever with positive blood cultures
of beta-strep group B. He was treated with Oxacillin per
Infectious Disease. He also had C-diff on the day of
transfer to [**Hospital **] Rehabilitation. He was discharged on
Augmentin with Flagyl for ten days.
He also has gangrenous left toe changes and returned because
of severe ischemic rest pain. TMA was planned for the
patient. Glucoses have been elevated to greater than 350
over the last day. He was admitted for further evaluation
and treatment.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
MEDICATIONS ON ADMISSION: Lantus 32 U at hs, regular Insulin
sliding scale before meals and at [**Hospital 21013**], Lopressor 50 mg
b.i.d., Lisinopril 10 mg q.d., Lasix 60 mg b.i.d., Lipitor 20
mg hs, Plavix 75 mg q.d., Aspirin 325 mg q.d., Heparin 5000 U
subcue b.i.d., Prevacid 30 mg q.d., Neurontin 300 mg b.i.d.,
Calcium Carbonate 100 mg b.i.d., Tamsulosin 0.4 mg b.i.d.,
Urecholine 25 mg b.i.d., Fentanyl patch 25 mcg/hr change q.2
hours, Morphine Sulfate 10 mg p.o. q.4 hours for breakthrough
pain, Tylenol 650 mg q.4 hours p.r.n. pain, Creon 10 three
tabs with meals, Ambien 5 mg at hs p.r.n., Trazodone 50 mg hs
p.r.n., Colace 100 mg b.i.d., Dulcolax suppository q.d.
p.r.n., Lactulose 20 mg q.d. p.r.n.
PAST MEDICAL HISTORY: Coronary artery disease with
myocardial infarction times four. Last myocardial infarction
was in [**2185-9-27**]. The patient underwent a coronary artery
bypass grafting in [**2185-10-28**]. He has ischemic
cardiomyopathy with an ejection fraction of 15-20%. The
patient's cardiac postoperative course was complicated by
atrial fibrillation. He has asymptomatic carotid stenosis by
ultrasound, less than 40% bilaterally. Type 1 diabetic with
neuropathy. History of hypertension. History of
dyslipidemia. History of gastroesophageal reflux disease.
History of chronic pancreatitis. History of malabsorption.
History of chronic renal insufficiency. History of benign
prostatic hypertrophy with urinary retention and Foley
placement. History of duodenal ulcer with gastrointestinal
bleed, remote.
PAST SURGICAL HISTORY: Bilateral SFA angioplasty with stents
in [**2182**]. Left SFA stent in [**2186-6-27**]. C-diff colitis in
[**2183-12-29**], treated. Coronary artery bypass grafting times
three in [**2185-10-28**] by Dr. [**Last Name (STitle) 70**]. Right popliteal to
dorsalis pedis vein bypass with right TMA in [**Month (only) 404**] of this
year. Right below-the-knee amputation in [**Month (only) 404**] of this
year.
SOCIAL HISTORY: He is widowed. He lives with his two sons.
[**Name (NI) **] has been at rehabilitation since his last hospitalization.
He has had blood transfusions in the past. He has a 30
pack-year smoking history. He has not smoked for 17 years.
He has alcohol occasionally.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.7??????, heart
rate 78, respirations 18, blood pressure 124/62, oxygen
saturation 96% on room air. General: He was an alert and
cooperative white male in no acute distress. HEENT:
Unremarkable. Carotids palpable without bruits. Pulse exam:
Exam showed palpable carotids bilaterally. Right radial is
1+, left radial 2+ and palpable. Abdominal aorta was
nonprominent. Femoral pulses were 2+ bilaterally.
Popliteals were absent bilaterally. He had a right
below-the-knee amputation, well-healed stump, clean, dry, and
intact, with staples in place. The left foot showed mild
erythema with ruborous changes, and the foot was very warm.
There were gangrenous toes, 1 and 2. Dorsalis pedis and
posterior tibial on the left were triphasic Dopplerable
signals. Chest: Lungs clear to auscultation. Heart:
Regular, rate and rhythm. Without murmur. The median
sternotomy was well healed. Abdomen: Unremarkable.
LABORATORY DATA: On admission white count was 5.8,
hematocrit 31.7, platelet count 350,000; BUN 30, creatinine
0.9.
Chest x-ray was not repeated on this admission with no active
cardiopulmonary disease.
Electrocardiogram showed sinus rhythm, normal axis, Qs in II,
III and AVF, no acute ST changes.
HOSPITAL COURSE: The patient was admitted to the Vascular
Service. PVRs were obtained which demonstrated significant
left SFA tibial disease with noncompressible vessels. Pulse
volume recordings on the left showed ankle amplitude of 11
mm, on the tarsal 7 mm. Ankle brachial index could not be
calculated secondary to noncompressibility of vessels.
Anticipated TMA was deferred. The patient underwent a
peripheral catheterization by Dr. [**Last Name (STitle) 911**] in the Cardiac
Catheterization Lab on [**2187-2-16**], and the patient at
that time underwent angioplasty of the anterior tibial with
residual 20% stenosis distally. It was a linear stable type
A dissection distally.
Vancomycin, Levofloxacin, and Flagyl were instituted at the
time of admission. The patient underwent on [**2-19**] a
left TMA. He tolerated the procedure well and was
transferred to the PACU in stable condition. He was returned
to the regular nursing floor for continued care.
His initial dressing was removed on postoperative day #1.
The TMA site was well approximated. Physical Therapy was
requested to see the patient for strict nonweightbearing.
The remaining hospital course was unremarkable. The patient
was discharged in stable condition. Wounds were clean, dry,
and intact. TMA dressing to be dry sterile dressing q.d.
DISCHARGE MEDICATIONS: Metoprolol 25 mg b.i.d., hold for
systolic blood pressure less than 100 or heart rate less than
55, Lisinopril 10 mg q.d., hold for systolic blood pressure
less than 100, Atorvastatin 20 mg at hs, Protonix 40 mg q.d.,
Tamsulosin 0.4 mg b.i.d., Bethanechol 25 mg b.i.d.,
Gabapentin 300 mg b.i.d., Creon 10 3 cap with meals and at
bed time, Calcium Carbonate 500 mg t.i.d., Zolpidem 10 mg at
hs p.r.n., Fentanyl patch 25 mcg/hr topical change q.72
hours, Colace 100 mg b.i.d., Senna 2 tab p.r.n., Colace
suppository 10 mg p.r.n., Lactulose 30 mg q.d. p.r.n.,
Aspirin 325 mg q.d., Plavix 75 mg q.d., Lasix 60 mg b.i.d.,
Morphine Sulfate immediate release 15-30 mg q.4 hours p.r.n.
For breakthrough pain.
DISCHARGE DIAGNOSIS:
1. Left foot gangrene secondary to peripheral vascular
disease.
2. Status post angioplasty of the left anterior tibial
artery.
3. Status post left transmetatarsal amputation.
4. Type 1 diabetes, Insulin controlled, stable.
5. Hypertension, controlled.
6. Coronary artery disease, stable.
7. Hyperlipidemia, treated.
8. Urinary retention.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2187-2-20**] 09:51
T: [**2187-2-20**] 09:56
JOB#: [**Job Number 109530**]
|
[
"4019"
] |
Admission Date: [**2197-11-15**] Discharge Date: [**2197-11-16**]
Date of Birth: [**2150-12-14**] Sex: M
Service: MEDICINE
Allergies:
Amlodipine
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Bronchoscopic large volume right lung lavage
History of Present Illness:
46-year-old man with history of hypertension, hyperlipidemia,
and alcoholic cirrhosis who presents for scheduled admission
after elective whole lung lavage for treatment of pulmonary
alveolar proteinosis.
Per the medical record, patient has been feeling unwell since
the end of [**Month (only) **]. He initially presented to his primary care
physician with symptoms of a respiratory tract infection, and he
was found to have bilateral infiltrates on CXR. He completed a
5-day course of azithromycin, followed by a 14-day course of
levofloxacin, and despite this he continued to decline in terms
of exertional dyspnea. Clinic notes mention that he was dyspneic
with one flight of stairs, and he complained of a persistent dry
couth. Furthermore, he had had a 10-lb weight loss over the past
2 weeks with a concomitant decrease in appetite. He has had
fevers and associated night sweats. He was referred to pulmonary
clinic and underwent CT and BAL, both suggestive of pulmonary
alveolar proteinosis.
The patient presented today for elective therapeutic whole lung
lavage. Per procedure notes, the patient had whole lung lavage
of his right lung. 20 liters of NS was instilled into right
lung, with [**Numeric Identifier 57095**] cc lavaged out. EBL reportedly zero. Per
report, patient's oxygen saturation was above 90% throughout the
procedure, save for a single several minute episode when it
dipped to high 80s. The patient was started on phenylephrine
briefly upon transfer to MICU, but was not reportedly
significantly hypotensive at any time during the procedure. Per
anesthesia flow sheet, MAPs appear to generally have been
between 50-80.
On the floor, patient is intubated and sedated.
Past Medical History:
--Liver mass: currently being worked up
--degenerative joint disease s/p Left knee surgery
--history of positive PPD / latent tuberculosis s/p INH
--lactose intolerance
--hyperlipidemia
--hypertension
--alcoholism
--alcoholic cirrhosis:
--pulmonary alveolar proteinosis
Social History:
Lives with wife; works at [**Hospital3 2576**], does international
billing; smoking history: current 25 pack-year smoker; alcohol-
daily
Family History:
N/C
Physical Exam:
Vitals: T:97.8 BP:153/80 P:94 (regular)
Ventilator: CMV/assist, 550 x 14, 100% FiO2, PEEP 5
General: Intubated, sedated, diaphoretic with sweaty forehead
HEENT: PERRL, EOMI, no conjunctival icterus or injection. ETT in
place. Neck supple, no LAD
Lungs: Mild crackles right apex anteriorly. No wheeze or
rhonchi.
Cardiovascular: RRR. Normal S1/S2. No S3/S4/M/R
Abdomen: Soft, NT/ND, NABS x4, no HSM. No pulsatile masses.
Genitourinary: Foley in place
Extremities: Warm and well perfused. Symmetric 2+ DP/PT/radial
pulses bilaterally. No cyanosis or edema.
Pertinent Results:
[**2197-11-15**] 08:15PM WBC-8.9 RBC-4.61 HGB-15.1 HCT-43.7 MCV-95
MCH-32.8* MCHC-34.5 RDW-15.0
[**2197-11-15**] 08:15PM NEUTS-91.0* LYMPHS-7.5* MONOS-0.8* EOS-0.6
BASOS-0.2
[**2197-11-15**] 08:15PM PLT COUNT-193
[**2197-11-15**] 08:15PM PT-13.9* PTT-25.3 INR(PT)-1.2*
[**2197-11-15**] 05:29PM TYPE-ART PO2-83* PCO2-38 PH-7.40 TOTAL CO2-24
BASE XS-0
[**2197-11-15**] 05:29PM GLUCOSE-113* LACTATE-1.0 NA+-134* K+-4.8
CL--99*
[**2197-11-15**] 08:15PM GLUCOSE-151* UREA N-12 CREAT-1.0 SODIUM-131*
POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-21* ANION GAP-15
[**2197-11-15**] 10:12PM TYPE-ART PO2-158* PCO2-44 PH-7.32* TOTAL
CO2-24 BASE XS--3
[**2197-11-15**] 10:12PM LACTATE-.9
Radiology
[**11-15**] CXR: extensive b/l interstitial opacities correlating with
crazy paving pattern seen on previous CT scan
[**11-16**] CXR: no apparent PTX or pleural effusion
Brief Hospital Course:
46-year-old man with history of hypertension, hyperlipidemia,
alcoholic cirrhosis and recently diagnosed pulmonary alveolar
proteinosis who presented intubated after elective whole lung
lavage for monitoring.
1. Pulmonary alveolar proteinosis: The patient has a new
diagnosis of pulmonary alveolar proteinosis and elected to
undergo whole lung lavage for management of this entity. He was
admitted directly to the chest disease unit for that procedure
and was ultimately lavaged with 21 liters of fluid. He
tolerated that procedure well and was discharged from it to the
ICU intubated. He remained on positive pressure ventilation
overnight and was extubated the follwoing morning. He was
weaned off oxygen and reported overall improvement in his
dyspnea symptoms. He will likely return in the middle of next
week for repeat procedure on his left lung.
2 History of EtOH / cirrhosis: the patient has a history of
significant alcohol use but no history of withdrawal and was
without signs of withdrawal. He was given MVI, thiamine, and
folate daily.
The patient tolerated a regular diet prior to discharge. He was
full code.
Medications on Admission:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary alveolar proteinosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for monitoring after a procedure to rinse
proteinaceous fluid out of your lungs. You tolerated the
procedure well and had the breathing tube removed early the
following day. You were not requiring supplementary oxygen and
were feeling well so you are being discharged home.
Your medications have not been changed. Please resume all
medicines as previously prescribed. We recommend you stop
smoking in order to improve the health of your heart and lungs.
Followup Instructions:
You will be contact[**Name (NI) **] by the interventional pulmonary clinic to
schedule a wash out of your other lung in the near future.
Please keep your previously scheduled appointments:
[**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**2197-12-20**] at 10:30; Phone:[**Telephone/Fax (1) 1142**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**2198-4-9**] at 2:30; Phone:[**Telephone/Fax (1) 1144**]
|
[
"4019"
] |
Admission Date: [**2143-3-18**] Discharge Date: [**2115-3-4**]
Date of Birth: [**2143-3-18**] Sex: M
Service: NEONATAL
This is an interim summary covering the dates of [**2143-3-18**]
through [**2143-4-3**].
HISTORY: The patient is an 1845 gram male infant, twin
number two, born at 34-2/7 weeks gestation, to a 39 year old
gravida 0, para 0 to 2 mother by cesarean section for
worsening pregnancy-induced hypertension.
PRENATAL SCREENS: Blood type A positive, rubella immune, RPR
nonreactive, Hepatitis B surface antigen negative, GBS
unknown. Pregnancy was conceived by in-[**Last Name (un) 5153**] fertilization
and was complicated by pregnancy-induced hypertension.
Mother was betamethasone complete at 29 weeks
gestation.
Delivery was by cesarean section, vigorous at birth. Apgar's
of 8 at one minute and 8 at five minutes. He was noted to
have retractions and grunting in the delivery room and was
given blow-by O2 and then facial CPAP. He was transported to
the Neonatal Intensive Care Unit for further care.
PHYSICAL EXAMINATION: On admission, temperature 98.1 F.;
heart rate 150s; respiratory rate in the 50s; blood pressure
57/34 with a mean of 44. Anterior fontanel was open and
flat. Palate intact. Heart is regular rate and rhythm with
no murmur. Pulses equal in all four extremities. Lungs with
subcostal retractions and fair air exchange. Symmetric
bilaterally. Abdomen soft, no masses palpable. Bowel sounds
present. Anus patent. Testes descended; normal male
external genitalia. Normal tone for gestational age.
HOSPITAL COURSE BY SYSTEMS:
1. CARDIOVASCULAR: The patient was cardiovascularly stable
throughout admission with normal blood pressure; no murmur.
2. RESPIRATORY: The patient intubated at several hours of
life and given Surfactant times one dose. Self extubated
several hours later and was placed on CPAP; weaned to room
air on day of life one. Subsequently breathing comfortably
in room air. The patient has had no apneic or bradycardic
spells; is not on caffeine.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Initially NPO on
intravenous fluids. Feeds initiated on day of life one and
were advanced as tolerated. Advanced on feeds without
difficulty reaching full feeds on day of life six. Calories
were then advanced and the patient is now receiving 150 cc
per kilogram per day of NeoSure 24 calories per ounce. The
patient has been alternating p.o. and gavage feeds. P.o.
intake has gradually improved, currently taking about [**1-4**] to
[**2-5**] of his feeds p.o. The patient has been gaining weight
well on this regimen, birth weight at 1845 grams, weight on
[**4-3**] is 2190 grams.
The patient is on Ferinsol and Vi-Daylin.
4. GASTROINTESTINAL: Bilirubin levels monitored and
phototherapy initiated for hyperbilirubinemia. Peak
bilirubin of 9.6/0.3 on day of life four. Phototherapy was
discontinued on day of life six with a bilirubin level of
6.1/0.2. Rebound bilirubin on day of life seven is stable at
6.2/0.3.
5. INFECTIOUS DISEASE: CBC and blood cultures sent on
admission; white blood cell count 13.0 with 35% polys and
zero bands, started on Ampicillin and Gentamicin. Blood
cultures with no growth at 48 hours and antibiotics were
discontinued. The patient's cord came off around day of life
13. His umbilicus has been monitored since while it
continues to heal over; currently healing well without signs
of infection. No further Infectious Disease issues.
6. HEMATOLOGY: On admission, 67.3% and platelets at 318.
The patient has not required any blood products during his
hospitalization.
7. SENSORY: Hearing screen was performed with automated
auditory brain stem responses. The patient passed
bilaterally on [**2143-4-1**].
8. ROUTINE HEALTH CARE MAINTENANCE: The patient received
Hepatitis B vaccine on [**4-1**]. The patient will need a car
seat test prior to discharge home. The patient is planning
to have circumcision prior to discharge home.
The primary pediatrician is Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37243**] of [**Location (un) 17927**].
Newborn screen sent on day of life three and repeated on day
of life 14 and results are pending.
CONDITION AT TIME OF DICTATION: Stable.
MEDICATIONS AT TIME OF DICTATION: Ferinsol and Vi-Daylin.
DISCHARGE DIAGNOSES:
1. Prematurity of 34 weeks gestational age.
2. Status post mild surfactant insufficiency.
3. Status post rule out sepsis.
4. Status post hyperbilirubinemia.
5. Feeding immaturity.
[**Name6 (MD) **] [**Name8 (MD) 38353**], M.D. [**MD Number(1) 38354**]
Dictated By:[**Last Name (NamePattern1) 50027**]
MEDQUIST36
D: [**2143-4-3**] 12:00
T: [**2143-4-3**] 12:48
JOB#: [**Job Number 55247**]
|
[
"7742",
"V290"
] |
Admission Date: [**2130-12-20**] Discharge Date: [**2130-12-30**]
Date of Birth: [**2062-9-11**] Sex: F
Service: MEDICINE
Allergies:
Hydrochlorothiazide
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
transfer from OSH for retroperitoneal bleed
Major Surgical or Invasive Procedure:
Rt thoracentesis
History of Present Illness:
68 yo female with h/o COPD, afib, CAD, DM, CHF who presented to
an OH with cough and shortness of breath, and was diagnosed with
a COPD exacerbation ([**12-8**]). In house, pt started to complain of
RUQ pain. RUQ ultrasound showed non-obstructive cholelithiasis
and moderately thickened gall bladder wall. HIDA scan negative.
It was thought that pt would benefit from an elective lap chole
per surgery and medicine. Transferred to the transitional unit
for coumadin reversal where Pt had drop in hematocrit (29-->25
in 1 hour). EGD showed a hiatal hernia and gastritis in the
antrum. Colonoscopy negative for GI bleed. Pt was guiac
negative. CT abdomen showed large right retroperitoneal hematoma
and extending from the level of the iliacus and psoas to the
right obturator externus muscle and a moderate to large acute
right rectus abdominus hematoma. Bleeds were thought to be
secondary to coumadin (afib) in addition to patient being put on
lovenox while in the transitional unit. A total 11 [**Location **], 8
[**Location 16678**], 30 of cryoprecipitate, and 8 bags of platelets given
to patient during stay in addition to DDAVP x 2 and protamine x
1, 14 L of fluid, in the setting of decreasing platelets and
increasing INR. WBC elevated in the 20's. XCR ([**12-20**]) showed
increasing pulmonary vascular congestion with right LL
infiltrate and pleural effusion. Hemotology consult thought
thrombocytopenia was dilutional. Pt's renal function
deteriorated in setting of hypotension and compromised renal
flow secondary to extrinsic compression by the hematoma.
Transferred to the [**Hospital1 **] for aggressive fluid hydration and further
management hypotension.
Past Medical History:
CAD, CHF, COPD, CRF (baseline 1.1-2) (?), Afib, non-obstructive
gallstone disease, gastritis, hiatal hernia, DMT2, spondylosis,
SSS, s/p MI (year?), S/p CabG, osteoporosis
Social History:
Lives at home alone. Is in contact with husband and daughter.
Denies EtoH.
Family History:
NC
Physical Exam:
98.9 80-100's 145/87 17-20 93% on 4L
Gen: obese woman in moderate resp distress
HEENT: MMM,
Neck: +JVP, R IJ in place.
CV: RRR, no m/r/g
Lungs: CTAB from posterior, but expiratory wheezes on ant exam
Abd: obese, soft, tender to palpation periumbilically and RUQ.
+large ecchymosis periumbilically
Back: +large ecchymosis R back, tender to palpation.
Ext: 2+ pitting edema bilaterally LE's.
Neuro: A&Ox3. MAEW.
Pertinent Results:
Chest CT [**2130-12-21**]
R pleural effusion - decreased and minimal.
Abd CT [**2130-12-21**]
Large right retroperitoneal hematoma extending from the right
posterior pararenal space down into the pelvis. Hemorrhage into
the right rectus muscle is also noted.
Echo [**2130-12-21**]
Mild symmetric LVH with normal LV systolic function. Normal RV
size and systolic function. Mildly dilated aorta. Moderately
thickened aortic valve with mild aortic stenosis and mild mitral
regurgitation. Moderate pulmonary hypertension
CXR [**2130-12-23**]
Pleural effusion with increasing opacity at the right base,
which may reflect an acute infiltrate.
Renal U/S [**2130-12-22**]
Large retroperitoneal hematoma on the right. Right kidney
displaced anteriorly. Arterial and venous flow within the kidney
is demonstrated. No
hydronephrosis is seen.
IV catheter tip:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). >15 colonies.
Urine cx [**2130-12-21**]:
Enterococcus sensitive to Vanc, but resistant to Levo and
Ampicillin.
Brief Hospital Course:
SOB-Pt clinical picture initially suspected to be COPD with
wheeze on exam, history of asthma and normal EF on TTE with
minimal sign of failure on CXR. Solumedrol was slowly titrated
up to 100mg q8h with poor response, as the pt was diuresed
approximately 1L neg each day for the first 5 days of
hospitalization. On [**12-24**] steroid taper was begun and more
agressive diuresis was begun. Oxygen requirement was weaned over
the next 4 days from 4LNC to 1L and had improved tachypnea with
stable O2 requirement of 1L NC. PE cont to suggests both
intravascular as well as total body volume overload with
anasarca, although MM cont to be dry. TTE had poor windows
although she appeared to have a normal EF but LVH and probable
diastolic HF. Difficult to assess what is rt hrt failure vs left
due to chronic pulm disease. Pt cont to have mild rale on rt of
unlclear source since they worsened with diuresus. Poor air
movement on PE suggest component of obstructive airway disease
although after discussion with pcp it appeared that she only had
moderate asthma with no PFT's in past. There also appears to be
a component of hypoventilation due to hematoma obtructing
diaphragmatic excursion on rt., along with obesity. CT surgery
was conusulted and were concerned that opacity at rt lung base
on CXR represented hemothorax although repeat CT showed only
effusion with fluid density. She was cont steroid taper now on
20mg prednisone to with plan for 20mg x1 days, 10mg x2days 5mg
x2days with last dose on [**2131-1-2**]. Creatinine remained stable so
will cont to diurese with BUMEX 1mg PO bid along with
acetazolamide for 5 more days as below.
Afib-pt had occasional tachycardia which may be due to
intravascular volume depletion with diuresis despite rate
control with diltiazem and digoxin while being paced. Diltiazem
was titrated up to 90 tid with HR in 80's. Rate control was
critical in pt with diastolic HF although we did not want to
blunt compensation for volume depletion. We held on
anticoagulation and it will need to be addressed as an outpt.
Retroperitoneal hematoma-Pt abdominal pain improved and Hct
remained stable with actual increase. Pain was thought likely
due to hematoma, although hct was stable for 9 days prior to
dishcarge. No need for intervention if Hct remains stable since
she would be poor surgical candidate per vascular. Risk of
hemorrhage outweighs stroke risk with afib so cont to hold
coumadin. Pt with severe ecchymosis on abdomen from sc heparin
so unclear if pt is hypersensitive.
Acute on chronic RF-Due to HF and possible compresive component
on ureter by hematoma although no hydroureter on CT abdomen. Pt
creat improved close to baseline of 1.2-1.5 now at 1.5. ABG
revealed metabolic alkalosis with combined respiratory acidosis.
Serum bicarb remains high so acetazolamide was added to help
correct contraction alkalosis to improve breathing drive with
plan for 5 days prior to discharge. Cont Bumex as above.
ID-Pt WBC increased again despite steroid dose stable. Steroids
remains suspected cause since no bandemia or suspected source.
Possible sources incuded VSE grown in Ucx although U/A neg at
the time so stopped vancomycin. Initial CXR showed RLL linear
atelectasis and min change on repeat which may have been due to
compression from effusion and no lg amount sputum production.
Cont to empirically treat for CAP with levofloxacin although CT
showed no clear infiltrate with plan for 10 day regimen.
DMII-Pt con to be better controlled FS likely due decreased
steroids. Will cont on RISS for now down to 30U NPH [**Hospital1 **], but
will titrate down as steroids are weaned.
FEN-diabetic renal diet
Px-PPI, bowel regimen, SC heparin stopped and on pneumoboots
Medications on Admission:
see admission note
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
Disp:*120 neb* Refills:*2*
3. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*120 neb* Refills:*2*
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
Disp:*60 Disk with Device(s)* Refills:*2*
7. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Brimonidine Tartrate 0.2 % Drops Sig: One (1) Drop Ophthalmic
Q8H (every 8 hours).
Disp:*qs * Refills:*2*
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
10. Prednisone 5 mg Tablet Sig: 1-2 Tablets PO once a day for 4
days: take 2 tabs for 2 days, 1 tab for the next 2 days with
last day on [**2131-1-2**].
Disp:*6 Tablet(s)* Refills:*0*
11. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
12. Insulin Regular Human Injection
13. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty
(30) units Subcutaneous twice a day.
Disp:*qs * Refills:*2*
14. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
15. Acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. Morphine Sulfate 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q8H (every 8 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*2*
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
Disp:*240 Tablet(s)* Refills:*2*
20. Bumetanide 2 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
COPD exacerbation
CHF exacerbation
retroperitoneal hematoma
Rt hemothorax
Discharge Condition:
Respiratory status stable on 1LNC O2
Discharge Instructions:
If you experience any fevers, chills, worsening shortness of
breath or abdominal pain, or weakness you should call your
primary care doctor ot your doctor at the rehabilitation center.
If he/she is not available you should go to the nearest
emergency room. You should take three more days of
antibiotics(Levofloxacin) and your Lasix medication was changed
to Bumex.
Followup Instructions:
You should call your primary care doctor after being discharged
from your rehabilitation center within 1-2 weeks for post
hospitalization follow-up.
Completed by:[**2130-12-30**]
|
[
"5849",
"4280",
"42731",
"5119",
"40391",
"486",
"0389",
"5990"
] |
Admission Date: [**2108-5-28**] Discharge Date: [**2108-5-30**]
Date of Birth: [**2053-4-24**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old man
who is here for coiling of a residual regrowth of a
previously treated ruptured anterior cerebral communicating
artery aneurysm. The patient had initially presented with
subarachnoid hemorrhage 2 years ago from which he made a
complete recovery and has been back at work. Serial angiography
showed a lateral regrowth of the aneurysm which has a wide-based
neck.
Upon admission, the patient was stable. He is a 6 foot 3
inch, 255-pound male, age 55. His vital signs, blood
pressure was 121/76, his heart rate was 67, SpO2 was 96 on
room air. He was in no apparent distress. His heart was
regular rate and rhythm, S1, S2, no murmurs, no rubs or
gallops. His lungs were clear to auscultation bilaterally.
Abdomen was protuberant, soft, nontender, with a well-healed
incision from previous surgery. His extremities show no
cyanosis, clubbing or edema. His strength was [**5-9**] x4.
MEDICATIONS UPON ADMISSION: The patient takes Lipitor 10 mg
q.d. and metoprolol 50 mg b.i.d.
ALLERGIES: He has no drug allergies.
SOCIAL HISTORY: He has a past history of alcohol abuse.
Currently, does not smoke, he quit in [**2105**]; he has a 20-pack-
year history. No recreational drug use.
PAST SURGICAL HISTORY: In [**10-5**], a prior brain aneurysm
coiling, and in [**11-5**], he had an IVC filter placed; and
abdominal hernia repair, date unknown.
HOSPITAL COURSE: On [**2108-5-28**], the patient was taken to the
operating room in a stable condition. He had a coiling done
of an aneurysm in the anterior communicating cerebral artery.
Procedure went without complications and patient was brought
to the PACU in a stable condition. Postoperatively, the
patient was alert and oriented x3, was moving all extremities
to commands. His vital signs were: Temperature was 95.1
degrees, blood pressure was 131/72, pulse was 56,
respirations were 19 and his SpO2 was 99% on room air. His
pupils were reactive 3 mm to 2. His extraocular movements
were all intact. His face was symmetric. Tongue was
midline. STM was full. Strength was [**5-9**] throughout.
At this point, the assessment and plan, he was stable
neurologically after the coiling, PACU overnight. His labs
at that time, his white blood cell count was 5.3, his
hematocrit was 42.1, and his platelet count was 191. His PT
was 12.7, PTT was 30.4, and his INR was 1.1.
Day 1 postop, all vital signs were stable. Temperature was
97.8 degrees, blood pressure was 140-128/80s, his heart rate
was 82 to 65, his respiratory rate was 15 and he was 98% on 3
liters. His ins and outs at this time, he was euvolemic.
His labs, white blood cell count was 6.3, his hematocrit was
39.7, his platelets were 208. His electrolytes, sodium was
141, potassium was 4.4, chloride 109. PCO2 was 22, his BUN
was 13, creatinine was 0.9, and his blood sugar was 140. PT
was 12.5, PTT was 25.8 and his INR was 1.0. At this point,
the patient was awake and alert. No complaints. Negative
blurry vision. No nausea. Extraocular movements were
intact. His face was symmetric. Sensory was symmetric.
There was no drift or rebound. His grips were [**5-9**]. Biceps,
triceps were [**5-9**], IPs were [**5-9**]. Today, he is going to be
transferred to the floor. Advance diet, out of bed as
tolerated, and discontinue the Foley. Keep blood pressure
between greater than 110 and less than 150.
On [**2108-5-30**], all vital signs were stable. He was afebrile.
He was awake and alert. Extraocular movements were intact.
His face was symmetric. No drift, rebound, IP is full. Diet
as tolerated today, ambulate, and patient will be discharged.
The patient is discharged in a stable condition. He is
instructed to return if any visual problems or weakness.
RETURN: He will follow up with Dr. [**Last Name (STitle) 1132**] in 1 month.
The patient has been given a list of medications, they
include atorvastatin, calcium 10 mg tablet 1 tablet p.o.
q.d., metoprolol tartrate 50 mg tablet 1 tablet p.o. b.i.d.,
and Percocet 5/325 mg tablet, 1-2 tablets p.o. q.4-6h. p.r.n.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) 23079**]
MEDQUIST36
D: [**2108-5-30**] 12:14:12
T: [**2108-5-30**] 21:24:48
Job#: [**Job Number 35978**]
|
[
"V1582"
] |
Admission Date: [**2142-11-7**] Discharge Date: [**2142-11-25**]
Date of Birth: [**2079-5-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
CPR
Endotracheal intubation and extubation
Cardiac catheterization
History of Present Illness:
Ms. [**Known lastname 101915**] is a 63yo female with ESRD on HD s/p VF arrest. She
completed dialysis (1L off, 3.0K bath), tolerated ok, and was
then found unresponsive. On arrival of CCU team, pt found ashen,
pulseless, apneic, unresponsive. CPR initiated with good effect,
lasted approximately 3 min. CPR prior to monitor leads being
placed-> identified polymorphic VT/VF. Shocked 200J-> CPR
continued, pt intubated. Given insulin 10U, D50. Rhythm checked
-> narrow complex brady, but still no pulse. CPR reinitiated,
[**11-27**] amp calcium given, Epi, bicarb, and atropine prepared, but
rhythm revealed sinus tach w/ good pulses.
Initial postcode blood pressure = 170/110, pt responsive and
fighting tube attempting to pull out. Transferred to CCU for
further management (did not receive remaining code drugs).
On arrival to CCU, pt requesting extubation, good MS, passed SBT
5/0. Therefore extubated, but then became anxious, tachypneic,
Sats high 80s on NRB->99-100 on CPAP NPPV. Subsequently, BP to
80s, and echo revealed new WMA and depressed EF. Therefore, pt
taken to cath lab emergently. Revealed no flow limiting disease,
PCWP 21.
Post-cath continued to do well, initiated on CVVHD for slow
fluid removal.
Past Medical History:
CAD (s/p NSTEMI-> OM1 stent in [**10-1**])
CHF/volume overload
Amyloidosis
Smoldering Myeloma
Schizotypal Disorder
Major depressive d/o
Basal cell carcinoma
Hypothyroidism
Hypercholesterolemia
ESRD on HD
Hypertension
Social History:
Divorced with two sons. Currently lives in [**Location 86**] with one of
her sons. Formerly worked as a teacher but currently lives off
SS assistance. Former smoker but quit 20yr ago. Prior EtOH
abuse, denies current. Denies illicits.
Family History:
Mother w/ CVA, brother w/ CAD, and another brother w/ IVDU.
Physical Exam:
Upon arrival to CCU:
Temp: 98F HR 112 BP 166/89 RR 29 O2sat 100%
Intubated: AC 550/ RR 14/ PEEP 5/ FIO2 1
Gen: Intubated and sedated
HEENT: PERRL, EOMI, ETT in place
Neck: JVP to thyroid cartilage
Chest: paradoxical sternal movement with inspiration. crackles
at lateral bases
CV: RRR harsh [**1-29**] late peaking systolic murmur at RUSB no
radiation
Abd: soft, NT, ND, +BS
Ext: warm, 2+DP pulses
Neuro: intubated and sedated on vent. moving all 4 extremities
symmetrically
Pertinent Results:
Laboratory results:
[**2142-11-6**] 11:00AM BLOOD WBC-7.7 RBC-3.29* Hgb-10.0* Hct-30.4*
MCV-92 MCH-30.5 MCHC-33.0 RDW-17.2* Plt Ct-354
[**2142-11-25**] 07:35AM BLOOD WBC-6.4 RBC-3.32* Hgb-10.3* Hct-31.1*
MCV-94 MCH-31.0 MCHC-33.2 RDW-17.6* Plt Ct-394
[**2142-11-25**] 07:35AM BLOOD PT-12.0 PTT-88.9* INR(PT)-1.0
[**2142-11-25**] 07:35AM BLOOD Glucose-104 UreaN-23* Creat-7.6*# Na-136
K-4.2 Cl-97 HCO3-27 AnGap-16
[**2142-11-17**] 12:05AM BLOOD CK-MB-NotDone cTropnT-0.34*
[**2142-11-19**] 09:30AM BLOOD calTIBC-164* Ferritn-863* TRF-126*
[**2142-11-11**] 09:49AM BLOOD TSH-2.0
[**2142-11-11**] 09:49AM BLOOD Free T4-1.4
[**2142-11-8**] 04:43PM BLOOD PEP-HYPOGAMMAG b2micro-15.4*
Relevant Imaging:
Cardiac Catheterization ([**11-7**]):
1. Coronary angiography in this right dominant system
demonstrated an LMCA free of angiographically significant
disease. The
first diagonal branch had a 70% stenosis at its origin. The LCX
system
demonstrated a widely patent previously placed stent in OM1; OM2
had a
50% stenosis. The RCA had a distal 40-50% lesion at the crux
involving
the RPDA and RPL branches.
2. Resting hemodynamics revealed normal systemic arterial
pressures.
There was moderate pulmonary artery hypertension and elevated
right
ventricular filling pressure.
ECHO ([**2142-11-9**]): There is moderate symmetric LVH. The LV cavity
is unusually small. There is mild to moderate global LV
hypokinesis. The ascending aorta is mildly dilated. The AV
leaflets are severely thickened/deformed. AS is estimated as
severe although severity may be overestimated. The MV leaflets
are mildly thickened. Trivial MR is seen. The LV inflow pattern
suggests impaired relaxation.
Compared with the prior study (images reviewed) of [**2142-11-7**],
there is no definite change.
[**2142-11-11**]: CTA chest/abd/pelvis:
1. No evidence of pulmonary embolism.
2. Bilateral pleural effusion with bibasilar atelectasis. New
confluent opacity in the right upper lobe, most likely
representing atelectasis, however, pneumonia cannot be excluded.
Follow-up imaging to document resolution and exclude an
underlying mass is advised
Brief Hospital Course:
In brief, the patient is a 63 yo female with Primary
Amyloidosis, ESRD on HD, CAD with stent placement in OM in [**10-1**]
and fixed septal defects in the lateral segments,
hypothyroidism, major depressive d/o, schizoaffect personality
d/o, s/p vtach/v.fib arrest in HD on [**2142-11-7**], PEA, and then
returned to NSR but with persistent hypotension and oxygen
requirement. Hypotension resolved with re-hydration and
initiation of midodrine.
1. CV.
-Coronary Artery Disease: The patient has a history of CAD with
stent placement in OM1 in [**10-1**] and fixed septal defects in the
lateral segments. Repeat catheterization following the cardiac
arrest revealed patent vessels with stable coronary disease.
Repeated EKGs showed no ischemic changes. She continued to
receive aspirin and plavix daily. Throughout her
hospitalization she c/o persistent CP which was likely due to
chest compressions, not ischemia related. No BB or ACE-I was
initially started due to tenuous blood pressure post HD
sessions. Her BP was supported w/Midodrine. As her BP improved
she was started placed on Lopressor 12.5mg [**Hospital1 **] which she was
able to tolerate. The Midodrine was stopped since her blood
pressure stabilized and Free Care was not able to cover this at
time of discharge.
-Rhythm: The patient presented with a VF arrest in the setting
of hemodialysis. The likely cause for the arrest was
multifactorial including: dehydration exacerbated by severe
aortic stenosis, electrolyte shifts associated with
hemodialysis, and QT prolongation secondary to anti-psychotics.
She was evaluated by the EP service and it was concluded that
her given her overall co-morbidities particularly the
amyloidosis that had been found in both bone marrow and kidney
would likely limit any benefit an ICD placement could offer.
Furthermore, as she would be treated with myelosuppressive
therapy for the amyloidosis/smoldering myeloma, the risk of
infection and needed to explant the device also made device
placement not indicated. She was started on amiodarone as VF
suppressive therapy.
-Pump: The patient has a diminished EF following the cardiac
arrest. The EF mildly improved when repeated during the
hospital stay. Her severe aortic stenosis with AV area 0.8cm2
limited her cardiac output. However, given her active
co-morbidities she was not considered a surgical candidate.
Also, the valve area was already at the estimated post-balloon
valvuloplasty diameter so pursuing this procedure would offer no
benefit. To optimize her blood pressure, her pre-load was
increased with re-hydration and she was started temporarily
placed on midodrine both of which acheived a good result.
2. Respiratory Failure: The patient was initially intubated
during the cardiac arrest and was successfully extubation. She
did have a persistent oxygen requirement that was thought to be
multifactorial including: pulmonary contusion, pulmonary edema,
aspiration pneumonia during the arrest, and splinting from the
sternal trauma of CPR. She was maintained with CVVH and HD near
her outpatient dry weight. She was treated for 10 days with
antibiotics for the aspiration pneumonia with flagyl and
ceftriaxone last day of abx [**11-20**]. Supplemental oxygen was
provided and weaned as tolerated.
3. Schizoaffective disorder and depression: She has a history of
schizoaffective disorder and depression. She had been on paxil
and zyprexa prior to admission. These medications were
discontinued following the arrest as there was concern for QT
prolongation and she was not showing signs of psychosis. She
remained persistently anxious and depressed given her poor
prognosis. She was restarted on Prozac and standing Ativan.
Social work was very involved in her care. Hospice care was
consulted to help with goals of care and transition to home
w/hospice care given poor prognosis.
4. ESRD: The patient has end-stage renal disease secondary to
amyloid nephropathy. She had her cardiac arrest during the HD
session as described above. While she was hypotensive she was
maintained with CVVHD in the CCU and transitioned back to
tradition HD. She was started on midodrine as above which was
stopped since Free Care does not cover this mediation. Her blood
pressure remains stable.
5. ? Multiple Myeloma versus Amyloid: The patient has a
relatively new diagnosis of amyloidosis and smoldering myeloma.
She has had prior chemotherapy with melphalan and steroids
during a prior hospitalization however she did not follow-up
with her therapy. The hematology consult service recommended
resuming therapy assuming that proper steady adherance to
treatment could be assured. However, given pt's difficulty to
comply w/appointments and treatment (she failed to keep her
outpatient Heme appointments as well as a few HD sessions prior
to this admission)heme was reluctant to initiate chemotherapy.
Given pt's overall poor prognosis and advanced involvement of
kidneys/heart, and lack of insight to comply w/treatment
discussions w/the pt and Attendings on service were had to
address goals of care. She was made DNR/DNI and will be
discharged to home with hospice services.
Medications on Admission:
CCU Meds:
Heparin 5000 UNIT SC TID
Levothyroxine Sodium 75 mcg PO DAILY
Aspirin 325 mg PO DAILY
Lorazepam 0.25-0.5 mg PO Q6H:PRN anxiety
Atorvastatin 80 mg PO DAILY
Morphine Sulfate 1-2 mg IV Q2H:PRN
Calcium Carbonate 500 mg PO TID
Oxycodone-Acetaminophen [**11-27**] TAB PO Q4-6H:PRN
Clopidogrel Bisulfate 75 mg PO DAILY
Docusate Sodium 100 mg PO BID
Ezetimibe 10 mg PO DAILY
Senna 1 TAB PO BID:PRN
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*3*
5. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*3*
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK
(MO,WE,FR): please take on days of hemodialysis only.
Disp:*180 Tablet(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QD () as needed for
pain.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1*
13. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day)
as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
1)Amyloidosis
2)ESRD on HD
3)s/p VF arrast
4)Severe aortic stenosis
5)Schizoaffective personality d/o
6)Depression
7)Anxiety
8)CAD
9)Hyperlipidemia
10)Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
1)Please continue to take all your medications as directed.
2)Please attend all appointments scheduled for you below.
3)You will continue to undergo dialysis once you are discharged
here at [**Hospital1 18**]. Your next dialysis will be Wednesday, [**11-28**]
at 11:30 on Floor 7 of the [**Hospital Ward Name 121**] Building.
4)If you notice increasing chest pain, nausea, vomiting, fevers,
lightheadedness or other worisome symptoms call your physician
or go to the emergency room.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2143-2-12**]
2:00
|
[
"9971",
"4280",
"4241",
"5070",
"41401",
"V4582",
"2449"
] |
Admission Date: [**2117-10-6**] Discharge Date: [**2117-10-20**]
Date of Birth: [**2049-8-24**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 60-year-old patient
who is known to Dr. [**Last Name (STitle) **] with a history of coronary artery
disease and aortic stenosis. She was seen originally on
[**2117-9-29**] from the history and physical. She was doing well
for several years. She had a prior coronary artery bypass
grafting and aortic valve replacement in [**2110**]. Approximately
one month ago she had an episode of chest pain which resolved
and then another episode of chest pain one week later and
dyspnea on exertion. An echocardiogram done on [**2117-9-13**]
showed concentric LVH with an ejection fraction of 50-55
percent, mild aortic insufficiency, severe AS with a peak
gradient of 113, and mean gradient of 72, moderate MR, mild
TR, and mild pulmonary hypertension. TE on [**2117-9-21**] showed
LVH with EF of 50-55 percent AS, mitral annular calcification
with mitral valve thickening, and moderate MR. Cardiac
catheterization performed prior to this admission on [**2117-9-29**]
showed severe native three vessel disease with a patent LIMA
to the LAD, circumflex 90 percent with a PTI stent, saphenous
vein graft to the OM had an 80 percent lesion, RCA 70 percent
lesion with significant damping, mild aortic insufficiency,
mild aortic arch dilatation. The patient reported angina,
dyspnea on exertion, but denied nausea, vomiting,
palpitations, diaphoresis. She reports a presyncopal event
times one yesterday. No peripheral edema.
PAST MEDICAL HISTORY:
1. AVR CABG in [**2110**] with [**Last Name (un) 3843**]-[**Doctor Last Name **] tissue valve and
LIMA to LAD, SVG to OM.
2. Rheumatic fever.
3. Spinal meningitis four to seven years ago.
4. Gastrointestinal bleed in [**6-27**].
5. Polyps.
6. Congestive heart failure.
7. AS.
8. Noninsulin-dependent diabetes mellitus.
9. Hypertension.
10. Hypercholesterolemia.
PAST SURGICAL HISTORY:
1. AVR CABG.
2. Hysterectomy.
3. Appendectomy.
4. Back surgery.
ALLERGIES: She is allergic to Crestor which gave her
splenomegaly and elevated LFTs.
Surgery was cancelled on [**2117-9-29**] for a platelet drop to a
low of 60,000. Hematology workup was in progress when the
patient was discharged with plans to follow-up with
Hematology, Dr. [**Last Name (STitle) **], as an outpatient and return for CABG
AVR when hematology issues and platelet issues were
controlled. The patient was complaining of shortness of
breath at home, orthopnea, and unable to have a conversation
secondary to shortness of breath. She called her PCP who
recommended that she go to the Emergency Department. The
patient presented to an outside hospital Emergency Department
and was treated for CHF with much improvement. The platelets
at the outside hospital were 110 and transferred in for
treatment and consideration for CABG AVR again on [**2117-10-7**].
PHYSICAL EXAMINATION: On examination, the patient's blood
pressure was 124/63, heart rate in sinus tachycardia at 94,
respiratory rate 25, saturating 97 percent. The patient was
sitting at the edge of the bed in no apparent distress. She
was short of breath with talking and at the time she was
laying flat for a chest x-ray with significantly increased
shortness of breath and heart rate. She was alert and
oriented, appropriate with a nonfocal neurologic examination.
She had rales at the bilateral bases. The heart revealed a
regular rate and rhythm, S1, S2, grade III-IV/VI systolic
ejection murmur that radiated to her carotids. Her abdomen
was soft, round, nontender, nondistended with positive bowel
sounds. The extremities were warm and well perfuse with no
varicosities and trace peripheral edema. She had 2 plus
bilateral radial pulses, 1 plus bilateral DP and PT pulses.
LABORATORY DATA: The preoperative laboratories revealed a
white count of 5.7, hematocrit 30.3, platelet count 83,000.
Sodium 142, K 4.0, chloride 105, bicarbonate 28, BUN 32,
creatinine 1.1 with a blood sugar of 166, PT 13.9, PTT 28.4,
INR 1.2. ALT 22, AST 29, LDH 354, alkaline phosphatase 94,
total bilirubin 0.8.
Chest x-ray showed bilateral effusions and CHF.
Bone marrow biopsy showed a question of early myelodysplasia
syndrome. Please refer to the official report.
Hematology was consulted again and felt that the platelet
count was probably closer to normal range then was
registering and the patient was probably sequestering
platelets in the spleen with splenomegaly. This was
discussed with Dr. [**Last Name (STitle) **] for a question of whether or not
the patient could continue and go to the Operating Room.
MEDICATIONS AT HOME:
1. Lopressor 50 mg p.o. twice daily.
2. Norvasc 7.5 mg p.o. daily.
3. Glyburide 5 mg p.o. twice daily.
4. Metformin 1,000 mg p.o. twice daily.
5. Lisinopril 20 mg p.o. twice daily.
6. Lasix 20 mg daily.
7. Aspirin 81 mg daily.
8. Paxil 5 mg daily.
HOSPITAL COURSE: The patient was admitted to the CCU and was
followed daily by Cardiology and was evaluated by the Cardiac
Surgery team as we awaited her hematology workup to be
completed and her platelet count to rise. The patient had an
episode of epistaxis on the 15th and was seen by Dr.
_________________ of Hematology. Platelet counts remained
low at 75,000. Surgery was delayed as Hematology continued
to work on this issue for Dr. [**Last Name (STitle) **]. The patient received
a transfusion of platelets preoperatively on the 15th. The
patient was also seen by Cardiology daily and received a
second unit of platelets on the 16th for her significant
thrombocytopenia which was 113 on the 16th. On the 17th, the
platelet count rose to 139 with a white count of 5.2 and
hematocrit of 29.7, creatinine was stable at 1.1 and INR of
1.2.
On the 17th, the patient was transferred out of the CCU to
[**Hospital Ward Name 121**] III, the step-down floor, as her preoperative workup
continued. On [**2117-10-11**], the patient underwent redo CABG with
a vein graft to the RCA and aortic valve replacement with a
19 mm mosaic porcine tissue valve. The patient was
transferred to the Cardiothoracic Intensive Care Unit in
stable condition on a milrinone drip at 0.3 micrograms per
kilogram per minute, Amiodarone drip at 2.4 mg per minute,
epinephrine 0.04 micrograms per kilogram per minute, Levophed
drip at 0.06 micrograms per kilogram per minute, Neo-
Synephrine drip at 0.3 micrograms per kilogram per minute,
and a titrated propofol drip. Of note, the patient did have
an asystolic cardiac rest at 12:15 a.m. on the morning prior
to surgery. She had some low blood pressures. Lasix was
held. She became unresponsive with bradycardia to asystole
noted on the telemetry strip. CPR was briefly initiated with
bagging but she became responsive within several seconds and
was sleepy but alert. The patient had good pulses which
returned spontaneously with blood pressure in the 120s/60s
which had dropped to 80/60. She had sinus tachycardia on EKG
and stable diffuse ST changes that were unchanged since her
recent EKGs. She was transferred back to the CCU. This was
all in the early morning hours prior to surgery.
On postoperative day number one, the patient had some
metabolic acidosis and received 3 amps of bicarbonate which
helped resolve this problem, lactate up to 11.6 and back down
to 6.0. Epinephrine was decreased. Milrinone was increased.
The patient received intravenous fluids and 20 of Lasix and
remained on Amiodarone, epinephrine, insulin, Levophed,
milrinone and propofol drips. Postoperatively, the platelet
count was 253,000 with an INR of 1.5. The white count was 21
and a hematocrit of 30. The K was 4.8, creatinine stable at
1.0. The patient began Plavix, continued Lasix diuresis with
the plan to wean epinephrine and keep the patient intubated.
On postoperative day number two, the patient received 1 unit
of packed red blood cells for a hematocrit of 26, platelet
counts dropped again to 79,000. A HIT screen was sent. The
patient was in sinus rhythm, hemodynamically stable. The
patient was alert and oriented. The patient had decreased
breath sounds at the bases. The examination was
unremarkable. The chest tubes were discontinued. Plavix was
held. Lasix was increased to 80 twice daily. Milrinone was
decreased down to 0.2. Amiodarone was switched over from
intravenous to oral. The patient remained in the Intensive
Care Unit on face mask after being extubated, saturating 100
percent on 4 liters nasal cannula.
The patient was also seen daily by the Hematology/Oncology
team. On postoperative day number three, aspirin was
decreased to 81, Zantac was changed to Protonix, Amiodarone
had been switched to oral, milrinone continued to be
decreased, Captopril was added in for blood pressure control.
The patient was in sinus rhythm in the 60s with a blood
pressure of 112/38 and the last chest tube was discontinued.
The patient was encouraged to be out of bed and ambulate
after she had been transferred from the Intensive Care Unit
to the floor.
On postoperative day number four, the patient had been
transferred out to the floor, was hemodynamically stable with
a platelet count that dropped again to 59,000 and a
creatinine was stable at 1.1. The patient did not appear to
be bleeding, was started on Lopressor beta blockade. The
patient was ambulating in the [**Doctor Last Name **]. The platelets were
transfused so that the pacing wires could be pulled. The
Foley was discontinued and aggressive diuresis was continued.
The patient was screened for rehabilitation, was restarted on
oral diabetes medicines as well as restarting the Plavix.
The patient was seen and evaluated by Case Management as part
of the screening process.
On postoperative day number five, the patient's platelets had
been transfused the evening prior. The pacing wires were
discontinued. The patient had an unremarkable examination.
The incisions were clean, dry, and intact. The Foley was
discontinued. The patient continued to ambulate as the
screening for rehabilitation continued.
On postoperative day number six, the blood sugar rose to 344.
The patient continued on beta blockade with a heart rate of
80, in sinus rhythm with a blood pressure of 106/46 as well
as intravenous Lasix. The patient had decreased breath
sounds bilaterally with occasional expiratory wheezes. The
patient had 1 plus peripheral edema. The incisions were
clean, dry, and intact. The sternum was stable. Metformin
was added back in. Lasix was switched over from intravenous
to twice daily. The patient continued to ambulate.
On postoperative day number seven, the patient had a small
amount of sternal drainage the afternoon prior but the
incision was clean and dry on the morning of postoperative
day number seven. There was no erythema. There was still
some increased peripheral edema and elevated glucose. Lasix
was increased. Lopressor was increased. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consult
for diabetes management was called. The patient was seen by
the [**Last Name (un) **] fellow and evaluation and recommendations were
reviewed.
On postoperative day number eight, the patient still had
significant peripheral edema, approximately 2 plus
bilaterally. The creatinine was stable at 1.1. The
hematocrit was 31.3. The patient was saturating 96 percent
on room air, continued with metformin and Glyburide. The
patient had some metabolic alkalosis from probable fluid
overload. Diamox was added and electrolytes were rechecked
with plans to hopefully discharge the patient in the morning.
The patient was seen again by the [**Last Name (un) **] fellow to evaluate
her diabetes management and recommended having the patient
following up as an outpatient with Dr. [**Last Name (STitle) **], beeper number
[**Serial Number 57556**]. Dr. [**Last Name (STitle) **] was the attending.
On postoperative day number nine, the patient was stable
overnight with a hematocrit of 30.4 and creatinine 1.2. The
examination was nonfocal neurologically. The patient had 2
plus peripheral edema. The incisions were clean, dry, and
intact. The patient was doing very well, much improved.
Glyburide was increased to 10 mg p.o. twice daily. The
patient was encouraged to ambulate and plans to discharge the
patient home with VNA services which was accomplished on
[**2117-10-20**].
DISCHARGE DIAGNOSIS:
1. Status post redo coronary artery bypass graft times one
and aortic valve replacement.
2. Status post aortic valve replacement and coronary artery
bypass graft in [**2110**].
3. Rheumatic fever.
4. Spinal meningitis.
5. Gastrointestinal bleed.
6. Polyps.
7. Congestive heart failure.
8. Aortic stenosis.
9. Mild insulin-dependent diabetes mellitus.
10. Hypertension.
11. Hypercholesterolemia.
DISCHARGE MEDICATIONS:
1. Potassium chloride 20 mEq p.o. twice daily times ten days.
2. Colace 100 mg p.o. twice daily.
3. Enteric coated aspirin 81 mg p.o. once daily.
4. Percocet 5/325 one to two tablets p.o. as needed every
four hours for pain.
5. Plavix 75 mg p.o. once daily.
6. Metformin 1,000 mg p.o. twice daily.
7. Paroxetine hydrochloride 5 mg p.o. once daily.
8. Lasix 40 mg p.o. three times daily times ten days and then
decrease the dose to Lasix 20 mg p.o. daily.
9. Metoprolol tartrate 25 mg p.o. twice daily.
10. Glyburide 10 mg p.o. twice daily.
DISCHARGE INSTRUCTIONS: The patient is to make a follow-up
appointment with Dr. [**Last Name (STitle) 17567**], the primary care physician, [**Name10 (NameIs) **]
one to two weeks and make an appointment to see Dr. [**Last Name (STitle) **]
in the office in four weeks for a postoperative surgical
visit.
DISPOSITION: The patient was discharged to home with VNA
services on [**2117-10-20**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2117-11-19**] 14:52:30
T: [**2117-11-19**] 16:53:09
Job#: [**Job Number 57557**]
|
[
"4280",
"2875",
"41401",
"25000",
"4019",
"2720",
"V4582"
] |
Admission Date: [**2195-12-28**] Discharge Date: [**2196-1-14**]
Date of Birth: [**2137-11-20**] Sex: M
Service: 1
CHIEF COMPLAINT: Sudden onset shortness of breath and chest
pain.
HISTORY OF PRESENT ILLNESS: This is a 58 year old man with
known coronary artery disease status post coronary artery
bypass graft in [**2184**], developed sudden onset of shortness of
breath and chest pain described as eight out of ten on
[**12-27**], admitted to an outside hospital and transferred
for rule out myocardial infarction. He was then transferred
to [**Hospital1 69**] for cardiac
catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post coronary artery
bypass graft times one in [**2184**] after failed percutaneous
transluminal coronary angioplasty.
2. Diabetes mellitus.
3. Hypertension.
4. Hypercholesterolemia.
PHYSICAL EXAMINATION: At time of admission, vital signs were
heart rate 90, sinus rhythm; blood pressure 100/64;
respiratory rate 18. Generally, comfortable in no acute
distress. HEENT: OPs are clear. Conjunctivae are clear.
Neck: Lying flat. Cardiovascular: Irregular rhythm.
Normal S1, S2, no S3 or S4. Slight systolic ejection murmur
at apex. Abdomen is obese, positive bowel sounds, nontender.
Extremities with no edema. One plus dorsalis pedis and
posterior tibial.
LABORATORY: Labs at time of admission: White count 12.1,
hematocrit 37, PT 14.3, PTT 39.1, INR 1.4. Electrolytes:
Sodium 141, potassium 3.4, chloride 102, CO2 27, BUN 26,
creatinine 1.1, glucose 182. CPK 153.
EKG rate in the 90s, atrial flutter with variable 2:1
conduction, normal axis. Q waves inferiorly, biphasic T
waves inferiorly.
MEDICATIONS: Prior to admission include:
1. Prevacid 30 q. day.
2. Norvasc 5 q. day.
3. Plavix 75 q. day.
4. Lipitor 20 q. day.
5. Klonopin 0.5 twice a day.
6. Zestril 10 q. day.
7. Glucophage 500 twice a day.
8. Glucotrol XL 20 q. day.
9. Lasix 40 q. day.
10. Micro K 8 q. day.
11. Wellbutrin 150 twice a day.
12. Heparin drip.
13. Nitroglycerin drip.
14. Metoprolol 75 three times a day.
SOCIAL HISTORY: Positive tobacco, one pack per day.
Occasional alcohol. No street drugs. He is married.
HOSPITAL COURSE: The patient was brought to the
Catheterization Laboratory after transfer from the outside
hospital. Please see catheterization report for full
details. In summary, the catheterization report showed 30 to
40% left main, left anterior descending with minor
irregularities, left circumflex 40 to 50%, right coronary
artery total occlusion and vein graft to the right coronary
artery also totally occluded. An intra-aortic balloon pump
was placed for hemodynamic stability. The patient was
transferred from the Catheterization Laboratory to the
Coronary Care Intensive Care Unit. Also, the Cardiothoracic
Surgery Group was consulted.
An echocardiogram done prior to his catheterization showed an
ejection fraction of 35 to 40% with global hypokinesis,
inferior lateral akinesis, four plus mitral regurgitation.
The patient was consented for surgery and on [**1-4**], was
brought to the Operating Room at which time he underwent a
mitral valve replacement. Please see the OR Report for full
details. In summary, the patient underwent mitral valve
replacement with a 29 CarboMedics Mechanical Valve. He
tolerated the surgery well and was transferred from the
Operating Room to the Cardiothoracic Intensive Care Unit.
At the time of transfer, the patient had aprotinin, Levophed
and Epinephrine infusing. He had arterial lines, a Swan-Ganz
catheter and intra-aortic balloon pump in his right groin,
two ventricular and two atrial pacing wires, two mediastinal
chest tubes.
Shortly after arrival in the Intensive Care Unit the patient
was noted to have absent left pulses in his right lower
extremity. The intra-aortic balloon pump was removed without
a return of his pulses, therefore Vascular Surgery was
consulted. Following the vascular consult, the patient
returned to the Operating Room where he underwent a right
ilia-femoral embolectomy and patch angioplasty. He tolerated
the procedure well and was transferred from the Operating
Room back to the Cardiothoracic Intensive Care Unit. At that
time, he had a weak dorsalis pedis pulse by Doppler.
The patient's embolectomy was complicated by compartment
syndrome as evidenced by increasing right calf pain over the
next 12 hours with CPKs that climbed to 12,000. He continued
to be followed by the Vascular Surgery service. No
additional interventions were required.
From a Cardiothoracic standpoint on postoperative day one,
the patient was doing well. He remained hemodynamically
stable. He was weaned from his Milrinone. His Propofol was
discontinued. He was weaned from the ventilator and
successfully extubated. On postoperative day two, the
patient remained hemodynamically stable. His Swan-Ganz
catheter was discontinued. His chest tubes were removed.
His diet was advanced and he was transferred to the floor for
continuing postoperative care.
On postoperative day three, the patient was noted to have
increasing severity of pain in his right calf. His right
foot was noted to be cooler than his left foot and Doppler
pulse signals in his right foot were now absent. Vascular
Surgery was again consulted and he was brought for an
angiogram of his right lower extremity. The angiogram showed
that he had an occlusion of his distal SFA. At that time,
they did not want to do any further intervention other than
starting the patient on intravenous heparin.
With the initiation of the intravenous heparin, the patient
slowly regained color and temperature in his foot. He also
had a faint dorsalis pedis pulse later on during that day.
Over the next several days, the patient remained on bed rest.
His intravenous heparin infusion was continued. The pain in
his right lower extremity gradually diminished until, on
postoperative day eight, with the guidance of the Vascular
Surgery Service, the patient was allowed ambulation with
assistance of Physical Therapy.
Over the next two days, the patient continued to ambulate
with the assistance of Physical Therapy. His heparin and
Coumadin were continued. On postoperative day ten, his INR
was 2.2; his heparin was discontinued and he was felt to be
stable and transfer to rehabilitation.
PHYSICAL EXAMINATION: At the time of transfer, the patient's
physical examination is as follows: Vital signs, temperature
97.7 F.; heart rate 66 atrial fibrillation; blood pressure
133/64; respiratory rate 20; O2 saturation 98% on room air.
Weight preoperatively 96 kilograms; at discharge 96.3
kilograms. On physical examination, alert and oriented times
three. Conversant; moves all extremities. Respiratory:
Clear to auscultation bilaterally. Heart sounds are
irregular rate and rhythm; S1 and S2 with loud clicks.
Sternum is stable with staples open to air, clean and dry.
Abdomen soft, nontender, nondistended. Normoactive bowel
sounds. Extremities are warm. Right leg with Doppler-able
pulses. Diminishing pain in the right calf. Right SVG sites
open to air, clean and dry.
Laboratory data at discharge, white count 16, hematocrit 28,
platelets 527, PT 17.9, PTT 110, INR 2.2. Sodium 135,
potassium 4.5, chloride 99, CO2 27, BUN 13, creatinine 1.0,
glucose 133.
MEDICATIONS AT TIME OF DISCHARGE:
1. Lasix 20 mg q. day times seven days.
2. Potassium chloride 20 mEq q. day times seven days.
3. Coumadin 7.5 mg q. day.
4. Plavix 75 mg q. day.
5. Wellbutrin 150 mg twice a day.
6. Glucotrol XL 20 mg q. day.
7. Lipitor 20 mg q. day.
8. Amiodarone 400 mg twice a day through [**1-21**], then q.
day.
9. Captopril 6.25 mg three times a day.
10. Glucophage 500 mg twice a day.
11. Protonix 40 mg q. day.
12. Dilaudid 2 to 4 mg q. four hours p.r.n.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post mitral valve replacement with a #29
CarboMedics.
3. Status post right thrombectomy with a patch angioplasty.
4. Diabetes mellitus.
5. Hypertension.
6. Hypercholesterolemia.
DISPOSITION: He is to be discharged to Rehabilitation.
DISCHARGE INSTRUCTIONS:
1. He is to have follow-up with Vascular Surgery in one
month.
2. Follow-up with Dr. [**Last Name (STitle) **] in one month.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2196-1-14**] 12:36
T: [**2196-1-14**] 13:21
JOB#: [**Job Number 15903**]
|
[
"4240",
"4280",
"5849",
"25000",
"4019"
] |
Admission Date: [**2182-4-4**] Discharge Date: [**2182-4-7**]
Date of Birth: [**2144-9-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 8263**]
Chief Complaint:
Alcohol intoxication
Altered mental status
Major Surgical or Invasive Procedure:
Intubation [**2182-4-4**]
Extubation [**2182-4-5**]
History of Present Illness:
Initial history and physical is as per ICU team.
.Mr. [**Known lastname 24927**] is a 37M with a history of severe alcoholism with
regular admissions to [**Hospital1 18**] for management of withdrawl,
complicated by DT's in the past, HBV, and HCV. Today at 2PM he
was found unresponsive by EMS at the T station, and brought to
the emergency department.
.
In the ED vitals were T=98.6, BP=111-134/79-96, HR=78-112,
RR=[**12-21**], O2sat=97%RA, FSBS 173. He was initially alert and
communicative, however, upon falling asleep, he became hypoxic
to 54% RA with an absent gag reflex, and was then intubated.
Sedated on a propofol drip, given 2mg Ativan given at 1442, 5mg
haldol, 2mg of narcan, and 1LNS. Right femoral CVL placed.
Labs were notable for an ETOH level of 280, and a leukocytosis
to 12,000. Otherwise tox screen was notable only for
benzodiazepines (patient was discharged on [**3-31**] for alcohol
intoxication, managed with BZDs). A head CT CT Cspine and CXR
were negative.
Past Medical History:
1. polysubstance abuse: ETOH, listerine, heroin, IVDU,
benzodiazepines
2. hepatitis C
3. hepatitis B
4. compartment syndrome RLE, [**2171**]
5. OCD and anxiety
6. depression with hx suicidal ideations and attempts
7. ethanol abuse, hx DTs and withdrawal seizures, intubated in
past
8. chronic bilateral hand swelling
9. Severe peripheral neuropathy
Social History:
The patient has previously reported he is homeless and lives in
front of [**Location (un) 7073**] train station. He drinks regularly, often a
liter of listerine and a fifth of vodka and additional beer
every day. He has a history of IV heroin and smoking cocaine but
has insisted he quit both of those activities >10 years ago. He
also smoked cigarettes in the past but claims he stopped in
[**2167**].
Family History:
Father with depression and alcoholism. Mother died of DM
complications.
Physical Exam:
Admission PE:
Vitals: T: 96.6, HR 86, BP: 104/76 HR:75
GEN: Sedated intubated
HEENT: Pupils pinpoint, equal and reactive bilaterally
NECK: No JVD, lymphadenopathy, trachea midline
CV: RRR, no M/R/G; 2+ radial, DP, and PT pulses bilaterally
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: Upon weaning propofol, opens eyes to voice, sits up,
moves all four extremities to command, babinskis downgoing, no
clonus.
SKIN: Lacerations at the left brow and cheek.
Pertinent Results:
Admission labs:
[**2182-4-4**] 01:57PM BLOOD WBC-11.3*# RBC-4.55* Hgb-12.9* Hct-39.3*
MCV-86 MCH-28.3 MCHC-32.8 RDW-17.3* Plt Ct-426#
[**2182-4-4**] 01:57PM BLOOD Neuts-35.7* Bands-0 Lymphs-56.8*
Monos-3.2 Eos-3.5 Baso-0.9
[**2182-4-4**] 01:57PM BLOOD Plt Ct-426#
[**2182-4-5**] 04:21AM BLOOD PT-13.0 PTT-28.5 INR(PT)-1.1
[**2182-4-4**] 01:57PM BLOOD Glucose-129* UreaN-11 Creat-1.0 Na-142
K-4.9 Cl-101 HCO3-32 AnGap-14
[**2182-4-4**] 01:57PM BLOOD ALT-132* AST-110* AlkPhos-87 TotBili-0.2
[**2182-4-4**] 01:57PM BLOOD Lipase-61*
[**2182-4-4**] 01:57PM BLOOD Calcium-9.1 Phos-4.4# Mg-2.2
[**2182-4-4**] 01:57PM BLOOD ASA-NEG Ethanol-280* Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2182-4-4**] 06:55PM BLOOD Type-ART pO2-545* pCO2-44 pH-7.40
calTCO2-28 Base XS-2 Intubat-INTUBATED
[**2182-4-4**] 06:55PM BLOOD Lactate-1.7
[**2182-4-4**] CT head: 1. No intracranial hemorrhage or edema.
2. Unchanged depressed left nasal bone fracture.
[**2182-4-5**] CT C spine: IMPRESSION:
No acute fracture.
NG tube appears to be looped within the pharynx.
.
CXR:
FINDINGS: In comparison with the study of [**4-4**], there is little
overall
change. Specifically, no evidence of acute pneumonia. Monitoring
and support
devices remain in place.
Brief Hospital Course:
Mr. [**Known lastname 24927**] is a 37M with a PMH s/f severe alcoholism with
multiple ICU admissions for management of airway
protection/withdrawl in the past, HCV, and HBV, found
unresponsive in the setting of alcohol intoxication, intubated
for airway protection and hypoxia prior to recieving benzos in
ED, with incidentally diagnosed leukocytosis on routine labs.
.
#. Altered mental status: DDX includes ETOH intoxication with
level of 280, other toxic ingestion, intracranial bleed from his
fall, seizure from ETOH withdrawl vs. trauma. Head CT negative
for a bleed, CT Cspine was negative, and no clear
toxic-metabolic abnormalities on initial labs. His mental
status improved.
.
#. Hypoxia: In the setting of alcohol intoxication, likely
secondary to an aspiration event. CXR was negative for
pneumonia. Pt was extubated in the ICU. His O2 sasts remained
stable after that.
.
#. ETOH intoxication: Patient has a history of withdrawl
seizures. Also has severe anxiety at baseline, and is difficult
to monitor with a CIWA scale, as his subjective symptoms have
been unreliable. We used vital signs (hyperthermia, HTN,
Tachycardia)to monitor ETOH withdrawl, and wrote for diazepam as
needed. He was given MVI, thiamine, and folic acid. The
patient was often very agitated and anxious and demanded valium
despite not showing any vital sign evidence of withdrawal. SW
was consulted but the patient eloped before he could be seen.
As previously documented in previous OMR notes, this patient
should be section 35ed for his safety if he continues to come to
the hospital intoxicated.
.
# HCV/HBV: previous hx transaminitis, at baseline
.
# FEN: Diet was advanced to Regular s/p extubation.
.
# PPX: heparin SC
.
# Access: hx of difficulty with pIV and pt combative, femoral
CVL placed in ED upon arrival. Removed before discharge.
.
# Code: Full code
.
# Dispo: On [**2182-4-7**], the [**Name8 (MD) 228**] RN went to check on him and he
was found to have eloped from the hospital.
.
This discharge summary is signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as Dr. [**Name (STitle) 61607**] is no longer working at [**Hospital1 18**].
Medications on Admission:
None
Discharge Medications:
Pt eloped
Discharge Disposition:
Home
Discharge Diagnosis:
ETOH intoxication
Discharge Condition:
Fair.
Discharge Instructions:
Pt eloped
Followup Instructions:
Pt eloped
|
[
"51881",
"311"
] |
Admission Date: [**2153-4-6**] Discharge Date: [**2153-4-23**]
Date of Birth: [**2089-11-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Aortic Valve Endocarditis
Major Surgical or Invasive Procedure:
[**2153-4-12**] 1. Re-do sternotomy and aortic root replacement with a 21
mm Homograft with coronary button reimplantation. 2. Coronary
artery bypass grafting x1, with a reversed saphenous vein graft
from the aorta to the distal right coronary artery.
History of Present Illness:
The patient is a 63 year-old male w/ CAD s/p CABG with AVR in
[**7-16**], DM2, HTN, ESRD on HD, and Hep C cirrhosis presenting to
OSH w/ high grade fever and altered mental status. The patient
was found to have high grade MRSA bacteremia and was treated
with tailored therapy with vancomycin since adm'n there on
[**2153-3-25**]. Source was thought to be left foot osteomyelitis
(suggested by bone scan). TTE and TEE were negative for any
vegetations. Altered mental status was thought to be from
infection, and improved dramatically with antibiotic treatment.
The patient was transferred here in stable condition for further
evaluation of his left foot as his prior podiatry care was here.
On ROS, the patient denies CP, SOB, dizziness, palpitations,
N/V/D, abd pain, dysuria.
Past Medical History:
1. Coronary artery disease, remote MI in his 40s in the setting
of cocaine use - left main and two-vessel coronary disease
diagnosed on cardiac cath from [**2152-7-31**] in the setting of non-ST
elevation MI (peak CK 190, MB 20, troponin T 4.5). CABG on
[**2152-7-31**]: LIMA to LAD, SVD-D1, SVD-OM1-OM3 with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 914**].
2. Moderate aortic stenosis status post 23 mm [**Initials (NamePattern4) 7624**] [**Last Name (NamePattern4) 12640**]
AvR
on [**2152-7-31**].
3. Diabetes, type 2 with neuropathy, nephropathy, and
retinopathy by notes, but not on insulin or other oral agents
4. End-stage renal disease on hemodialysis Monday, Wednesday,
and Friday.
5. Hypertension x 10 years.
6. Hypercholesterolemia.
7. Hepatitis C with reported child's A cirrhosis, Grade I
Varices by EGD [**2150**], no varices on last EGD [**2151**].
8. Gout.
9. Charcot deformity of the feet with left exostectomy, ulcer
excision, and bone stimulator removal on [**2152-7-18**].
10. Left forearm fistula placement [**6-13**].
Social History:
He is a single without children and lives with his nephew and
wife. [**Name (NI) **] has remote history of smoking which he cannot quantify
but quit 20 years ago. He previously drank [**2-11**] drinks two times
a week but denies current alcohol. He denies prior intravenous
drug use, but has a history of cocaine used in the past. He is
retired, used to own a sub shop.
Family History:
Parents are both deceased. Father, late 60s of unknown cause;
mother, age 65 of myocardial infarction. He has two brothers,
one who had a myocardial infarction age 45 and underwent CABG.
Other brother has no significant medical
history. There is no family history of sudden cardiac death or
cardiomyopathy.
Physical Exam:
Admission Physical Exam:
T 98 HR 72 BP 135/82 RR 16 O2 97%/RA
GEN: NAD
Skin: no petechaie, no rashes
HEENT: EOMI, PERRL, no LAD, MMM
Neck: supple, no thyromegaly
Heart: RRR, 3/6 systolic murmur in aortic area, nl S1 S2
Chest: CTABL
Abd: soft, NT/ND, no HSM, BS +
Extr: no edema. L heel ulcer with no probing to bone, no
erythema or drainage
Neuro: AAO x 2. no focal neuro deficit
Pertinent Results:
[**2153-4-6**] 10:47PM BLOOD WBC-11.5*# RBC-4.14* Hgb-11.6* Hct-35.2*
MCV-85 MCH-28.0 MCHC-33.0 RDW-17.3* Plt Ct-256
[**2153-4-6**] 10:47PM BLOOD Neuts-79.9* Lymphs-14.7* Monos-4.7
Eos-0.4 Baso-0.3
[**2153-4-6**] 10:47PM BLOOD Glucose-206* UreaN-27* Creat-5.9* Na-136
K-4.4 Cl-97 HCO3-25 AnGap-18
[**2153-4-6**] 10:47PM BLOOD PT-15.0* PTT-26.9 INR(PT)-1.3*
[**2153-4-6**] 10:47PM BLOOD ALT-40 AST-36 LD(LDH)-298* CK(CPK)-21*
AlkPhos-133* Amylase-104* TotBili-0.5
[**2153-4-8**] 07:00AM BLOOD ESR-57*
[**2153-4-8**] 07:00AM BLOOD CRP-106.6*
[**2153-4-6**] L FOOT XRAY: New osseous destructive changes about the
mid foot - metatarsal articulation are consistent with
osteomyelitis.
[**2153-4-9**] TEE: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium/left atrial appendage or the body of
the right atrium/right atrial appendage. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). There are simple atheroma in the
aortic arch.and descending thoracic aorta. A well-seated
bioprosthetic aortic valve prosthesis is present. There is a
1.2x0.7cm mobile echodensity attached to the aortic side of the
posterior aortic valve leaflet c/w a vegetation (see clip #[**Clip Number (Radiology) **]).
No aortic regurgitation is seen. The posterior aortic root is
somewhat thickened and heterogeneous with areas of echolucency
suggestive of an aortic root abscess. No flow is seen into this
area. The mitral valve leaflets are structurally normal. No mass
or vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen.
[**2153-4-10**] Abdominal Ultrasound:The liver again demonstrates a
coarsened echotexture appearance. No focal masses were
identified. There is no biliary dilatation and the common duct
measures 0.4 cm. The portal vein is patent with hepatopetal
flow. The gallbladder is normal without evidence of stones. The
spleen is again noted to be enlarged measuring 15.4 cm. The
kidneys are again noted to be atrophic but there is no
hydronephrosis identified. No ascites is seen. IMPRESSION:
Cirrhosis but no focal hepatic lesions identified. Splenomegaly.
No ascites is seen.
[**2153-4-12**] Head CT Scan: There is no evidence of hemorrhage, edema,
mass, mass effect, or acute vascular territorial infarction. The
ventricles and sulci are moderately prominent, most consistent
with age-related involutional change. There is no fracture.
Visualized paranasal sinuses are normally aerated.
Brief Hospital Course:
Admitted to the podiatry service on [**2153-4-6**] from [**Hospital **]
Hospital with fevers, MRSA bacteremia, felt due to a lfet foot
wound. He was readily transferred to the medical service due to
his complicated medical history. He developed heart block, and
underwent placement of a temporary screw-in pacmaker on [**2153-4-9**].
He then had a surgical debridement of his left foot. On [**4-12**] he
was noted to have recurrent positive blood cultures, an dmental
status changes,a nd was taked to the OR urgently for an
AVR/homograft. Please see operative report for details of
surgical procedure.
Post-op, he required vasopressors and inotropes, which were
weaned off by POD # 3. He remained on mechanical ventilation,
and was extubated on POD # 4. He was also on CVVH until he was
transitioned to hemodialysis, which was started on POD # 6. The
neurology service was consulted due to ongoing delirium, which
they attributed to metabolic issues. He initially failed his
swallow eval due to his mental status, but he later passed as
his mental status cleared over the next few days. On post-op
day # 6, he was transferred to the telemetry floor.
He had remained hemodynamically stable over the next few days,
and discharge planning was in progress. On [**4-23**], am, he had
complained of "not feeling well", with no specific complaints.
Hi vital signs were stable, and he was transported to the
dialysis unit for his usual treatment. Prior to initiation of
dialysis, he had a cardiac arrest. The code team was called,
and CPR was initiated. He was intubated, and transported to the
CVICU, where he was noted to be in EMD. CPR and ACLS protocol
was continued with poor response. His chest was opened, and
there was no spontaneous heart movement, and no blood in the
pericardial space. The resuscitation was stopped after approx.
30 minutes, and he was pronounced at 0908.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
MRSA endocarditis now s/p redo sternotomy, bental
homograft(21mm), reimplantation of LMCA/SVG-diag/SVG-OM1-OM2,
CABGx1(SVG-RCA)
foot osteomyelitis
s/p CABG/AVR(tissue) [**7-16**], DM, HTN, ESRD on HD-L forearm
fistula, and Childs A Hep C cirrhosis, charcot arthropathy,
polyneuropathy, multiple foot ulcers, L foot osteo.
Discharge Condition:
expired
Discharge Instructions:
Followup Instructions:
Completed by:[**2153-4-23**]
|
[
"40391",
"2720",
"42731",
"412",
"V4581"
] |
Admission Date: [**2192-7-12**] Discharge Date: [**2192-7-23**]
Date of Birth: [**2122-4-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Coronary artery disease
Major Surgical or Invasive Procedure:
CABG x2
History of Present Illness:
Mr. [**Known lastname 916**] is a 70-year-old male who was transferred from an
outside institution urgently with an intra-aortic balloon pump
in place after he was found to have
a 90% left main stenosis involving the origin of the left
anterior descending. His ejection fraction was preserved. He is
presenting for urgent coronary surgery.
Past Medical History:
Diabetes mellitus (diet controlled)
Hyperlipidemia
Gout
COPD/asthma
Social History:
Patient has a 90 pack-year history of smoking, quit 8 years ago,
rare ETOH, denies drugs
Family History:
Mother and father had both CAD and DM
Physical Exam:
Afebrile, HR 60's, BP 138/78, RR 20, SPO2 99%2L
NAD, awake and alert
PERRLA, no carotid bruits
RRR, +2/6 SEM at LUSB
CTA b/l
Abd soft, NT/ND, NABS
Ext warm, no varicosities
Pertinent Results:
[**2192-7-12**] 11:19AM BLOOD WBC-8.2 RBC-4.91 Hgb-15.2 Hct-43.5 MCV-89
MCH-31.0 MCHC-34.9 RDW-13.9 Plt Ct-385
[**2192-7-12**] 11:19AM BLOOD Plt Ct-385
[**2192-7-12**] 11:19AM BLOOD PT-14.2* PTT-94.7* INR(PT)-1.3
[**2192-7-12**] 11:19AM BLOOD Glucose-126* UreaN-22* Creat-0.8 Na-137
K-4.4 Cl-100 HCO3-27 AnGap-14
[**2192-7-12**] 03:42PM BLOOD ALT-22 AST-23 LD(LDH)-165 AlkPhos-59
Amylase-90 TotBili-0.4
[**2192-7-12**] 03:42PM BLOOD Lipase-34
[**2192-7-12**] 11:19AM BLOOD Calcium-10.1 Phos-2.2* Mg-2.1
Cholest-219*
[**2192-7-12**] 11:19AM BLOOD Triglyc-67 HDL-66 CHOL/HD-3.3
LDLcalc-140*
Brief Hospital Course:
The patient was admitted to the hospital on [**2192-7-12**] and was
urgently taken to the operating room the following day, where he
underwent a CABG x2. Please see operative note for full details.
The patient tolerated this procedure well. Following surgery, he
was transferred to the CSRU for recovery. That night, the
patient acutely desaturated. A chest xray showed a right tension
penumothorax, and a chest tube was emergently placed. The IABP
was removed on post-op day #1. That day, the patient's LFT's
were found to be markedly elevated, and a hepatico-biliary
surgery consult was called. Work-up included a right upper
quadrant ultrasound, which revealed a few gallstones but did not
show evidence of cholecystitis, biliary tree dilation, or
enlarged common bile duct. The patient's transaminitis
eventually improved, and it was felt that, in the end, this was
most likely due to hemolysis secondary to IABP. On post-op day
#3, the patient was transferred to the floor. On post-op day #4,
routine chest xray demonstrated a persistent pneumothorax that
was refractory to chest tube suctioning. A thoracic surgery
consult was called, and a new chest tube was inserted. On
post-op day #5, repeat chest xray demonstrated an interval
increase in the pneumothorax, and the chest tube was replaced by
thoracic surgery. On post-op day #7, the decision was made to
undergo doxycycline pleurodiesis. On post-op day #10, chest xray
showed near resolution of the patient's pneumothorax. The chest
tube was removed, and the patient was discharged home in stable
condition.
Medications on Admission:
ASA 325mg PO Qdaily
Lopressor 25mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*1*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 30 doses.
Disp:*30 Tablet(s)* Refills:*0*
5. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-20**]
Puffs Inhalation Q4H (every 4 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease
Discharge Condition:
Stable
Discharge Instructions:
Please return tot he hospital or call Dr. [**Last Name (STitle) **] office of you
experience chills or fever greater than 101 degrees F. Please
call if you notice redness, swelling, or tenderness of your
chest wound, or if it begins to drain pus.
No heavy lifting or driving until follow up with Dr. [**Last Name (STitle) **].
You may shower. Wash incision with mild soap and waten, then pat
dry.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**Name10 (NameIs) 62755**], MD Follow-up appointment should be in 1 week
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks.
|
[
"41401",
"25000",
"4019",
"53081",
"2724",
"V1582"
] |
Unit No: [**Numeric Identifier 74335**]
Admission Date: [**2101-6-5**]
Discharge Date: [**2101-6-13**]
Date of Birth: [**2101-6-5**]
Sex: M
Service: Neonatology
IDENTIFICATION: Baby [**Name (NI) **] [**Known lastname 74336**] is a 7-week-old at term
infant who is being discharged from the neonatal intensive
care unit at the [**Hospital1 69**]
following evaluation for fever and desaturation episodes.
HISTORY: Baby [**Name (NI) **] [**Known lastname 74336**] was born on [**2101-6-5**] as the
4275 gm product of a 37 and [**5-12**] week gestation pregnancy to a
27-year-old gravida 1, para 0-1 mother with [**Name (NI) 37516**] of [**2101-6-20**]. Prenatal Lab Corp studies included blood type A+,
antibody negative, RPR nonreactive, rubella-immune, hepatitis
B surface antigen negative and group B streptococcus
negative. Maternal history and prenatal course were notable
for asthma, gestational diabetes mellitus and pregnancy-
induced hypertension. Maternal medications included insulin
and albuterol. The infant was delivered by C-section due to
macrosomia. No sepsis risk factors were identified. At
delivery the infant was vigorous with Apgars of 9 and 9. He
was well-appearing, but initial D-sticks were noted to be
under 30. Infant was also found to be mildly hypothermic and
to turn dusky during 1st feeding attempt; due to these
concerns the infant was brought to the NICU.
HOSPITAL COURSE BY SYSTEMS: Respiratory: Infant remained
comfortable on room air throughout admission without evidence
of significant respiratory distress. However, occasional
desaturation episodes were noted; these were primarily with
feeding attempts, although were occasionally seen at rest as
well. Desaturations episodes gradually improved with
improvement in feeding skills and by the time of discharge
the infant has been free of desaturation episodes at rest for
over 5 days and free of desaturation episodes with feedings
for over 3 days. Overall, feedings are noted to be much more
coordinated by the time of discharge than were seen in the
1st few days after birth.
Cardiovascular: The infant has remained hemodynamically
stable throughout admission. No cardiovascular concerns have
been noted.
Fluids, electrolytes, nutrition: The infant has been
maintained on ad lib feeding throughout hospitalization of
breast milk and Similac 20. Total intake has been adequate
and urine and stool output has been normal throughout. As
mentioned, the infant was hypoglycemic shortly after birth
with 2 blood sugar values under 40; however, with routine
feeding these normalized and blood sugars remained within
normal range subsequently. As mentioned above, initial
feedings were described as somewhat discoordinated resulting
in frequent desaturation; these gradually improved with time
and by the time of discharge the infant is feeding well
without difficulty. Birth weight was 4275; weight at the time
of discharge was 4110g.
GI: Infant experienced mild physiologic jaundice. Bilirubin
level on day of life 3 was 8.7/0.3, phototherapy was not
necessary.
Hematology: The infant's hematocrit was measured on day of
life 2 and was found to be 56. No other hematologic issues
have been identified.
Infectious disease: No perinatal sepsis risk factors were
identified. On day of life 2 however, the infant was noticed
to have developed a temperature to 101. Infant gradually
defervesced, but did have mildly elevated temperatures above
100 for the next 12-24 hours. A sepsis evaluation was
performed including a CBC that was unremarkable and CSF
analysis that was also reassuring. Blood and CSF cultures
were subsequently negative. The infant was begun on
ampicillin, gentleman and acyclovir. Antibiotics were
discontinued at 48 hours. CSF was sent for HSV, PCR, this
returned negative on day of life 6, at which time acyclovir
was discontinued. Of note, a transient exanthem was noted the
day following the fever; overall course is most suggestive of
a viral illness.
Neurology: The infant had maintained a normal urologic exam
throughout admission. Hearing screen was performed with
automated auditory brainstem responses and was passed
bilaterally.
CONDITION AT DISCHARGE: Stable, on room air with mature
respiratory and feeding patterns.
DISCHARGE DISPOSITION: Infant is being discharged to home.
PRIMARY PEDIATRICIAN: Dr. [**First Name5 (NamePattern1) 25897**] [**Last Name (LF) 74337**], [**First Name3 (LF) 392**]
Pediatrics, [**Telephone/Fax (1) 42643**].
PHYSICAL EXAMINATION AT DISCHARGE: Weight 4110g, head
circumference 37.5cm, length 53.5cm. Infant is a well-developed
infant in no distress. Infant is comfortable and reactive with
exam. Fontanelles are soft and flat. Ears and nares are normal.
Red reflex is present bilaterally. Palate is intact. Neck is
supple. Chest is clear to auscultation without grunting,
flaring or retractions. Cardiac exam is regular rate and
rhythm without murmur. Abdomen is soft and nondistended with
active bowel sounds. Genitalia that of a normal male, testes
are descended bilaterally, anus is patent. Hips and back are
normal. Tone and activity are appropriate.
CARE AND RECOMMENDATIONS:
1. Feeds: Breast milk or Similac 20 ad lib.
2. Medications: None.
3. Car seat position screening: Car seat safety screening
was performed and was passed.
4. State newborn screening: Newborn State screen was sent on
day of life 3 as per protocol. No abnormal results have
been reported to date.
5. Immunizations received: Hepatitis B vaccine was given on
[**2101-6-10**], day of life 5.
6. Immunizations recommended:
1. Influenza immunization is recommended annually in the
fall for all infants at least 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.
2. This infant has not received rotavirus vaccine. The
American Academy of Pediatrics recommends initial
vaccination of preterm infants at or following
discharge from the hospital if they are clinically
stable and at least 6 weeks or fewer than 12 weeks of
age.
7. Followup: Infant will followup with primary pediatrician
within 3 days of discharge.
DISCHARGE DIAGNOSES:
1. At term gestation.
2. Hypoglycemia.
3. Sepsis evaluation.
4. Viral illness.
5. Feeding immaturity.
6. Apnea.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 37928**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2101-6-12**] 19:42:08
T: [**2101-6-12**] 20:40:02
Job#: [**Job Number 74338**]
|
[
"V290",
"V053"
] |
Admission Date: [**2115-7-25**] Discharge Date: [**2115-7-30**]
Date of Birth: [**2057-7-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Substernal chest pain and throat tightness with exertion
Major Surgical or Invasive Procedure:
[**2115-7-25**]
1. Off pump coronary artery bypass graft x3, left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to diagonal, and obtuse marginal arteries.
2. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
This is a 57-year-old patient with extensive coronary artery
disease history with previous stenting presented again with
symptoms and was investigated and found to have a significant
lesion in the left anterior descending artery diagonal and the
obtuse marginal arteries. Left ventricular function is well
preserved and she was electively admitted for off pump coronary
artery bypass grafting.
Past Medical History:
Coronary artery disease(s/p MI [**2104**]), BMS to proximal LAD [**2104**],
DES to mid LAD [**2112**], DES to edge ISR of mid LAD DES and stenosis
distal to stent [**2112**], DES to OM1, [**2115-1-31**]).
diastolic congestive heart failure
Hypertension
Dyslipidemia
Morbid obesity
COPD
GERD
Rt rotator cuff injury/bursitis(outpt PT-2x/wk,
Migraines,
Depression/Anxiety
DJD
Hemorrhoids
Rosacea
Left foot tendion repair
Social History:
Lives in [**Location **] with her grandchildren. She quit smoking 11
years ago. She does not drink or use drugs.
Family History:
She was a [**Hospital1 **] of the state and does not know her family.
Physical Exam:
Physical Exam
Pulse: 86 Resp:20 O2 sat:98%
B/P Right: 132/68 Left:
Height: 5'2 Weight:210
General: AAOx3, NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x]non-distended [x]non-tender [x]bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: +2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right:cath site Left:+2
Carotid Bruit: None
Pertinent Results:
Echocargiogram [**2115-7-25**]
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV.
Left-to-right shunt across the interatrial septum at rest.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal regional LV systolic function.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Simple atheroma in ascending aorta. Normal descending
aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
Pre operative:
The left atrium is normal in size. There is a small PFO with a
left-to-right shunt across the interatrial septum. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. There
are simple atheroma in the ascending aorta. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion.
Chest X-Ray [**2115-7-28**];
There is mild-to-moderate cardiomegaly. Bilateral pleural
effusions are
small. Aside from atelectasis in the left lower lobe, the lungs
are grossly clear. Almost complete resolution of atelectasis in
the left upper lobe. Sternal wires are aligned. Widened
mediastinum has improved. A small air-fluid level in the
retrosternal region suggests the presence of a tiny pneumothorax
and small effusion. These are most likely located in the left
side.
[**2115-7-30**] 06:05AM BLOOD WBC-11.7* RBC-3.06* Hgb-10.4* Hct-30.5*
MCV-100* MCH-33.9* MCHC-34.0 RDW-13.5 Plt Ct-253
[**2115-7-29**] 06:15AM BLOOD WBC-11.1* RBC-3.23* Hgb-11.1* Hct-32.1*
MCV-99* MCH-34.4* MCHC-34.6 RDW-13.3 Plt Ct-230
[**2115-7-27**] 08:20AM BLOOD WBC-14.0* RBC-3.26* Hgb-10.8* Hct-32.3*
MCV-99* MCH-33.2* MCHC-33.4 RDW-13.3 Plt Ct-192
[**2115-7-30**] 06:05AM BLOOD Na-137 K-4.1 Cl-97
[**2115-7-29**] 06:15AM BLOOD Glucose-161* UreaN-19 Creat-1.1 Na-136
K-4.0 Cl-97 HCO3-29 AnGap-14
[**2115-7-28**] 08:00AM BLOOD Glucose-230* UreaN-14 Creat-0.9 Na-136
K-4.1 Cl-98 HCO3-26 AnGap-16
[**2115-7-27**] 08:20AM BLOOD Glucose-238* UreaN-16 Creat-1.0 Na-134
K-4.6 Cl-100 HCO3-22 AnGap-17
[**2115-7-26**] 04:00AM BLOOD Glucose-98 UreaN-13 Creat-0.9 Na-136
K-4.7 Cl-106 HCO3-23 AnGap-12
Brief Hospital Course:
The patient was brought to the Operating Room on [**2115-7-25**] where
the patient underwent Off pump coronary artery bypass graft x3,
left internal mammary artery to left anterior descending artery
and saphenous vein grafts to diagonal, and obtuse marginal
arteries. Endoscopic harvesting of the long saphenous vein.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. She required
Nitroglycerin for hypertension her first night post op but was
transitioned to oral betablocker and diuretics. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable. The patient was transferred to the telemetry floor for
further recovery. Chest tubes and pacing wires were discontinued
without complication. She was started on plavix due to being
done off pump and will it need to be continued for six months.
Blood sugars were closely monitored and she was restarted on her
home regime which have slowly improved. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. 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
home with visiting nurse services in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Atorvastatin 40 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Benzonatate 100 mg PO TID:PRN tos
4. Clopidogrel 75 mg PO DAILY
5. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
6. Glargine 80 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Metronidazole Gel 0.75%-Vaginal 1 Appl VG HS
10. Naproxen 500 mg PO Q8H:PRN pain
11. Nitroglycerin SL 0.4 mg SL PRN cp
12. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
13. Pantoprazole 40 mg PO Q12H
14. Ropinirole 0.25 mg PO QPM
15. Valsartan 80 mg PO DAILY
16. Aspirin 325 mg PO DAILY
17. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*1
4. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
RX *fluticasone [Flovent HFA] 220 mcg 2 puffs twice a day Disp
#*1 Inhaler Refills:*0
5. Glargine 50 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth Q 4
hrs Disp #*30 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Ropinirole 0.25 mg PO QPM
9. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
10. Ibuprofen 600 mg PO Q6H:PRN pain
take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
11. Metoprolol Tartrate 25 mg PO TID
Hold for HR < 55 or SBP < 90 and call medical provider.
[**Last Name (NamePattern4) 9641**] *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
12. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride 20 mEq 1 tablet by mouth daily Disp #*7
Tablet Refills:*0
13. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
RX *albuterol 2 puffs PRN Q 4 hrs Disp #*1 Inhaler Refills:*0
14. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease(s/p MI [**2104**]), BMS to proximal LAD [**2104**],
DES to mid LAD [**2112**], DES to edge ISR of mid LAD DES and stenosis
distal to stent [**2112**], DES to OM1, [**2115-1-31**]).
diastolic congestive heart failure
Hypertension
Dyslipidemia
Morbid obesity
COPD
GERD
Rt rotator cuff injury/bursitis(outpt PT-2x/wk,
Migraines,
Depression/Anxiety
DJD
Hemorrhoids
Rosacea
Left foot tendion repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] on [**2115-8-8**] at
10:45a
Surgeon Dr. [**First Name (STitle) **] on [**2115-8-27**] at 2:15p
Cardiologist: [**Doctor First Name **] Fish [**2115-8-12**] at 2:20pm ([**Location (un) **] office)
Please call to schedule the following:
Primary Care Dr [**Last Name (STitle) 410**] in [**3-7**] weeks [**Telephone/Fax (1) 6662**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2115-7-30**]
|
[
"41401",
"5180",
"4280",
"4019",
"496",
"2724",
"53081",
"311",
"412",
"V4582",
"V1582"
] |
Admission Date: [**2121-9-27**] Discharge Date: [**2121-10-1**]
Date of Birth: [**2071-1-31**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Delirium
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 50 yo woman with PMH of Depression w/ psychotic
features, who presented initially to [**Hospital3 **] w/ c/o
acute MS changes and tremors in her arms and legs b/l. Pt c/o
being "confused" at night, not sleeping, increased agitation x
past 2 weeks. Per pt's husband, x past 2 weeks, pt has had
increased confusion, agitation, talking/hallucinating in her
sleep, arm and leg tremors. Recent medication changes include
lidocaine patch for tongue pain, as well as percocet and
phenergan, initiated after dental procedure 1 week PTA. Pt also
has had discontinuation of her outpt Zyprexa [**1-2**] hyperglycemia
awhile ago, and abilify was started. Dose adjustments have been
made with her abilify b/c at too high of a dose, her agitation
increases. Abilify was recently d/ced and then restarted at 5mg
1 day PTA. Pt denies any intentional medication OD. States
that the "shaking" in her arms and legs had occurred on and off
x years due to side effects of her psychiatric medications (per
outpt psychiatrist, pt h/o fine tremors).
At [**Hospital3 **], pt was evaluated, received an LP which
was negative. She was given a number of doses of ativan 9.5 mg
total) for agitation, and was transferred to [**Hospital1 18**] for further
care w/ working diagnosis of ?lidocaine toxicity.
Upon arrival at [**Hospital1 18**] ER, pt was afebrile, VSS. On exam she was
noted to have dilated pupils, dry mucous membranes and dry
armpits all indicating anticholinergic overdose. Labs notable
only for urine tox positive for benzos (given at OSH). She was
administered physostigmine w/ some improvement in her mental
status initially - pt awoke and was communicating. However,
after clearing of MS, pt then became somewhat somnolent again
(?[**1-2**] ativan given @ OSH) and had remaining clonus on exam.
Toxicology (Dr. [**Last Name (STitle) **] has seen pt in ED, agrees w/ dx of
anti-cholinergic OD w/ subsequent ?benzo OD vs polydrug OD w/
lithium toxicity (level pending) vs serotonin syndrome vs other
pharmacological OD.
Currently pt w/ continued agitation, myoclonus, otherwise
conversive.
Past Medical History:
Depression w/ psychotic features - + hospitalizations in past,
most recently 2 years ago. H/o 1 suicide attempt in the past a
number of years ago.
Social History:
Abilify 5mg daily
Effexor 150mg qam 75mg qpm
lidocaine PRN
percocet PRN
phenergan PRN
wellbutrin 150mg qam 75mg qpm
luvox 100mg qam 200mg qpm
ativan PRN
lamictal 100mg [**Hospital1 **]
OTC motrin and tylenol
Family History:
H/o depression, CAD, both parents w/ lung cancer
Physical Exam:
Vitals - T 97.3, HR 111, BP 124/73, O2 98% on 3L, RR 16
General - somewhat sleepy, but arousable and conversant, +
myoclonus and other extra-pyramidal signs w/ facial movements,
slightly disoriented (did not know was in [**Location (un) **]), orientable
but easily re-forgets. Appears to be having ?visual
hallucinations (acting out drinking out of a bottle of water).
HEENT - Pupils dilated, equally reactive to light, extra-ocular
movements intacts, no sceral icterus, dry mucous membranes w/
some dry caked blood on lips
CVS - tachycardic, regular, no M/R/G
Lungs - CTA b/l
Abd - soft, NT/ND, no HSM
Ext - No LE edema b/l
Skin - warm, dry
Neuro - sleepy but alert, oriented x 2 (not to place ->
orientable but then forgets again), HEENT as above, strange
myoclonal movements w/ facial movements occasionally,
unintentional. Hyper-reflexic throughout.
Pertinent Results:
[**2121-9-26**] 09:00PM WBC-8.5 Hgb-10.5 Hct-29.4 MCV-82 RDW-13.0 Plt
Ct-369
[**2121-10-1**] 05:50AM WBC-9.1 Hgb-10.3 Hct-29.1 MCV-82 RDW-13.2 Plt
Ct-375
.
[**2121-9-30**] 04:01AM Glucose-96 UreaN-7 Creat-0.6 Na-138 K-3.6
Cl-101 HCO3-30
.
[**2121-9-27**] 03:50AM ALT-65 AST-71 LD(LDH)-272 CK(CPK)-2433
AlkPhos-66 Amylase-60 TotBili-0.4
[**2121-9-28**] 03:46AM ALT-74 AST-55 LD(LDH)-200 CK(CPK)-958
AlkPhos-66 TotBili-0.3
[**2121-9-28**] 09:51AM CK(CPK)-739*
[**2121-9-29**] 03:43AM ALT-119* AST-78* CK(CPK)-468* AlkPhos-69
TotBili-0.2
Brief Hospital Course:
Pt is a 50 yo woman with PMH of depression w/ psychotic features
who p/w MS changes, sz, [**1-2**] serotonin syndrome vs lidocaine
toxicity or a combination of the two.
.
## Mental status changes: Initially dx unclear upon
presentation to OSH. W/u there included LP, which was negative.
Pt given ativan for agitation. Upon arrival here, pt w/
signs/sxs of anti-cholinergic activity (dilated pupils, dry
mucous membranes and dry armpits), and was administered
physostigmine w/ resolution of MS [**First Name (Titles) **] [**Last Name (Titles) **]. However, upon arrival
in MICU, pt remained with myoclonus vs coarse tremor, delirium
w/ hallucinations, dilated pupils, dry mouth. Therefore, given
outpt medication regimen and new changes including addition of
percocet and lidocaine solution post dental procedure and
addition of aripiprazole w/in 1 week PTA, after discussion w/
pt's outpt psychiatrist, ? contribution of serotonin syndrome to
explain MS changes along w/ anti-cholinergic syndrome. Less
likely on differential is NMS. She was monitored in the ICU,
and her symptoms rapidly dissipated. Her aripirazole was held on
discharge due to a ? as to whether it had anything to do with
her presentation.
.
## Depression w/ psychotic features: Pt w/ h/o bipolar d/o and
depression, on abilify, effexor, wellbutrin, lamictal, ativan,
luvox as outpt. All medications initially held, but restarted
when patients delirium improved. Only aripirazole was held due
to a ? as to whether it was the inciting [**Doctor Last Name 360**].
Medications on Admission:
Abilify 5mg daily
Effexor 150mg qam 75mg qpm
lidocaine PRN
percocet PRN
phenergan PRN
wellbutrin 150mg qam 75mg qpm
luvox 100mg qam 200mg qpm
ativan PRN
lamictal 100mg [**Hospital1 **]
OTC motrin and tylenol
Discharge Medications:
1. Lamotrigine 25 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
2. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO QPM (once a day (in the
evening)).
3. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2)
Capsule, Sust. Release 24HR PO QAM (once a day (in the
morning)).
4. Bupropion 75 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
5. Bupropion 100 mg Tablet Sig: 1.5 Tablets PO QPM (once a day
(in the evening)).
6. Fluvoxamine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
Delirium, medication-induced
Discharge Condition:
Stable, ambulatory.
Discharge Instructions:
Please keep all of your follow-up appointmetns.
.
Please take all of your medicines as prescribed. Please do not
take your Abilify (aripiprazole) until instructed to do so by
your psychopharmacist and psychologist.
.
Please return to the hospital if you experience chest pain,
shortness of breath, fevers or changes in your mental status.
Followup Instructions:
Please follow up with your psychologist and psychopharm
specialist as scheduled.
.
Please make a follow-up appointment with your primary care
physician [**Last Name (NamePattern4) **] [**12-2**] weeks.
|
[
"2859"
] |
Admission Date: [**2163-8-26**] Discharge Date: [**2163-9-10**]
Date of Birth: [**2084-12-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Cortisone / Adhesive Tape
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Unstable angina, shortness of breath.
Major Surgical or Invasive Procedure:
[**2163-9-5**] AVR(19 mm [**Company 1543**] Mosaic Porcine) / cabg x2 (LIMA to
LAD, SVG to OM)
History of Present Illness:
78 yo female with known coronary artery disease, s/p PCI/stent
who presented to an outside hospital with one weeks of angina.
She r/o for MI and underwent left and right heart
catheterization with coronary angiography.
This demonstrated a 75% left main stenosis, luminal
irregularites of the LAD, RCA and circumflex, 50% 2nd diagonal
lesion and a patent distal RCA stent. Right sided pressures were
PA 38/16, CVP 12 and the [**Location (un) 109**] was 0.7cm2, with a 35mm gradient.
The CI was 2.49l/min.
She was transferred to this institution for surgical treatment.
Past Medical History:
Diabetes
hypercholesterolemia
s/p appendectomy
s/p hysterectomy
depression
s/p cholecystectomy
s/p PCI/Stent
Social History:
remote smoker ( 30 yrs ago)
lives with husband who suffers from [**Name (NI) 2481**] disease
Denies ETOH use
Retired
Family History:
No cardiac history
Physical Exam:
Vitals:Temp 99.1 Tmax:99.4 P:59 BP:120/52 RR:18
Vent:97%
General: aaox3, no acute distress
HEENT: perrl, op clear, mmm
Neck: supple. no lad. no thyromeg.
Respiratory: cta bilaterally w/out wheezes/rhonchi/rales
Cardiovascular: III/IV systolic murmur best heard on the right
upper sternal border. cresc/decresc.
Back: no ST tenderness
Gastrointestinal: +bs, soft, NT, ND, no organomegaly appreciated
Genitourinary: WNL
Musculoskeletal:WNL
Skin:A 5cm by 5x5cm rash in the left gluteal region. There are
multiple small pustules on an erythematous base. Another
similar
smaller rash 2x2cm 3cm superior to this rash. Along S2 vs S3
dermatome.
Dermatographic erythematous plaques on chest in shape of
telemetry leads.
Neurological: WNL
Psychiatric:WNL
Pertinent Results:
[**2163-8-26**] 09:21PM PT-13.5* PTT-21.5* INR(PT)-1.2*
[**2163-8-26**] 09:21PM PLT COUNT-274
[**2163-8-26**] 09:21PM WBC-6.6 RBC-3.88* HGB-12.0 HCT-35.6* MCV-92
MCH-30.8 MCHC-33.6 RDW-13.5
[**2163-8-26**] 09:21PM ALT(SGPT)-15 AST(SGOT)-19 LD(LDH)-160 ALK
PHOS-40 AMYLASE-37 TOT BILI-0.3
[**2163-8-26**] 09:21PM GLUCOSE-156* UREA N-20 CREAT-1.0 SODIUM-138
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
[**2163-8-29**] Carotid Duplex Ultrasound
Bilateral 1-39% ICA stenosis. Bilateral vertebral antegrade
flow.
[**2163-9-5**] ECHO
Prebypass
1. No atrial septal defect is seen by 2D or color Doppler.
2.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 ascending aorta. 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 (1+)
aortic regurgitation is seen.
6. The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral regurgitation is seen.
7. Dr. [**Last Name (STitle) **] was notified in person of the results on
[**2163-9-5**] at 930am.
Post bypass
1. Patient is being AV paced .
2. Biventricular systolic function is unchanged.
3. Mitral regurgitation is 2+
4. Bioprosthetic va;lve seen in the aortic position. Leaflets
move well and the valve appears well seated. Peak gradient
across the aortic valve is 17 mm Hg.
5. Aorta intact post decannulation.
Brief Hospital Course:
Ms. [**Known lastname 40009**] was transferred from [**Hospital3 417**] Hospital to the
[**Hospital1 18**] on [**2163-8-26**] for definitive surgical treatment of her aortic
stenosis and coronary artery disease. She underwent routine
preoperative testing including a carotid duplex ultrasound which
showed bilateral 1-39% internal carotid artery stenosis. She had
a brief episode of CP after admission which resolved without
intervention. Herpes zoster was noted on exam for which
acyclovir was started. An infectious disease consult was
obtained who obtained a culture which was positive for herpes
simplex virus type 2 and agreed with antiviral treatment.
Augmentin was started for moraxella catarrhalis in her sputum.
On [**2163-9-5**], Ms. [**Known lastname 40009**] was taken to the operating room where
she underwent an aortic valve replacement (porcine valve) and
coronary artery bypass grafting to two vessel. Please see
operative not for details. Postoperatively she was taken to the
cardiac surgical intensive care unit for monitoring. She was
later extubated without difficulty. Her vasoactive drips were
weaned and her chest tubes removed. She was transferred to the
step down floor. Her wires were removed. [**9-10**] she was
ambulating well, her sternal wound was improved. She will be
discharged today on keflex for 5 days.
Medications on Admission:
Avapro 150mg/D
Glyburide 7.5mg/D
ASA 325mg/D
Plavix 75mg/D
Protonix 40mg/D
Zoloft 50mg/D
Metformin500mg [**Hospital1 **]
Lipitor 40mg/D
Imdur 60mg/D
ToprolXL 25mg/D
Discharge Medications:
Glyburide 5mg/D
Irbesartan 150 mg Tablet/d
Metoprolol 25 mg po BID
pantoprazole EC 40 mg/d
sertraline 50 mg po/d
atorvastatin 40mg po daily
Fenofibrate Nanocrystallized [Tricor]145mg po/d
ASA 81 mg po/d
Furosemide 20mg iv q12hrs
Docusate 100mg po bid
plavix 75 mg po daily
Glucophage 500mg po bid
cephalexin 500mg po q6hrs X 5days
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
aortic stenosis
coronary artery disease
diabete mellitus
hypertension
s/p MI
dyslipidemia
s/p PCI/ stent
depression
GERD
herpes zoster
Pneumonia
Discharge Condition:
good
Discharge Instructions:
take all medications as prescribed
no lifting more than 10 pounds for 10 weeks
keep wounds clean and dry, ok to shower daily, no baths or
swimming
no creams, lotions or powders to incisions
report any drainage or redness of incisions
report any temperature greater than 101
no driving for one month AND off all narcotics
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr [**Last Name (STitle) **],[**First Name3 (LF) **] M. in [**1-16**] weeks ([**Telephone/Fax (1) 3183**])
Completed by:[**2163-9-10**]
|
[
"4241",
"41401",
"496",
"25000",
"2720"
] |
Admission Date: [**2110-10-8**] Discharge Date: [**2110-10-27**]
Date of Birth: [**2054-1-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Shortness of Breath/Dyspnea on exertion
Major Surgical or Invasive Procedure:
Tracheostomy
PEG placement
Central line placement - right subclavian
Arterial line placement
PICC line placement
History of Present Illness:
This 56 year old female with history of interstitial pulmonary
fibrosis on 2L home O2 chronically presents with cough and chest
pain. She stated that the cough and chest pain began one week
prior. She also reported some nasal congestion and fevers. Her
cough was productive of green sputum and was accompanied by
right sided sub sternal chest pain. The pain is intermittent in
nature, sharp, it doesn't radiate. She reported no sick
contacts, no hemoptysis. No abdominal pain, no N/V/D. Her
daughter said that she was sick last weekend, felt a little
better over the weekend, sounded a lot better the day prior to
admission. She presented to [**Company 191**] where she was seen by Dr.
[**Last Name (STitle) 1538**] and was found to have decreased O2 sats, she was sent
to the ED for evaluation.
At baseline she is on home O2 2L, 3-4 liters at night. In the
ED she was found to have decreased BS at the bases with wheezes.
Her CXR showed rt pleural effusion, ? of pneumonia. She was
treated with combivent, solumedrol, Ceftazadime, and Zithromax.
She was reassessed and found to be somnolent, tachypneic with
very little air movement. The decission was made to intubate
her based upon these symptoms and she was intubated. A chest CT
was performed and she was transferred to the MICU.
Past Medical History:
1. Pulmonary fibrosis thought [**2-5**] old Tb (on right side), on 2L
O2 at home at baseline, unchanged x 5 yrs
2. Pulmonary HTN
3. Osteoporosis
4. DJD R knee
5. Thalassemia trait
6. Depression
7. Anemia
8. Tuberculosis, treated in [**2079**] and [**2081**] x 6 months
9. Attention deficit disorder
10. Hx pseudomonal pna [**2104**], requiring intubation x 3 weeks
Social History:
No EtOH, no tobacco
Lives in [**Hospital1 **], on disability
Family History:
Mother died of colon CA
Physical Exam:
Vitals Temp 99.5, HR 90, BP 102/57, RR 38, sat 98% on A/C
400X18, FIO2 100%, PEEP 5
Gen: sedated, intubated female in NAD
HEENT: PERRL, MMM, OP with ET tube in place
Neck: no JVD, no lymphadenopathy
Lungs: diffuse rhonchi, more air movement on left than right,
also with intermittent wheezes
CV: RRR, nl S1S2, no murmers
Abd: soft, NT, ND, positive BS
Ext: no edema
Skin: no rashes
Pertinent Results:
Admission Labs:
[**2110-10-8**] 01:45PM WBC-10.0# RBC-3.45* HGB-10.3* HCT-33.2*
MCV-96 MCH-29.8 MCHC-31.0 RDW-13.0
[**2110-10-8**] 01:45PM NEUTS-84.4* BANDS-0 LYMPHS-7.9* MONOS-7.1
EOS-0.4 BASOS-0.3
[**2110-10-8**] 01:45PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
[**2110-10-8**] 01:45PM PLT SMR-NORMAL PLT COUNT-167
[**2110-10-8**] 01:45PM PT-14.3* PTT-27.3 INR(PT)-1.4
[**2110-10-8**] 06:39PM TYPE-ART TEMP-34.8 RATES-15/0 TIDAL VOL-450
PEEP-8 O2-100 PO2-489* PCO2-62* PH-7.48* TOTAL CO2-47* BASE
XS-19 AADO2-187 REQ O2-39 INTUBATED-INTUBATED VENT-CONTROLLED
[**2110-10-8**] 06:39PM O2 SAT-98
[**2110-10-8**] 01:48PM LACTATE-0.8
[**2110-10-8**] 01:45PM GLUCOSE-123* UREA N-8 CREAT-0.4 SODIUM-140
POTASSIUM-4.6 CHLORIDE-90* TOTAL CO2-44* ANION GAP-11
Additional pertinent labs/studies:
.
[**2110-10-8**] CXR: Interval increase in amount of air in the bullae
in the right hemithorax. CT recommended.
[**2110-10-8**] CT Chest: 1. Severe bronchiectasis and volume loss in
the right lung which is probably of minimal or no function.
Moderate-to-severe left lower lobe bronchiectasis slightly
improved when compared to [**9-2**] without new focal
consolidation.
2. Interval increase in right lung base bulla when compared to
the prior
study.
3. Chronic fibrotic changes with calcifications in the left
upper lobe,
likely related to prior granulomatous disease.
4. Severe, chronic pulmonary hypertension.
5. There are no pleural effusions.
6. Enlarged pulmonary arteries, likely due to pulmonary artery
hypertension.
7. In the axial images, the ET tube appears to be at the level
of the carina. Withdrawal of 1 cm should be prudent.
8. Small tracheal diverticulum.
[**2110-10-13**] ECHO: 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. Right ventricular
chamber size and free wall motion are normal. The aortic arch is
mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Moderate pulmonary artery systolic hypertension.
Preserved global biventricular systolic function.
Compared with the prior report (tape unavailable for review) of
[**2105-4-10**], the findings are similar.
[**2110-10-13**] CXR: 1. Worsening multifocal opacities within the left
lung, most likely due to worsening multifocal pneumonia
superimposed upon chronic bronchiectasis.
2. Stable appearance of chronic bronchiectasis and volume loss
in the right lung as well as a large right lung bulla.
[**2110-10-19**] CXR: The previously identified edema in the left lung
has been increased. There is continued fibronodular opacity in
the left upper lobe as described.
[**2110-10-23**] CXR: 1) Status post tracheostomy tube placement with
interval removal of NG tube, and interval placement of a PICC.
The distal tip of the PICC is difficult to ascertain, but may
terminate in the right atrium.
2) Apparent lucency below the right hemidiaphram worrisome for
free air. This was discussed with Dr. [**Last Name (STitle) 26969**] at the time of
interpretation of the study. (Note that this was not present in
the initial preliminary report).
[**2110-10-26**] CXR: Tracheostomy tube and right PICC line remain in
place, with the PICC line terminating in the expected location
of the right atrium. There is volume loss in the right
hemithorax with collapse of majority of the right lung with
associated bronchiectasis. A large bulla is noted in the right
lower lung zone. Within the left lung, there are diffuse
bronchiectatic changes, with interval increase in
peribronchiolar opacities, particularly within the left lower
lobe. Finally, note is made of free intraperitoneal air within
the abdomen, which has decreased in severity in the interval.
.
IMPRESSION:
1. Decrease in amount of free intraperitoneal air.
2. Slight worsening of peribronchiolar opacities, especially in
the left lower lobe. This may represent progressive infection in
this patient with underlying bronchiectasis.
Discharge Labs:
.
[**2110-10-27**] 03:06AM BLOOD Hct-27.3*
[**2110-10-9**] 01:46AM BLOOD Neuts-88.9* Lymphs-7.9* Monos-3.0 Eos-0
Baso-0.1
[**2110-10-27**] 03:06AM BLOOD Glucose-122* UreaN-9 Creat-0.3* Na-139
K-3.8 Cl-98 HCO3-35* AnGap-10
[**2110-10-27**] 03:06AM BLOOD Calcium-8.6 Phos-3.9 Mg-1.4*
Brief Hospital Course:
56 year old female with history of pulmonary fibrosis probably
from TB presenting with respiratory distress, with worsening CXR
and lung CT, intubated for respiratory support with difficulty
weaning off the vent now s/p course of levofloxacin for
Pseudomonal PNA sensitive to FQ and s/p trach.
1. Respiratory distress - On admission we considered that Mrs.
[**Known lastname 16905**] could have worsening brochiectasis vs. pneumonia with
underlying lung disease. She has relatively [**Name2 (NI) 26970**] respiratory
function at baseline due to her history of TB, pulmonary
fibrosis, and having only one functional lung. She is on 2L O2
by NC at home at baseline, with 3-4L at night, and a recent
diagnosis of OSA requring nightime BIPAP. She also has a prior
history of pseudomonal pneumonia with [**Hospital Unit Name 153**] stay a year ago
requiring intubation. On that stay she responded to Levofloxacin
and Ceftazidime and the pseudomonas was sensitive to these
antibiotics. Sputum during this hospitalization grew strep
pneumococcus and pseudomonas, both pan-sensitive. She was
initially treated with Levofloxacin and Ceftazidime until the
sensitivities returned, and then the ceftazidime was
discontinued. She completed a ten day course of levofloxacin,
with no recurrence of fevers or elevation of WBC count after
treatment was completed. CT of the chest did show worsened
bronchietasis as well. She was also treated with standing
nebulizer treatments. Initial attempts to wean the ventilator
support were moderately sucessful, and she was extubated
[**2110-10-16**]. However, she became hypercarbic with PaCO2 in the high
90's, and became more confused. Therefore she was reintubated.
Following this repeated attempts to wean the ventilatory support
were unsuccessful, with repeated hypercarbia (PaCo2 up to the
100's). Therefore on [**2110-10-23**] a tracheostomy was performed to
allow a slower wean from the ventilator. A PEG was placed at the
same time for nutritional support during her wean. Of note: she
is a CO2 retainer with baseline HCO3 of 40's. Her outpatient
pulmonologist is Dr. [**Last Name (STitle) **], and he was notified of her
admission, and updated on her course. The patient has since
completed her course of antibiotics. Although the patient
continues to look well clinically, remains afebrile without
increased secretions, a repeat chest film performed yesterday,
[**2110-10-26**], demonstrated slight worsening of peribronchioloar
opacities, especially in the left lower lobe, which was
interpreted as possibly consistent with progressive inefection.
However, as the patient looks clinically well as above, the
decision is being made to have patient continue discharge to
vent rehab without an additional course of antibiotics. She will
need to be followed closely clinically to distinquish between
colonization and true infection.
2. Cardiovascular: Mrs. [**Known lastname 16905**] [**Name (STitle) **] had some hypotensive
episodes with low urine output, and briefly required Levophed
(less than 24 hours). However, this was quickly weaned off, and
she was hemodynamically stable. On admission she had a right
subclavian TLC and an A-line placed on admission. The central
line was discontinued after approximately a week when CVP
monitoring was deemed no longer necessary, and her A-line was
changed twice - maintained to follow ABGs for ventilator
weaning. She had an ECHO which showed a normal EF and moderate
pulmonary artery systolic hypertension. Her CXR did appear to
show signs of mild failure, and she was diuresed a small amount.
This did not significantly improve her respiratory function, and
it was not felt that cardiovascular function was at the root of
her decreased respiratory function.
3. Anemia: Mrs.[**Known lastname 16906**] hematocrit is 33 at baseline. Early
in her admission she received one unit pRBCs for a hematocrit of
23.5. She raised her hematocrit appropriately to this treament,
and was stable thereafter.
4. GERD: Mrs. [**Known lastname 16905**] was continued on protonix as per her home
regimen for GERD.
5. FEN: Mrs. [**Known lastname 16905**] was NPO with tubefeeds via her OG tube,
which she tolerated well. Post placement of her PEG, she resumed
tubefeeds via her PEG. A small amount of free air was present
after her PEG placement, a common event post-PEG placement.
Thoracic surgery followed ,a nd serial abdominal exams were
benign. She was also given intermitant IV fluid boluses to
maintain urine output. However, caution was used to avoid fluid
overload as she has only one functional lung, and her CXR did
show signs of mild congestive failure, and we did not want to
worsen her respiratory status.
6. Prophylaxis: Mrs. [**Known lastname 16905**] was on subcutaneous Heparin for
DVT prophylaxis and protonix for ulcer prophylaxis.
7. Access: Mrs [**Known lastname 16905**] initially had a R SC TLC and L A-line.
The A-line was changed twice, and she was maintained with PIVs
after the central line was discontinued approximately one week
into her stay. A PICC line was placed [**2110-10-22**] for more
long-term access while she is weaning off the ventilator.
8. Mrs. [**Known lastname 16905**] is FULL code
9. Communication: We communicated frequently with Mrs. [**Known lastname 16905**]
about her progress and her plan, and talked with her daughter
[**Name (NI) 11556**] as well, who is her health care proxy. Mrs. [**Known lastname 16905**]
consented for her own procedures.
10. Dipso: Mrs. [**Known lastname 16905**] was discharged to [**Hospital3 **]
for further management of ventilatory support and
rehabilitation.
Medications on Admission:
1. Protonix
2. Fosamax
3. Combivent
4. Advair
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q4H (every 4 hours).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
6. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
7. Midazolam 1 mg/mL Solution Sig: 1-2 mg Injection Q6H (every 6
hours) as needed for anxiety.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
10. fentanyl Sig: 12.5 mg Intravenous (only) every six (6)
hours as needed for pain.
11. Colace 150 mg/15 mL Liquid Sig: Ten (10) ml PO twice a day.
12. heparin Sig: 5000 (5000) units Subcutaneous three times a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]--[**Hospital1 **]
Discharge Diagnosis:
Primary:
pseudomonal pneumonia
Secondary:
Pulmonary fibrosis
Pulmonary HTN
Osteoporosis
DJD R knee
Thalassemia trait
Depression
Anemia
history of tuberculosis
Attention deficit disorder
Discharge Condition:
Stable, with tracheostomy and on ventilator PS 15/5 w/ 40% FiO2,
with PEG for nutrition (tolerating tube feeds)
Discharge Instructions:
Please notify your caregivers if you have any trouble breathing,
feel feverish, nauseated, or are vomiting, or have any other
health concern.
Followup Instructions:
Please call your primary care doctor for an appointment within
7-10 days of discharge from rehab.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **],MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2110-12-24**]
11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2111-1-27**] 12:00
Completed by:[**2110-10-27**]
|
[
"51881",
"4280",
"4168",
"53081",
"2859"
] |
Admission Date: [**2107-7-1**] Discharge Date: [**2107-7-20**]
Date of Birth: [**2048-7-4**] Sex: M
Service: MEDICINE
Allergies:
Nadolol
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Elevated total bilirubin (refrred by outpatient clinic).
Major Surgical or Invasive Procedure:
ERCP ([**2107-7-13**]).
Intubation
History of Present Illness:
Recently admitted ([**Date range (1) 34960**]) with jaundice and liver failure.
Up to that point, he had noticed a one month history of jaundice
and scleral icterus.
Discriminant function at admission to OSH was 26. He was started
no prednisone and discharged on 20mg daily. Given grade I
varices on EGD nadolol and a PPI were started.
At the time of discharge, his total bili was 24. Upon recheck
after discharge it was noted to be 31 with his other LFTs also
up from discharge. Noted to have ascited and to be afebrile in
liver clinic. Given the worsening LFTs and ascites he was
admitted for further evaluation.
Since discharge, the patient has been feeling well. Denies any
fevers/chills, abdominal pain, emesis, diarrhea, constipation,
melena or BRBPR. Hasn't noticed any change in his abdominal
size. Since [**Month (only) 404**] his weight has decreased from 210 to 189
pounds.
Past Medical History:
1. Alcoholic liver disease
2. Alcoholism
3. Diverticulosis
4. Left Knee arthroscopic surgery
Social History:
Patient lives with his wife and 3 children (13,17,22), has
another son who is incarcerated. He was a policeman for 10yrs
and has subsequently been working in [**Location (un) 86**] at Massport for the
past 19 yrs. He drives into [**Location (un) 86**] daily. Current stressors in
his life include financial difficulty and concern about his
incarcerated son.
Smoking: 50 pack years
EtOH: 1 bottle of wine/day. Moderate drinker as long as wife can
remember (for 17 years). Then 5 years ago, drinking increased.
Patients endorses drinking for past 40yrs. As per pt, he has
began working with a substance abuse counselor, and plans to use
the support of his family and a ?psychiatrist at [**Hospital1 1562**] to aid
his cessatio of alcohol use.
IVDU: never
Family History:
Adopted at 1 yr of age. Per wife, his biological mother may have
had alcoholism
Physical Exam:
gen - jaundiced, lying in bed in no distress
heent - icteric sclera, no palor
cv - rrr, no murmurs, nl s1,s2
pulm - crackles at left base; otherwise clear
abd - soft but obese; non-tender; liver is difficult to palpate
but appears 1-2cm below costal margin
ext - warm with 1-2+ edema bilaterally, no nail changes
skin - jaundice, no palmar erythema, no obvious spider angiomas
or telangiectasias
Pertinent Results:
[**2107-7-1**] 08:10PM ALT(SGPT)-242* AST(SGOT)-270* LD(LDH)-292*
ALK PHOS-181* TOT BILI-25.7* ALBUMIN-2.0*
[**2107-7-1**] 08:10PM PT-19.2* PTT-35.1* INR(PT)-1.8*
[**2107-7-1**] 08:10PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
[**2107-7-1**] 08:10PM ETHANOL-NEG ACETMNPHN-10.6
[**2107-7-1**] 08:10PM WBC-22.3*# RBC-3.98* HGB-14.8 HCT-44.0
MCV-111* MCH-37.1* MCHC-33.6 RDW-15.9* PLT COUNT-204
[**2107-7-1**] 08:10PM GLUCOSE-108* UREA N-19 CREAT-0.9 SODIUM-135
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-25 ANION GAP-13
[**2107-7-1**] DUPLEX DOP ABD/PEL LIMITED: 1. No significant change
since [**2107-6-24**], with evidence of heterogeneous echogenic liver,
which may be secondary to fatty liver, but cirrhosis cannot be
excluded by ultrasound. No focal intrahepatic lesions.
2. Unchanged appearance of flow reversal within the portal
venous system, without definite evidence of thrombus.
[**2107-7-1**] CHEST (PA & LAT): Lungs are fully expanded and previous
interstitial pulmonary abnormality in the lung bases has
cleared. There is no pleural effusion or evidence of central
adenopathy. Azygous distention his unchanged.
.
ERCP BILIARY&PANCREAS BY GI UNIT [**2107-7-13**] 12:56 PM
Ten fluoroscopic images are available for review obtained
without a radiologist present. Cholangiogram demonstrates a
normal-appearing common bile duct, cystic duct, opacified
gallbladder, and intrahepatic biliary radicles. No strictures or
filling defects to suggest stone is identified.
IMPRESSION: Unremarkable cholangiogram.
.
US ABD LIMIT, SINGLE ORGAN [**2107-7-14**] 3:46 PM
Four-quadrant ultrasound reveals a small amount of ascitic
fluid. The volume is not suitable for therapeutic paracentesis.
.
CT ABDOMEN W/CONTRAST [**2107-7-19**] 5:43 PM
1. Tiny bilateral pleural effusions.
2. Ascites.
3. Sigmoid diverticulosis without evidence of diverticulitis.
4. Diffuse anasarca, which is symmetric.
5. No evidence of soft tissue or intramuscular gas.
.
KNEE (AP, LAT & OBLIQUE) LEFT PORT [**2107-7-19**] 10:35 AM
There are no previous studies available for a direct comparison.
Please note that the study is limited due to difficulty in
positioning patient due to pain.
The left hip joint is suboptimally evaluated due to the
patient's large body habitus and technique. However allowing for
this, no focal fractures are identified. The rest of the femur
is intact. No gas is seen within the subcutaneous soft tissues.
There are mild degenerative changes seen of the medial knee
joint with small marginal osteophytes. A small knee joint
effusion is present on lateral view. The left tibia and fibula
are intact without acute fractures. No gas is seen within the
subcutaneous soft tissues of the left leg.
Limited study without signs for acute bony injury or soft tissue
gas.
.
UNILAT LOWER EXT VEINS LEFT [**2107-7-19**] 4:28 AM
No evidence of DVT.
Brief Hospital Course:
59 yr old male with hx of alcoholic cirrhosis admitted [**7-1**] for
worsening liver failure.
Floor course:
1. Liver disease- Has history of significant alcohol use; this
is presumed to be the cause of his liver disease. At OSH prior
to his recent admission, he had hepatitis serologies which
showed: [**Last Name (un) **] neg, HbC IgA neg, HbSAg neg, HCV neg. An AFP was
1.9. Over the initial days of his hospitalization, the LFTs
remained stable if markedly elevated. Ultrasound of the liver
was performed which and showed a heterogeneous echogenic liver
flow reversal within the portal venous system. A trans-jugular
biopsy was performed and was consistent with obstruction and
showed extensive sinusoidal fibrosis, increased portal fibrosis,
with bridging fibrosis (Stage 3). Given the possibility of
obstruction, an ERCP was perfomed - it did not show any evidence
of this. Prednisone was continued despite the poor response.
Ursodiol and cholestyramine were also used. Lactulose and
rifaximin were initially added, although the lactulose was
stopped given persistent diarrhea.
2. Acute renal failure- Developed acute renal failure on [**7-16**]
(SCr increased to 1.9), with the possibility of hepatorenal
syndrome. Urine sodium was <10. Was challenged with IVF;
resulting improvement in creatinine made a pre-renal state much
more likely.
3. Diarrhea-Soon after initiation of lactulose, developed
diarrhea with up to 10 or more bowel movements per day. The
diarrhea continued even with titration of the lactulose down and
off. C.diff was sent and negative, but empiric treatment was
begun with Flagyl.
4. Grade I Varices- Continued propranolol, although he missed
many doses given his low blood pressures.
5. Alcohol use- Report sobriety since [**6-21**]. Monitored for
withdrawal signs/symptoms.
MICU course:
[**7-18**] on floor patient began to complain of left thigh pain and
overnight developed erythema of the LLE. No evidence of DVT.
Started on Vancomycin in the AM. Was noted to be hypotensive on
routine vital signs check with a BP 76/p. He was given 1.3
liters of NS bolus and started on albumin 5% 25 gm IV once. BP
to 85/50. Pt was oriented to self. ABG PH 7.34/PCO2 24/P02 91.
Lactate 5.2. A foley was placed with 125 cc urine. Pt was
transferred to the MICU, where exam positive for 2+ LE edema
with feet cool bilaterally. Pulses dopplerable. LLE exquisitely
tender to palpation out of proportion to exam. Erythema and
swelling. Dark discoloration of posterior thigh and calf. Great
concern for necrotizing fascitis, though patient previously with
diarrhea. Pt was started on pressors, broad antibiotic coverage
with Vanco/ceftriaxone/ Clindamycin/ flagyl changed to
vanc/clinda/zosyn after discussion with infectious disease.
Stress dose steroids given. Surgery consulted, concern for
sepsis in the setting of nec fasc, but pt unstable dependent on
four pressors, acidotic. [**7-20**] Pt intubated for respiratory
distress/ severe acidosis. Episodes of bradycardia down to the
30's with hypotension. Brief attempt at Epi drip without
improvement. Continued discussion with family and code status
confirmed DNR.
1:31 AM pt expired with family and medical team at bedside.
Medications on Admission:
1. Prednisone 20 mg DAILY
2. Nadolol 20 mg DAILY
3. Pantoprazole 40 mg DAILY
4. Lactulose 10 g/15 mL 30 ML [**Hospital1 **]
5. Hexavitamin
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
1. Liver failure, alcohol induced.
Pt expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Pt expired
|
[
"5849",
"2875",
"0389",
"99592",
"2762"
] |
Admission Date: [**2149-10-12**] Discharge Date: [**2149-10-15**]
Date of Birth: [**2094-7-2**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Visipaque
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
scheduled cath
Major Surgical or Invasive Procedure:
cath [**10-13**]
History of Present Illness:
55 yr old male w/3 vessel disease, s/p MI [**9-20**], s/p LAD/LCX
intervention on [**9-26**], now returning for staged RCA intervention,
creat is 1.5, diabetic.
Originally presented to OSH on [**9-18**] with chest pressure x 10
minutes, not alleviated by rest. He did not take SL NTG at home.
At OSH he had a peak CK of 220, MB 4.2, TropI 1.18. Because of
recurrent episodes of CP with inferolateral ST depressions and
HTN (and presumably the results of the stress test), he was
transferred to [**Hospital1 18**] for cath.
The patient arrived in CCU CP free on IABP. The plan initially
was to cont the IABP and heparin until the patient could have a
CABG. However, CT [**Doctor First Name **] upon further eval felt that the patient's
obesity and DM made him a high risk surgical candidate.
Therefore, the patient went back to the cath lab on [**9-23**] where
he had his LCx and LAD stented, and the plan was to have his RCA
stented after an interval of [**1-3**] weeks to avoid dye-related ATN.
In the meantime the pt was maintained on [**Date Range **], BB, ACEI, statin,
Plavix.
The patient has been chest pain free and med compliant over this
time. He reports stopping smoking completely over the last 2
weeks. He has no chest pain w/ exertion but does have occasional
SOB after walking his dog. No SOB at rest. No PND or orthopnea.
He denies N/V,F/C or diaphoresis.
Past Medical History:
CAD w/ PTCA [**58**] yr ago, HTN, DM2 (diet controlled),
hyperlipidemia (not on meds), morbid obesity, OSA, GERD, hiatal
hernia, arthritis (knees, s/p L TKA) on vicodin, depression/
anxiety
Cardiac Studies:
[**2149-9-23**] for NSTEMI
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful stenting of the LCX w/Pixel and Cypher DES.
3. Successful stenting of the LAD w/Cypher DES.
RCA was not selectively engaged.
Cath [**9-20**]: 70% mid LAD, subtotally occluded Lcx w/ slow flow,
distal 80-90% RCA stenoses; per V-gram EF 50%, no MR
Social History:
retired roofer and carpenter; married with two sons
etoh - none
tob - 2-6ppd for 30+ years (60-180 pack years); stopped smoking
x 2 weeks
drugs - none
Family History:
GM - died from MI at 72yo; M with CRI on HD, Breast CA
Physical Exam:
PE: HR 70, RR 16, O2 sat 95% ,
Gen-well-appearing, anxious, but in NAD
HEENT- EOMI, OP Clear
Neck- no JVD
Pulm-CTA bilaterally, no r/r/w
CV- RRR. no m/r/g. nl s1/s2
Abd-obese, soft, NT,ND. suprapubic cath in place
Ext- no c/c/e. 2+ distal pulses UE/LE
NEuro-CN II-XII intact
Pertinent Results:
[**2149-10-12**] 04:10PM PT-13.5 PTT-28.4 INR(PT)-1.2
[**2149-10-12**] 04:10PM PLT COUNT-275#
[**2149-10-12**] 04:10PM WBC-5.4 RBC-3.82* HGB-11.5* HCT-33.8* MCV-89
MCH-30.1 MCHC-34.0 RDW-13.5
[**2149-10-12**] 04:10PM CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-2.1
[**2149-10-12**] 04:10PM CK-MB-NotDone cTropnT-<0.01
[**2149-10-12**] 04:10PM CK(CPK)-73
[**2149-10-12**] 04:10PM GLUCOSE-89 UREA N-28* CREAT-1.4* SODIUM-142
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-27 ANION GAP-14
Brief Hospital Course:
This is a 55 yr old male w/3 vessel disease, s/p MI [**9-20**], s/p
LAD/LCX intervention on [**9-26**], now returning for staged RCA
intervention, creat is 1.5, diabetic. A brief hospital course is
outlined below.
1. CAD- s/p stenting of LAD,LCX. s/p selective cath and stenting
of RCA. He was found to be chest pain free on admission, with no
EKG changes and negative enzymes. He was continued on his
[**Month/Year (2) **],B-Blocker,Plavix,Statin and Nitrates. He was pre-hydrated
with 300cc bicarb and was given two doses of acetylcysteine
pre-cath. On [**10-13**], he went for selective cath of his RCA. Per
cath report, shortly after initiation of guidewire, he became
hypotensive and flushed, without evidence of hives, rash or
respiratory compromise. The event also correlated w/ changing
visipaque to optiray dye. He required a short course of pressors
and was treated with pepcid,benadryl and Solumedrol IV. Left and
right heart pressures were not found to be elevated and cardiac
function was perserved, consistent with peripheral
vasodilatation. After stabilizing, the RCA was stented with 2
cypher stents without event. He was transferred to CCU for
monitoring post-cath. He was able to maintain his BP off
pressors, with no intubation required. He returned to the [**Hospital Unit Name 196**]
service on [**10-15**] and was found to be hemodynamically stable,
chest pain free and breathing comfortably on room air. He
continued to do well overnight without event. He has been listed
as having an allergy to dye and will need pre-medication prior
to future dye loads. He will follow-up with his pcp [**Last Name (NamePattern4) **] [**2-4**]
weeks.
2. DM- He was maintained on sliding scale insulin. Metformin was
held given his scheduled cath. Metformin will be re-started on
discharge.
3. Anxiety- Buproprion, Citalopram, trazadone prn
4. pain- tylenol prn, percocet prn
5. supra-pubic cath: The patient will follow-up with Dr. [**Last Name (STitle) **]
in Urology on [**10-16**] to have his catheter removed.
6. Health Maintenance: He was encouraged to continue smoking
cessation. He is currently taking wellbutrin to help with this.
In addition he is encouraged to maintain his diabetic
diet/healthy heart diet and exercise regularly.
Medications on Admission:
[**Month/Year (2) **],atorvastatin,pantoprazole,
donepezil,citalopram,buproprion,albuterol prn,ipatropium prn,
plavix, tylenol prn, metoprolol, lisinopril, isosorbide
mononitrate, metformin
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD
(once a day).
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
5. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
8. Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO
HS (at bedtime).
9. Ipratropium Bromide 0.02 % Solution Sig: [**1-3**] Inhalation Q6H
(every 6 hours) as needed.
10. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO
QD (once a day).
11. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: please take 1
tab under tongue as needed for chest pain, repeat in 5 minutes
if chest pain not alleviated .
Disp:*30 tabs* Refills:*2*
14. Resume Metformin at home dose 10/14.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
1. CAD
Discharge Condition:
good. hemodynamically stable. chest pain free
Discharge Instructions:
Please report fever,chills, shortness of breath or chest pain to
your pcp.
Call 911 if you have chest pain not alleviated after sublingual
nitroglycerin
Please continue to refrain from smoking. Please let your PCP
know if you need further help to quit.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) 3314**] in [**2-5**] weeks. His # is
[**Telephone/Fax (1) 3183**]
2. Please follow-up with Urology (Dr. [**Last Name (STitle) **] as you have
scheduled on [**10-16**]. Call tommorrow morning to confirm your
appointment time. The number is: [**Telephone/Fax (1) 6445**]
|
[
"41401",
"412",
"4019",
"25000"
] |
Admission Date: [**2104-8-25**] Discharge Date: [**2104-9-18**]
Date of Birth: [**2063-7-4**] Sex: M
Service: MEDICINE
Allergies:
Cefazolin
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
transferred from OSH - headache and new onset seizure.
Major Surgical or Invasive Procedure:
[**2104-8-28**] OR for steriotactic biopsy with pathology in OR showing
high grade glioma however final path sig. for toxoplasmosis
History of Present Illness:
41 y.o male from [**Country 651**] who presented to [**Hospital **] Hospital on [**8-25**]
with a a progressive HA over a few weeks and new onset of
seizure and found to have on CT a large left intracranial mass .
He was loaded with Cerebryx and given Decadron 10 mg IV x1 and
transferred to [**Hospital1 18**] for further care. On arrival patient was
thought to be disoriented, confused even with cantonese
interpreter. He had a repeat CT showing a large mass in the left
basal ganglia with vasogenic edema, mass effect and 7 mm
rightward shift of septum on head CT and MRI with Irregular
rim-enhancing mass centered within the left thalamus with
inferior extension into the brainstem.
.
On [**8-28**] he underwent a stereotactic brain biopsy with prelim
results showing malignant glioma. On further review pathology
showed toxoplasma gondii with staining + for Ab and parasites
seen in tissue.
.
ID was consulted and pt was placed on Pyrimethamine,
Sulfadiazine and folinic acid for toxoplasmosis treatment. He
was continued on Phenytoin for seizure prophylaxis.
.
On [**8-31**] he complained of itchy scalp and forhead and on [**9-2**]
developed raised vessicles on right forehead with eyelid
swelling. DFA + for VZV and he was started on Acyclovir.
Ophthamology was consulted and detected no ocular involvement
from zoster or toxoplasmosis; pt was started on prophylactic
erythromycin otic. Over time, pt developed some R upper eyelid
erythema and edema. Cefazolin was started for concern of an
overlying cellulitis.
On [**9-2**] he spiked a fever to 102.9 with rigors and tachycardia
and passed 40cc-50cc BRBPR. Blood, urine cultures and CXR were
all negative. Pt's fever lifted the next day, his tachycardia
after 3 days. GI was consulted for blood - colonoscopy
significant only for hemorrhoids, no evidence of CMV colitis or
other infections / masses.
On [**9-5**], pt was transferred to the floor. He was noted to have
intermittent bouts of hiccups, thought to be secondary to his
brain lesion and increasing liver enzymes. Hepatitis serologies
returned positive for Hepatitis B surface antigen, core antibody
with a viral load over 3 million.
On [**9-6**], pt developed [**Location (un) **] erythematous rash over chest, arms
and legs. Thought to be a drug rash, cefazolin was stopped
(eyelid erythema / edema had resolved) and pt was switched from
phenytoin to keppra. Over 3-4 days, rash diminished.
From [**9-6**] to [**9-10**], pt continued on medication, improved
neurologically, started asking more questions, eating,
ambulating well.
On [**9-11**] - pt spiked a fever, U/A was leukocyte and nitrite
positive. Pt started on Cipro for suspected UTI. Urine cultures
grew E.Coli sensitive to cipro. Blood cultures pending. Foley
d/c'ed. Pt responded well to antibiotics and continued to
improve.
Past Medical History:
CAD: " small invasive procedure on his heart with placement of
a piece of metal to keep blood flowing to his heart". procedure
included minor incision in his groin indicating cardiac cath.
His
was taking medication for this up until recently and was stopped
per cardiologist as not indicated anymore
MI: possible minor heart attack last year
Unknown speech / language disorder, communicates more by
writing.
Social History:
Cantonese speaking, born in [**Country 651**]. Lives by himself, fully
independent, disabled secondary to "speech" impairment. Per
Brother, HIV positive, multiple sexual partners in past (unclear
men, women or both), has not used contraception or STD
prophylaxis. No IVDU, no previous blood transfusions
Family History:
Mother with uterine Ca.
Physical Exam:
Physical Exam:
Vitals: 99.6 104/79 100 18 99%on RA.
General: Thin Cantonese man, sitting quietly in chair, in NAD.
HEENT: 2cm biopsy scar over left frontal skull. Crusting
vesicular lesion over R side opthalmic trigeminal area - no
vesicles or open areas. Slight droop to R eyelid, no swelling or
erythema. PERRL 3mm a 2mm, white sclera. No oropharyngeal
thrush. Moist mucous membranes.
Neck: supple
Lungs: Clear to auscultation bilaterally no rales, wheezes or
rhonchi
CV: tachycardic to 100, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, nontender, nondistended, bowel sounds present, no
rebound tenderness or guarding.
Ext: Warm, well perfused, 2+ pulses bilaterally. no peripheral
edema
Neuro: Alert, following commands, answering questions
appropriately, stuttering unchanged. CN II-XII in tact. Strength
[**4-7**] in flexors and extensors for L arm, [**3-8**] in flexors and
extensors of R arm. Plantar flexion [**4-7**] bilaterally, [**3-8**]
dorsiflexion on right [**4-7**] on left, [**4-7**] leg extension / flexion
bilaterally. Slightly decreased pronator drift on R side. Gait
not tested this AM
Skin: No rash.
Pertinent Results:
IMAGING
[**2104-8-26**] MRI head w/wo contrast - Irregular rim-enhancing mass
centered within the left thalamus with inferior extension into
the brainstem. The imaging characteristics including inferior
extension favor a glioblastoma multiforme. Less likely in the
differential are metastasis, lymphoma and PNET. Of note, it has
been shown that slow diffusion within the enhancing portion of a
glioblastoma multiforme, as in this case, is associated with an
aggressive behavior.
.
[**2104-9-2**] - CXR - No signs of acute cardiopulmonary process
.
[**2104-9-5**] - Bilat LE US - No evidence of bilateral lower extremity
deep venous thrombus
.
[**2104-9-15**] - ABDOMINAL US - LIVER, GALLBLADDER - The liver is
normal in echotexture. No focal lesion is identified. There is
no intra- or extra-hepatic biliary dilatation. The common bile
duct measures 3 mm. The gallbladder is not distended. A small
amount of sludge is noted within the gallbladder. There is no
pericholecystic fluid or wall edema. The spleen measures 12.2 cm
in length and is unremarkable. The main portal vein is patent
with appropriate direction of flow.
.
[**2104-9-16**] CT HEAD w/o contrast - 1. New high density, presumably
blood in part of the wall of the lesion. This change is most
likely treatment related.
2. Decrease in edema, midline shift, and distortion of the third
and lateral ventricles.
.
.
CULTURES
[**2104-9-2**] - Skin Scraping - Positive VZV
[**2104-9-5**] - HIV antibody positive - CD4 154
[**2104-9-7**] - CMV IgG ANTIBODY (Final [**2104-9-9**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA.
292 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
.
CMV IgM ANTIBODY (Final [**2104-9-9**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
[**2104-9-7**] - HBV Viral Load (Final [**2104-9-11**]):
Greater than 38,000,000 IU/ml.
HCV VIRAL LOAD (Final [**2104-9-9**]):
HCV-RNA NOT DETECTED.
[**2104-9-11**] - Urine - Positive for EColi -
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2104-9-11**] - Blood cultures x 2 : no growth.
[**2104-9-15**] - Stool cultures, no C.diff, no salmonella, shigella,
or campylobacter, no O&P, no giardia, no cryptosporidium.
LABS:
[**2104-8-25**] 02:30PM BLOOD WBC-4.5 RBC-4.85 Hgb-11.2* Hct-34.5*
MCV-71* MCH-23.1* MCHC-32.5 RDW-14.4 Plt Ct-207
[**2104-8-29**] 06:45AM BLOOD WBC-6.4 RBC-5.36 Hgb-12.3* Hct-37.8*
MCV-70* MCH-22.9* MCHC-32.5 RDW-16.1* Plt Ct-185
[**2104-9-5**] 12:50PM BLOOD WBC-4.8 RBC-4.68 Hgb-11.1* Hct-33.5*
MCV-72* MCH-23.8* MCHC-33.2 RDW-15.6* Plt Ct-135*
[**2104-9-8**] 12:50PM BLOOD WBC-3.5* RBC-4.90 Hgb-11.4* Hct-34.7*
MCV-71* MCH-23.2* MCHC-32.8 RDW-15.9* Plt Ct-164
[**2104-9-13**] 06:40AM BLOOD WBC-2.9* RBC-4.20* Hgb-10.1* Hct-29.9*
MCV-71* MCH-24.1* MCHC-33.8 RDW-16.1* Plt Ct-244
[**2104-8-25**] 02:30PM BLOOD Neuts-69.2 Lymphs-27.8 Monos-2.3 Eos-0.5
Baso-0.2
[**2104-8-25**] 02:30PM BLOOD PT-13.9* PTT-33.8 INR(PT)-1.2*
[**2104-9-5**] 10:40AM BLOOD WBC-5.8 Lymph-34 Abs [**Last Name (un) **]-[**2067**] CD3%-86
Abs CD3-1689 CD4%-8 Abs CD4-154* CD8%-77 Abs CD8-1523*
CD4/CD8-0.1*
[**2104-8-25**] 02:30PM BLOOD UreaN-11 Creat-0.7 Na-129* K-3.6 Cl-96
HCO3-25 AnGap-12
[**2104-9-1**] 06:15AM BLOOD Glucose-116* UreaN-11 Creat-0.6 Na-129*
K-4.1 Cl-95* HCO3-25 AnGap-13
[**2104-9-5**] 12:50PM BLOOD UreaN-6 Creat-0.7
[**2104-9-7**] 09:25AM BLOOD Glucose-98 UreaN-6 Creat-0.6 Na-132*
K-3.5 Cl-102 HCO3-23 AnGap-11
[**2104-9-10**] 07:35AM BLOOD Glucose-103 UreaN-3* Creat-0.6 Na-138
K-3.3 Cl-105 HCO3-27 AnGap-9
[**2104-9-13**] 06:40AM BLOOD Glucose-84 UreaN-4* Creat-0.7 Na-138
K-3.6 Cl-104 HCO3-26 AnGap-12
[**2104-9-5**] 05:48AM BLOOD ALT-48* AST-24 LD(LDH)-239 AlkPhos-95
Amylase-93 TotBili-0.2
[**2104-9-8**] 12:50PM BLOOD ALT-90* AST-60* AlkPhos-179* TotBili-0.3
[**2104-9-9**] 12:55PM BLOOD ALT-137* AST-90* AlkPhos-228* TotBili-0.3
[**2104-9-10**] 07:35AM BLOOD ALT-99* AST-46* AlkPhos-200* TotBili-0.3
[**2104-9-11**] 07:50AM BLOOD ALT-69* AST-21 LD(LDH)-169 AlkPhos-196*
TotBili-0.5
[**2104-9-13**] 06:40AM BLOOD ALT-42* AST-19 AlkPhos-181* TotBili-0.3
[**2104-8-26**] 04:00AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.1
[**2104-9-10**] 07:35AM BLOOD Calcium-7.7* Phos-2.9 Mg-2.0
[**2104-9-6**] 09:00AM BLOOD calTIBC-160* Ferritn->[**2095**] TRF-123*
[**2104-9-8**] 12:50PM BLOOD HCV Ab-NEGATIVE
[**2104-9-11**] 10:13AM URINE Blood-MOD Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2104-9-11**] 10:13AM URINE RBC-[**5-13**]* WBC-[**10-23**]* Bacteri-MOD
Yeast-NONE Epi-0
Brief Hospital Course:
Patient was admitted with new onset seizures with workup
revealing a left thalamic lesions. CT torso on [**2104-8-26**] revealed
no malignancy and MRI with contrast finding's consistent with
Glioblastoma Multiforme. The patient went to the operating [**Last Name (un) **]
on [**2104-8-28**] for a left steriotactic biopsy with initial pathology
revealing a high grade glioma. Patient was noted to have vomited
twice after large meals on [**2104-8-29**]. Patient continued to
demonstrate a right pronator drift on exam. He was found to
have vesicular rash on R side of face and culture confirmed
Herpes Zoster. The final pathology from his brain biopsy was
positive for toxoplasmosis and ID was consulted. He started on a
appropriate therapy. Opthomology was also consulted regarding
shigles on face due risk of corneal erosion - they found no
evidence of VZV or toxoplasmosis involvement. Per pt family he
has a past history of multiple sex partners who had known HIV.
On [**9-5**] he had intermittent episodes of tachycardia and slight
hypotension resolved with fluids. He then had BRBPR and GI was
consulted, this was determined by colonoscopy to be due to
internal hemorrhoids with no signs of colitis. He was then
transferred to the Medicine service for management of multiple
medical problems. On the medical floor, pt neurologic condition
continued to improve. He was able to follow commands, answer
basic questions. He was advanced to regular diet. His floor
course was complicated by 2-3 days of diarrhea (C. diff
negative, culture negative) which spontaneously resolved and a
catheter associated UTI, which was treated with 5 days of Cipro.
His symptoms on the floor included pain around his VZV rash and
chronic bilateral vision blurriness, which he stated he had had
for months before and did not prevent him from seeing / [**Location (un) 1131**].
.
TOXOPLASMOSIS - L thalamic lesion frozen section initially
consistent with glioblastoma multiforme, however, final path
demonstrated toxoplasmosis. Pt started on Pyrimethamine,
Sulfadiazene and Folinic Acid treatment. Pt showed no signs of
mass effect or herniation. His neuro exam improved over time; he
was more alert, oriented, answering questions appropriately and
trying to communicate with staff. His RUE weakness, R pronator
drift and RLE dorsiflexion weakness remained. He stated his
vision remained slightly blurry bilaterally, but was not
associated with vision loss, pain or other changes during his
hosptial stay. A follow up CT on treatment day 12 showed
decrease edema and mass effect, with some blood thought to be
secondary to treatment. He remained confused throughout his stay
and was unable to describe why he was in the hospital. Discharge
treatment includes:
.
- Pyrimethamine 75 mg po daily
- Sulfadiazene 1-1.5grams po q 6 hours
- Folinic acid 10-20 mg po daily
.
UTI: Pt developed catheter related E. Coli UTI towards the end
of his hospital course, which was treated with Cipro x 5 days.
No fever since starting treatment. Other investigations for
infectious causes, including CXR and blood cultures, were
negative.
.
GI BLEED: Prior episode of 40cc-50cc BRBPR with tachycardia. Hct
remained stable. Per GI, Colonoscopy positive for hemorroids, no
colitis or other pathology seen. They could not rule out UGIB
including PUD.
.
ANEMIA: Appears to have iron overload (90% transferritin
saturation) with very high ferritin. Per hemoglobin
electrophoresis, pt has studies consistent with beta thalassemia
trait - which is likely contributing to his anemia. Also
contributing could be his active HIV / Hepatitis B, inflammatory
process, and to a lesser extent, minor intermittent hemorrhoid
bleeding.
.
TRIGEMINAL NERVE VZV INFECTION: Rash over R face confirmed
zoster infection. Crusting, healing with Acyclovir. Initial
concern for cellulitis due to some edema, erythema over R upper
eyelid, however, this seem to resolve spontaneously over time.
Ophthamology determined no ocular involvement as of [**2104-9-5**]. Per
ID, we will continue Acyclovir to complete 14 days of treatment
as well as erythromycin optic. We recommend Acetominophen and
oxycodone to alleviated facial pain associated with zoster,
given side effect profile of Gabapentin.
.
ORAL THRUSH: Oral thrush disappeared with daily nystatin. Pt
complained of no dysphagia and was taking PO well at discharge.
Nystatin d/c'ed at discharge.
.
HIV: HIV antibody positive with CD4 abs 154. Pt started on
Atovaquone for PCP [**Name Initial (PRE) 1102**]. ID recommends waiting to start
HIV therapy, pending additional lab tests. He should have his
CD4 count rechecked as an outpatient as his wbc decreased during
admission with treatment of his infection. He may require
additional prophylaxis based on his repeat counts.
.
RASH: Pt developed [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], erythematous rash covering chest,
extremities; blanching, no mucosal involvement. Thought to be
secondary to cephalosporin - which was being given for presumed
cellulitis over zoster infection. Cefazolin stopped and rash
dissapated over 3-4 days. In addition, given unknown etiology of
rash, Phenytoin was changed to keppra.
.
HEPATITIS: Hep B surface antigen and core antibody positive,
with negative surface antibody and high viral load, indicating
active chronic hepatitis B. Hep C antibody negative. Pt had
transient increses in liver enzymes, which were stable /
trending down at discharge. It was thought that hepititis could
be exacerbating anemia. Pt was screened for HCC and had low AFP
and no masses seen on ultrasound.
.
SEIZURE: Questionable seizure activity on admission, no seizure
activity throughout hospitalization. Switched to keppra from
phenytoin , due to chance of phenytoin drug rash. Pt maintained
on Keppra 1000mg [**Hospital1 **]. Will f/u with neurosurgery in 1 month for
repeat CT and re-evaluation. This should be scheduled as an
outpatient. He should continue Keppra until his follow up.
.
Medications on Admission:
None.
Discharge Medications:
1. Pyrimethamine 25 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
2. Sulfadiazine 500 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
Disp:*360 Tablet(s)* Refills:*2*
3. Leucovorin Calcium 5 mg Tablet Sig: Four (4) Tablet PO Q 24H
(Every 24 Hours).
Disp:*120 Tablet(s)* Refills:*2*
4. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) teaspoons
(10ml) PO DAILY (Daily).
Disp:*1 bottle* Refills:*2*
5. Erythromycin 5 mg/g Ointment Sig: 0.5 Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*1 bottle* Refills:*2*
6. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO 5X/D () for 2
days.
Disp:*10 Tablet(s)* Refills:*0*
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed. Tablet(s)
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:*2*
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for face pain.
Disp:*30 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
Please fax the following laboratory studies weekly to the [**Hospital **]
clinic at [**Hospital1 18**] - fax [**Telephone/Fax (1) 432**] attn Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**]
1 CBC (WBC, PLT, HCT, HGB)
2 LFTs (AST, ALT, ALK, TBILI)
Discharge Disposition:
Extended Care
Facility:
Shaugnessy - [**Hospital 656**] rehabilitation hospital network
Discharge Diagnosis:
Primary:
AIDS CD4 154
Hepatitis B
Toxoplasmosis brain lesion
Trigeminal Varicella Zoster
B thalassemia trait
Secondary:
Oral Thrush
E-Coli UTI
Anemia
Internal Hemorrhoids
Discharge Condition:
vital signs stable, taking PO well, ambulating without
assistance.
Discharge Instructions:
You were transferred to [**Hospital1 18**] from [**Hospital **] Hospital with a
headache and possible new onset seizure after imaging showed a
large mass in your brain.
.
A biopsy of the mass was done, and, originally, it was thought
that this mass was a type of brain cancer, glioblastoma
multiforme.
.
However, on further evaluation, it was discovered that the mass
was from an infection, known as toxoplasmosis. Around the same
time, you also developed a rash on your face, known as
trigeminal varicella zoster, and white plaques in your mouth,
known as thrush.
We did many tests and discovered the following:
- you have HIV / AIDS with a CD4 count of 154
- you have active Hepatitis B
- you do not have Hepatitis C
- you have anemia
We gave many medications to treat your toxoplasmosis brain
lesion, your trigeminal zoster and your oral thrush. In
addition, we gave medicines to prevent other opportunistic
infections associated with HIV (Atovaquone for PCP), and
medications to prevent possible seizures (Keppra). We did not
yet start medications to treat HIV.
You are being discharged to a rehabilitation facility to
continue your recovery.
It is extremely important that you follow up with all doctors
[**Name5 (PTitle) 2176**] to manage your illness. It is also very important that
you take all medications prescribed to you; this is the only way
to prevent further infections.
New Medications:
Pyimethamine
Sulfadiazine
Leucovorin
Atovaquone
Erythromycin Eye Ointment
Acyclovir
Levetiracetam
Acetaminophen as needed for pain
Omeprazole
Please take all medications
Please keep all follow up appointments. You have an appointment
at the Infectious Disease Clinic on [**2104-10-13**] at:
Division of Infectious Disease
Department of Medicine
[**Hospital1 69**]
[**Hospital **] Medical Office Building, Suite GB
[**Last Name (NamePattern1) 439**]
[**Location (un) 86**] , [**Telephone/Fax (1) 79895**]
Please call beforehand to confirm your appointment
Please call neurosurgery at [**Telephone/Fax (1) 79896**] to schedule an
appointment and follow up CT in 1 month (mid [**Month (only) **])
Please have your rehab facility fax the following laboratory
studies weekly to the [**Hospital **] clinic at [**Hospital1 18**] - fax [**Telephone/Fax (1) 432**] attn
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**]
1 CBC
2 LFT's
Please return to the hospital or seek further medical care if
you have fever, chills, increasing headache, trouble with vision
or swallowing, cough, trouble breathing, chest or abdominal
pain, dizziness, weakness, or anything else that concerns you.
Followup Instructions:
Please follow up with your infectious disease physician at the
time and location below:
You have an appointment at the Infectious Disease Clinic on
[**2104-10-13**] at -
Division of Infectious Disease
Department of Medicine
[**Hospital1 69**]
[**Hospital **] Medical Office Building, Suite GB
[**Last Name (NamePattern1) 439**]
[**Location (un) 86**] , [**Telephone/Fax (1) 79895**]
Please call beforehand to confirm your appointment.
Please have your rehab facility fax the following laboratory
studies weekly to the [**Hospital **] clinic at [**Hospital1 18**] - fax [**Telephone/Fax (1) 432**] attn
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**]
1 CBC
2 LFT's
Please call neurosurgery at [**Telephone/Fax (1) 79896**] to schedule an
appointment and follow up CT in 1 month (mid [**Month (only) **])
|
[
"5990",
"2851",
"2875"
] |
Admission Date: [**2145-1-17**] Discharge Date: [**2145-1-21**]
Date of Birth: [**2067-6-6**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Atenolol / Bupropion Hcl
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Hyperkalemia, Junctional Rhythm, Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
77 yo female with multiple medical problems who was brought into
the [**Name (NI) **] by ambulance after patient complaining of dyspnea, and
feeling very cold. Patient had an EKG done in the ED that showed
junctional rhythm and she was found to be in acute renal failure
with hyperkalemia. She received atropine, glucagon, and insulin
for hyperkalemia. Patient also became hypotensive and required
pressors for a very brief period of time but was quickly weaned
off with aggresive IVF. Of note, patient mentioned that she had
been having a cold with thick, green sputum production and was
being treated with Azithromycin during the time of her
presentation. No other associated symptoms. Was admitted to the
ICU initially and then called out to the regular medical wards.
Past Medical History:
1. Hypertension
2. Type II Diabetes Mellitus
3. Hyperlipidemia
4. Osteoarthritis
5. Chronic Vertigo
6. Anxiety
7. Subclinical hypothyroid
8. Bells Palsy
Social History:
Unable to obtain from her at time of presentation
Family History:
Non contributory
Physical Exam:
VS: Temp 98.9, Pulse 85, BP 156/70, RR 16, O2 sat 96% on 2
liters nasal canula
Gen: comfortable, NAD, lying in bed
HEENT: PERRLA, EOMI
Lungs: rhonchi and wheezes throughout
Heart: S1, S2, RRR, no murmurs, rubs, gallops heard
Abd: obese, soft, ND, NT, no HSM, + bowel sounds
Extrem: 2+ edema but improved from before
Neuro: AAO x 3
Pertinent Results:
[**2145-1-20**] 06:15AM BLOOD WBC-7.2 RBC-3.00* Hgb-10.3* Hct-30.4*
MCV-101* MCH-34.2* MCHC-33.8 RDW-15.8* Plt Ct-196
[**2145-1-20**] 06:15AM BLOOD Plt Ct-196
[**2145-1-20**] 06:15AM BLOOD PT-14.0* PTT-35.1* INR(PT)-1.2
[**2145-1-20**] 06:15AM BLOOD Glucose-112* UreaN-32* Creat-0.9 Na-144
K-4.4 Cl-104 HCO3-31* AnGap-13
Brief Hospital Course:
77 yo female with multiple medical problems presents with
junctionla rhythm likely in the setting of hyperkalemia from
acute renal failure all of which have resovled, and patient
currently being treated for pneumonia.
1. Pneumonia - patient has atypical pneumonia and so on
Levofloxacin 500mg po daily. Will need 10 more days of
treatment.
2. Renal - patient had presented with acute renal failure likely
secondary to combination of sepsis and nephrotixic drugs. All of
the nephrotoxic agents were held, and she was given aggresive IV
fluids and her renal function improved, and she was back to her
baseline at the time of discharge. We decided to hold her ACEi
but we started giving her Lasix and she tolerated that well.
Need to continue diuresis.
3. Hypertension - ACEi and HCTZ was stopped in the setting of
acute renal failure; cont with hydralazine and imdur at this
time, and also added Norvasc, her BP appeared stable and back to
her baseline; can titrate medications as needed to keep BP well
controlled.
4. Diabetes - initialy hyperglycemic and so required Insulin gtt
but secondary to infection; sugars better controlled at this
time, and she is on Glyburide 2.5mg po bid. She should have her
fingersticks checked at least 2-3 times a day and covered with
regular insulin as per sliding scale if needed.
5. Heme - patient's HCT remained stable during her stay on the
medical wards. this is her baseline. She was guaic negative.
Medications on Admission:
[**Doctor First Name **] 60mg po bid
Allopurinol 300mg po daily
Lipitor 10mg po daily
Buproprion 100mg po daily
Enalapril 20mg po bid
Glyburide 1.25mg po bid
Lasix 20mg po daily
HCTZ 12.5mg po bid
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Glyburide 1.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Hydralazine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
4. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) puff Inhalation Q12H (every 12 hours).
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
7. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
8. Imdur 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet
Sustained Release 24HR PO once a day.
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-7**]
puff Inhalation every 4-6 hours.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
1. Pneumonia
2. Acute Renal Failure (resolved)
3. Hypertension
4. Type II Diabetes Mellitus
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed.
Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**2-7**] weeks.
Followup Instructions:
Please take all your medications as directed.
Please follow up with your Primary Care Physician [**Last Name (NamePattern4) **] [**2-7**] weeks.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"486",
"5849",
"2767",
"2762",
"4280",
"42789",
"2449",
"25000",
"2724",
"4019"
] |
Admission Date: [**2129-11-9**] Discharge Date: [**2129-11-14**]
Date of Birth: [**2070-7-27**] Sex: M
Service: NEUROLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old
gentleman with a history of a ruptured aneurysm and
subarachnoid hemorrhage from [**2129-5-7**]. He is status post a
coiling of the basilar tip aneurysm at that time, and then
coiling with stenting on [**2129-9-7**], and then coiling of the
aneurysm neck on [**2129-10-7**]. The patient had an episode of
headache, diplopia and hemiplegia on the right side this
morning, on the morning of admission, and was transferred
from an outside hospital to [**Hospital6 2018**] for further management. He had left pupil dilation
and deviation on the left side at the outside hospital. It is
unclear whether seizure activity was witnessed.
PHYSICAL EXAM: On his arrival to [**Hospital3 **] [**Hospital **]
[**First Name (Titles) **] [**Last Name (Titles) **], his temp was 98.6, pulse 78, BP 110/59. He
was awake, alert and oriented x 3. His speech was fluent.
His cranial nerve exam was intact. His pupils were 3 down to
2 on the left, and 2.5 to trace reactive on the right. His
EOMS were full. His visual fields were full to
confrontation. He could count fingers at 8'. He did
complain of blurry vision at far distance subjectively. Face
was symmetric. No drift. Grasps were [**5-9**]. His motor
strength was [**5-9**] in all muscle groups. Sensation was intact.
He had an MRI/MRA that was unremarkable, that showed good
flow through the vertebral basilar system.
HOSPITAL COURSE: He was admitted to the ICU for neurologic
observation. He underwent an angio on [**2129-11-10**] which
showed no evidence of stent thrombus, or slow flow, or
stenosis, and the coil mesh was in place. The patient
continued on Plavix and aspirin and heparin. The heparin was
DC'd on [**2129-11-11**]. The sheath was removed. The patient was
out-of-bed ambulating, tolerating a regular diet. He was
seen by the neurology stroke service for this TIA episode.
They recommended getting an echocardiogram, continuing Plavix
and aspirin, and hold BP meds to avoid hypotension. The
transthoracic echo was done this morning. The patient is
being discharged to home on [**2129-11-14**] with follow-up with
Dr. [**Last Name (STitle) 1132**] in 2 weeks.
CONDITION AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Hydrochlorothiazide 25 mg po qd.
2. Pantoprazole 40 mg po qd.
3. Aspirin 325 po qd.
4. Plavix 75 mg po qd.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2129-11-14**] 10:16
T: [**2129-11-14**] 10:31
JOB#: [**Job Number 48650**]
|
[
"4019"
] |
Admission Date: [**2134-7-25**] Discharge Date: [**2134-7-28**]
Date of Birth: [**2078-11-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 1399**] is a 55 year old male with nonocclusive right femoral
and popliteal DVT, obstructive sleep apnea and obesity who was
doing well until two days ago. He reports waking up with left
groin pain. He went for lunch and then noticed acute onset of
shortness of breath with minimal exertion leading him to present
to [**First Name8 (NamePattern2) 1495**] [**Hospital 122**] Hospital.
At OSH ED, his inital vitals were 134/83 107 95%3LNC and
breathing 24-26. Due to creatinine of 1.6, he got a V/Q scan to
evaluate for pulmonary embolism which showed high probability
for pulmonary embolism. LENIS showed DVT. CTA confirmed saddle
pulmonary embolism. He was given fundoparinaux 10 mg and
transferred to ICU. TTE showed right ventricular strain with
paradoxic motion of the septum, right ventricular dilatation
ands severe pulmonary hypertension. He was offered TPA vs OSH
transfer for thrombectomy. He opted for OSH transfer for
thrombectomy and thus [**Hospital1 18**] ICU transfer.
At [**Hospital1 18**] MICU, he reports 20% improvement in his shortness of
breath at rest though no chest pain or dizziness.
Past Medical History:
Multiple right lower extremity DVTs approximately two years ago.
He was treated with Coumadin for six months and has been off of
the Coumadin for over a year. He saw a hematologist who could
not find any cause for the multiple DVTs. Hypercoagulable workup
did not reveal any causes
High triglycerides
Obstructive sleep apnea, uses CPAP at home
Obesity
Past Surgical History
Bilateral knee surgery for torn meniscus three years ago
Ruptured appendix s/p emergent lapraroscpic appendectomy
Social History:
Occupation: He is a safety director.
Tobacco: never
Alcohol: None
Recreational Drugs: None
Family History:
Significant for coronary artery disease or
myocardial infarction. He denies a family history of blood
clots or bleeding disorders.
Physical Exam:
Admission Exam
76 114/72 96% 2LNC
General: The patient is a middle-aged obese male, in no acute
distress.
Neuro: Alert and oriented x3, pleasant, and cooperative.
HEENT: Head is atraumatic and normocephalic. Trachea is
midline. Neck: Supple. No carotid bruits noted.
Lungs: Increase work of breathing. Clear to auscultation
bilaterally.
Heart: Regular rate and rhythm. S3 present.
Abdomen: Soft, obese, and nontender. No masses noted. He has
an umbilical hernia.
Extremities: He has [**1-29**]+ right lower extremity edema. 2+ left
lower extremity edema. He has a palpable posterior tibial pulse
bilaterally.
Discharge Exam
VS 98-98.3 66-75 136/91-98 18 96%RA
GEN Alert, oriented, no acute distress, breathing comfortably
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, 2+ pitting edema b/l
R>L. No calf tenderness.
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Admission Labs
[**2134-7-25**] 07:15PM BLOOD WBC-8.0# RBC-4.70 Hgb-13.7* Hct-41.8
MCV-89 MCH-29.2 MCHC-32.8 RDW-14.0 Plt Ct-137*
[**2134-7-25**] 07:15PM BLOOD Neuts-71.9* Lymphs-22.0 Monos-4.4 Eos-1.3
Baso-0.5
[**2134-7-25**] 07:15PM BLOOD PT-11.6 PTT-30.4 INR(PT)-1.1
[**2134-7-25**] 07:15PM BLOOD Glucose-114* UreaN-15 Creat-1.1 Na-139
K-4.3 Cl-106 HCO3-25 AnGap-12
[**2134-7-25**] 07:15PM BLOOD ALT-39 AST-27 LD(LDH)-238 AlkPhos-71
TotBili-0.3
[**2134-7-25**] 07:15PM BLOOD cTropnT-0.04* proBNP-[**2031**]*
[**2134-7-25**] 07:15PM BLOOD Albumin-3.9 Calcium-8.9 Phos-2.3* Mg-2.0
[**2134-7-25**] 08:30PM BLOOD D-Dimer-2609*
[**2134-7-28**] 06:00AM BLOOD WBC-6.2 RBC-4.80 Hgb-13.8* Hct-41.9
MCV-87 MCH-28.8 MCHC-33.0 RDW-13.8 Plt Ct-151
[**2134-7-25**] 07:15PM BLOOD Neuts-71.9* Lymphs-22.0 Monos-4.4 Eos-1.3
Baso-0.5
[**2134-7-28**] 06:00AM BLOOD Plt Ct-151
[**2134-7-28**] 06:00AM BLOOD PT-13.4* PTT-39.6* INR(PT)-1.2*
[**2134-7-27**] 04:45PM BLOOD PT-12.3 PTT-37.4* INR(PT)-1.1
[**2134-7-27**] 06:10AM BLOOD PT-11.9 PTT-37.4* INR(PT)-1.1
[**2134-7-26**] 02:51PM BLOOD PT-12.1 PTT-73.3* INR(PT)-1.1
[**2134-7-27**] 06:10AM BLOOD Glucose-110* UreaN-11 Creat-0.9 Na-139
K-4.3 Cl-104 HCO3-27 AnGap-12
[**2134-7-26**] 02:09AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
[**2134-7-25**] 08:30PM BLOOD D-Dimer-2609*
TTE [**2134-7-26**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is at least 15 mmHg. 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. The right ventricular
cavity is mildly dilated with severe global free wall
hypokinesis. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. The
descending thoracic aorta is mildly dilated. A 1cm mobile
echogenic mass is seen at the pulmonary artery bifurctation
(clip [**Clip Number (Radiology) **]) c/w possible saddle embolus. 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 severe pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Suboptimal image quality. Right ventricular cavity
size with free wall hyopkinesis and severe pulmonary artery
systolic hypertension. Possible saddle embolus.
Brief Hospital Course:
# Pulmonary embolism: He has known history of hypercoagulable
state. LENIS at OSH revealed DVT. CTA and V/Q at OSH showed
saddle pulmonary embolism with right heart strain on TTE.
Troponin I elevated at 0.1. Pt transferred to [**Hospital1 18**] for possible
thrombectomy, but remained hemodynamically stable to procedure
not indicated.
Initially on IV heparin transitioned to Lovenox and Coumadin
given hemodynamic stability. INR rose slightly to 1.2 during
admission, but pt was not yet therapeutic, so lovenox continued.
Pt was discharged home on both medications with close PCP
[**Name9 (PRE) 702**] and instructions to have repeat INR drawn in two days.
Plan is to continue lovenox for five days AND until coumadin is
therapeutic for at least 24 hours (goal 2.0-3.0). Patient should
have repeat TTE next week to reassess RH function.
# HLD: Chronic, stable. Continued Tricor. Aspirin d/c'ed while
on coumadin/lovenox.
TRANSITIONAL ISSUES:
# Health maintenance: Given unexplained hypercoaguability,
patient should have age-appropriate cancer screening
(colonoscopy, PSA if PCP [**Name Initial (PRE) 103795**]).
# Incidental lung nodule: PCP should arrange [**Name9 (PRE) 702**].
Medications on Admission:
1. Aspirin 325 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Tricor 48 mg po qdaily
Discharge Medications:
1. Enoxaparin Sodium 150 mg SC Q12H
RX *enoxaparin 150 mg/mL q12hrs Disp #*10 Syringe Refills:*0
2. Warfarin 7.5 mg PO DAILY16
RX *warfarin 7.5 mg 1 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. Outpatient Lab Work
Draw PT/INR
ICD 415.19 (Acute pulmonary embolism)
Fax results to [**Telephone/Fax (1) 103796**] Attn: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**]
5. Tricor *NF* (fenofibrate nanocrystallized) 145 mg Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary Embolism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 1399**],
You were transferred to our hospital for treatment of your
pulmonary embolus (blood clot in your lungs). We treated you
with heparin to ensure that your clot did not expand and with
oxygen to help you breath more comfortably. When your breathing
improved, we changed your IV heparin to injections of enoxaparin
(low molecular weight heparin). We also started you on coumadin
tablets. We have been checking your INR, which is a blood test
used to make sure that you are getting the correct dose of
coumadin. Your goal INR value is between 2.0 and 3.0. You will
have to have your INR checked regularly and your coumadin dose
adjusted to make sure your INR stays between 2.0 and 3.0. Your
last INR was 1.2. You will have to continue taking enoxaparin
(Lovenox) until your INR is above 2.0.
Please have your blood drawn tomorrow ([**2134-7-29**]) to check your
INR.
We have made the following changes to your medications:
1. enoxaparin (Lovenox) - we have added this medication
2. coumadin - we have added this medication
3. Aspirin - we have stopped this medication
We have scheduled a follow-up appointment with your primary care
physician. [**Name10 (NameIs) **] you cannot keep this appointment, please call to
reschedule.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] R
Address: 382 DW HWY, [**Location (un) **],[**Numeric Identifier 83818**]
Phone: [**Telephone/Fax (1) 103797**]
Date/Time: Wednesday, [**2134-8-4**] 12:15pm
|
[
"4168",
"2875",
"32723",
"2724"
] |
Admission Date: [**2165-4-13**] Discharge Date: [**2165-4-18**]
Date of Birth: [**2117-2-25**] Sex: F
Service: TRANSPLANT SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 40 year old
female known to transplant service, who has been evaluated
prior for a kidney transplant, who presented to the [**Hospital1 1444**] Emergency Department with
acute onset of left lower quadrant pain. The patient said
the pain began at around 9:00 p.m. the night of admission and
included nausea and vomiting. The patient denies any fever,
chills, melena, bright red blood per rectum, shortness of
breath or chest pain. She had her last hemodialysis on
Friday.
On review of systems, she does report having a history of
constipation and takes soft softeners at baseline.
PAST MEDICAL HISTORY:
1. End stage renal disease.
2. Diabetes mellitus.
3. Coronary artery disease.
4. Cerebrovascular accident.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft in [**2158**].
2. Bilateral femoral popliteal bypass graft.
3. Status post cesarean section times two.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg p.o. q.o.d.
2. Dilantin 300 mg p.o. q.h.s.
3. Celexa 10 mg p.o. q.h.s.
4. Remeron 45 mg q.h.s.
5. Wellbutrin 200 mg p.o. twice a day.
6. Pamelor 70 mg p.o. once daily.
7. Levoxyl 0.2 mg p.o. once daily.
8. Reglan 10 mg p.o. twice a day.
9. Allopurinol 100 mg p.o. once daily.
10. Nephrocaps once daily.
11. Epogen 5000 units subcutaneous q.Monday, Wednesday and
Friday.
12. Prevacid 50 mg p.o. once daily.
13. Klonopin 4 mg p.o. q.p.m.
14. Insulin pump.
15. Aspirin.
ALLERGIES: Penicillin, shellfish and gadolinium.
SOCIAL HISTORY: The patient denies ETOH use, quit tobacco
several years ago and lives at home.
PHYSICAL EXAMINATION: On admission, examination revealed a
temperature of 98.3, heart rate 62 and blood pressure 134/54.
She appeared comfortable in no acute distress. Chest was
clear bilaterally. The heart was regular. The abdomen was
soft, with tenderness in the left lower quadrant, with a
palpable mass, no rebound or guarding. Rectal was guaiac
negative with stool in the vault. There was palpation of the
posterior tibial bilaterally and the dorsalis pedis only on
the right side. There was a skin graft which showed a
positive thrill.
LABORATORY DATA: On admission, white blood cell count was
9.2, hematocrit 36.0. Potassium 5.0, blood urea nitrogen 30
and creatinine 4.6. INR 1.1. All other laboratories were
within normal limits.
CT of the abdomen demonstrated a complete small bowel
obstruction with an abnormal segment in the distal jejunum
which was consistent with closed loop obstruction.
Electrocardiogram on admission showed normal sinus rhythm, no
ischemic changes.
HOSPITAL COURSE: The patient was immediately taken to the
operating room. Prior to going to surgery, the patient had a
pulmonary artery catheter placed which immediately
demonstrated adequate cardiac output and index and good
intravascular volume resuscitation. After hemodynamics were
established and found to be adequate, she was taken to the
operating room where exploratory laparotomy was performed and
lysis of adhesions was performed on a band which had caused a
closed loop obstruction. After the completion of the lysis
of adhesions, all the bowel was found to be viable and the
patient was closed and taken to the Post Anesthesia Care Unit
in stable condition. The details of the surgery are found in
the operative note.
Postoperatively, the patient remained in stable condition
with good hemodynamics from the pulmonary artery catheter.
Electrocardiogram showed no changes. The patient was ruled
out with cardiac enzymes times three. She then spent the
night in the Post Anesthesia Care Unit and postoperative day
number one her pulmonary artery catheter was changed to a
central venous line and she was transferred to the floor for
continuation of her care. Postoperative day number two, the
patient remained afebrile and reported flatus and her
nasogastric tube was discontinued. During her postoperative
course, she was followed by [**Hospital **] Clinic for her diabetes
mellitus for which she was on insulin pump and her insulin
was kept in good control. She was also followed by the renal
fellow and she continued on her hemodialysis as an inpatient
without incident. On postoperative day number three, she was
started on some clears, had minimal nausea and was continued
on hemodialysis. On postoperative day number four, the
patient was advanced. Nausea had subsided. On postoperative
day number five, the patient reported bowel movement,
tolerating diet, ambulating and is now ready for discharge.
The patient was seen by [**Last Name (un) **] and renal and will follow-up
with them as appropriate.
DISCHARGE DIAGNOSES:
1. Status post exploratory laparotomy, lysis of adhesions
for complete small bowel obstruction.
2. Diabetes mellitus.
3. End stage renal disease on hemodialysis.
4. Coronary artery disease.
5. History of cerebrovascular accident.
MEDICATIONS ON DISCHARGE:
1. Reglan 10 mg p.o. twice a day.
2. Nortriptyline 70 mg p.o. q.h.s.
3. Bupropion 200 mg p.o. twice a day.
4. Clonazepam 2 mg p.o. once daily.
5. Protonix 40 mg p.o. once daily.
6. Allopurinol 100 mg p.o. once daily.
7. Mirtazapine 45 mg p.o. q.h.s.
8. Synthroid 200 mcg p.o. once daily.
9. Phenytoin 100 mg p.o. three times a day.
10. Atenolol 25 mg p.o. once daily.
11. Percocet one to two p.o. q4hours p.r.n.
12. Aspirin 81 mg p.o. once daily.
13. Insulin pump [**First Name8 (NamePattern2) **] [**Hospital **] Clinic.
14. Colace 100 mg p.o. once daily.
15. Senna p.r.n.
FOLLOW-UP: The patient will follow-up with Dr. [**First Name (STitle) **] next
week in clinic and will call for an appointment. The patient
will follow-up with the renal team and [**Hospital **] Clinic as
appropriate and will call them also in the morning for
follow-up appointments. The patient of note was going to
have a coronary angiography to evaluate for coronary artery
disease. She will call Dr. [**Last Name (STitle) **] and arrange for an
angiography at a future date after her follow-up appointment
with Dr. [**First Name (STitle) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2165-4-18**] 16:10
T: [**2165-4-21**] 11:02
JOB#: [**Job Number 106987**]
|
[
"41401",
"V4581"
] |
Admission Date: [**2182-4-1**] Discharge Date: [**2182-4-7**]
Date of Birth: [**2118-1-10**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: Mr. [**Name14 (STitle) 19523**] is a 64-year-old
male who had been experiencing substernal chest pain starting
early in [**2181-11-30**]. The pain was constant and
increased with cold exposure and with exertion. Pain
decreased back to baseline with rest. In [**Month (only) 404**], the
patient's episodes began to increase and the patient said
that he felt some baseline burning, similar to indigestion.
The patient underwent a stress test on [**2182-3-18**]
which showed equivocal EKG changes, moderate to severe
reversible perfusion defect involving mid to distal LAD
associated with hypokinesis of the anterior and left
ventricular wall with an ejection fraction of 59%.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Verapamil 360 q.p.m.
3. Zocor 80 q.p.m.
4. Atenolol 50 q.d.
ADMISSION LABORATORY DATA: White count 5.9, hematocrit 38.6,
platelets 266,000. The electrolytes were within normal
limits. The INR was 1.0.
HOSPITAL COURSE: The patient underwent cardiac
catheterization with LIMA to LAD showing a tight LMCA, 70%
LAD, 50% mid RCA, EF 60%.
The patient underwent CABG times three on [**2182-4-2**]. The
patient tolerated the procedure well. The patient had an
uncomplicated hospital course. By postoperative day number
five, the patient was able to tolerate a regular diet. The
patient had good p.o. pain control and was able to ambulate
to a level V for physical therapy.
The patient is to be discharged to home.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg b.i.d.
2. Ibuprofen 400 mg q. eight hours.
3. Tylenol 325-650 mg q. 4-6 hours p.r.n.
4. Aspirin 325 mg q.d.
5. Percocet one to two tablets q. 4-6 hours p.r.n.
6. Colace 100 mg b.i.d.
7. Lopressor 25 mg b.i.d.
FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) **] in
four weeks time and Dr. [**Last Name (STitle) **] and Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], his
primary care provider, [**Name10 (NameIs) **] one to two weeks.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
graft times three.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2182-4-6**] 06:55
T: [**2182-4-6**] 19:07
JOB#: [**Job Number 19524**]
cc:[**Last Name (NamePattern1) 19525**]
|
[
"41401",
"4240",
"2720",
"4019"
] |
Admission Date: [**2112-4-5**] Discharge Date: [**2112-4-15**]
Service: Neurosurgery
The patient is awaiting discharge at the time of this
dictation.
HISTORY OF PRESENT ILLNESS: This is an 89 year old white
female with a history of long-standing Alzheimer's dementia,
hypertension, and a history of recent falls who is now
admitted with a subdural hematoma. She recently fell on the
[**1-23**] and was found to have a left sided subdural at
that time, however, no treatment was offered. She next had a
seizure on [**3-26**], and CT scan showed no change, and she was
begun on Dilantin at that time and discharged to a
rehabilitation facility.
On the day of admission, the [**4-5**], she was noticed to
be lethargic with nausea and vomiting and was taken to an
outside hospital where a CT scan showed increased size of the
subdural hematoma with a new acute component and she was
therefore transferred to the [**Hospital1 188**].
PREVIOUS MEDICAL HISTORY:
1. Dementia, of Alzheimer's type.
2. History of hypertension.
3. History of hypothyroidism.
4. History of bipolar disease.
CURRENT MEDICATIONS:
1. Darvon.
2. Dilantin.
3. Celexa.
4. Bactrim.
5. Levoxyl.
6. Dulcolax.
7. Valproic acid.
PHYSICAL EXAMINATION: Her vital signs at the time of
admission are temperature of 98.8 F.; blood pressure 141/79;
heart rate 76; respiratory rate 18; O2 saturation 99%. She
was disoriented and only followed very basic commands and was
aphasic. Her Head, Eyes, Ears, Nose and Throat were
unremarkable. Pupils were 3 mm to 2 mm with light reactivity
bilaterally. The neck was supple with a positive 3 cm lymph
node on the left neck. The chest was clear to percussion and
auscultation. Heart rate was regular and rhythmic.
Abdominal examination was unremarkable. Extremities were
warm with no edema. She showed some spontaneous purposeful
movements of the extremities and squeezed her hand on
command.
ADMISSION LABORATORY STUDIES: Showed a white blood cell
count of 10.7, hematocrit of 35; platelet count 469. A PT of
12.6, PTT 22.9, INR 1.1. Chem-7 within normal limits.
Urinalysis showed white blood cells six to 10 per high
powered field with rare bacteria and less than one epithelial
cell. Dilantin level was 12. Valproic acid level was 18.
HOSPITAL COURSE: A CT scan showed the left sided subdural
hematoma with acute component and the patient therefore was
admitted to the Neurosurgical Intensive Care Unit where a
beside bur-hole drainage of the left sided subdural hematoma
was performed at the time of admission.
The patient tolerated the procedure well and remained in the
Neurosurgery Intensive Care Unit and following the drainage
she showed the ability to converse in short phrases with
frequent paraphrasic errors and perseveration. She was
oriented to name only and the examination was limited
secondary to pain; the right arm was weak and the left arm
moved spontaneously. She wiggled her toes bilaterally, but
otherwise showed only minimal improvement.
Due to the clinical findings, a repeat CT scan was taken
which showed no significant improvement in the size or
consistency of the subdural hematoma and she was therefore
taken to the Operating Room on the [**2112-4-7**], where
under general endotracheal anesthetic, the patient underwent
a left frontal craniotomy with evacuation of the subdural
hematoma. This was performed by Dr. [**Last Name (STitle) 6910**]. The patient
tolerated this procedure well and was returned to the
Neurosurgical Intensive Care Unit.
However, her neurologic examination remained somewhat
limited. She was arousable to voice and responded to pain
and moved all extremities, but her neurologic examination did
not improve markedly from that status throughout the
remainder of her hospitalization.
On the 23rd and [**4-15**], discussions were held with the
family between Dr. [**Last Name (STitle) 6910**] and primarily Mr. [**First Name8 (NamePattern2) 892**] [**Known lastname 107272**],
the patient's son, and after Mr. [**Known lastname 107272**] [**Last Name (Titles) 107273**] with his
siblings, a decision was made to place the patient on comfort
measures only and discontinue the NG tube, and allow the
patient to be kept comfortable only.
At the time of dictation of this summary, the patient is now
on comfort measures only and there will be an addendum
dictated at a later date.
[**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**]
Dictated By:[**Doctor Last Name 7311**]
MEDQUIST36
D: [**2112-4-15**] 13:13
T: [**2112-4-18**] 13:12
JOB#: [**Job Number **]
|
[
"5990",
"2449",
"4019"
] |
Admission Date: [**2113-1-15**] [**Month/Day/Year **] Date: [**2113-1-30**]
Date of Birth: [**2049-3-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62M with extensive medical history including recurrent strokes,
aspiration pna, recent hospitalization for pneumonia requiring
ICU care ([**11/2112**]) discharged from rehabilitation this past
[**Year (4 digits) 2974**] presenting with acute onset of inability to talk,
left-sided weakness per EMS and vomiting x 1. Patient has
residual deficits on the left side including face, arm and leg,
unclear how this is different than his baseline. Pt's baseline
MS confirmed with family and stroke was ruled out. Also notes
small amount of bleeding from his penis since rehab. Admitted
from home with complaint of recent vomiting. Family that since
rehab pt is failing and decided he needed evaluation today.
.
ED Course notable for code stroke called on arrival. EKG noted
to be nSR 79, NA, T wave inversions 2,3,avf, v3-v6 , no STEMI.
Chest x-ray: no pna, ptx, w mild effusions. FS on arrival 133.
Covered with vancomycin and zosyn for presumed pna. Also given
duoneb for wheezing. INR (1.2) was subtherapeutic and pt was
placed on Heparin gtt @ 900u/hr @12:30pm. Pt does not make urine
so no foley placed. Pt is tremulous at baseline with hx of
seizure d/o. Labs notable for creat 9.7, anion gap 26, WBC 10
(differential not checked), lactate 2.7, plts 96, serum tox
negative. Cardiac enzymes showed trop 0.05 and mb 2. CT head was
negative for hemorrhage and showed chronic b/l MCA territory
infarcts. VS prior to transfer:97.6 89 177/80 22 95%/RA. Stroke
team recs included treating with home AED (administered keppra
and lacosamide at 1500), no EEG needed as he has generalized
convulsions, treat seizure activity > 3 min with PRN ativan [**1-23**]
mg. Neuro confirmed MS baseline: dysarthric, minimal verbal
output. Access 20g x 2 with dialysis cath.
.
Transfer to the floor was delayed by fever spike to 102
(received tylenol) and tachycardia to HR 130s. HR decreased to
104 and BP 110/57 on transfer.
.
On the floor, he reports feeling better than in the ED. Does
have chills. Denies pain at dialysis catheter site, fever at
home, diarrhea, nausea or pain.
.
Review of systems: Unable to obtain full ROS given neurological
impairment.
(+) Per HPI
- ESRD on HD (M/W/F at [**Location (un) **])
- h/o multiple prior CVAs - per last dc summary ambulates at
home, has residual left-sided weakness
- Seizure disorder
- Chronic hepatitis B
- Chronic aspiration with failed speech and swallow eval -
family wants him to continue eating despite risks
- HTN
- CAD
- h/o MSSA bacteremia after manipulation of fistula
- hospitalization in [**12-31**] for incarcerated inguinal hernia
complicated by ESBL Klebsiella bacteremia and PNA
- Hyperlipidemia
- GERD
- S/p SBO [**2109**]
- Hernia repair
- Hypoglycemia
Past Medical History:
- ESRD on HD (M/W/F at [**Location (un) **])
- h/o multiple prior CVAs - per last dc summary ambulates at
home, has residual left-sided weakness
- Seizure disorder
- Chronic hepatitis B
- Chronic aspiration with failed speech and swallow eval -
family wants him to continue eating despite risks
- HTN
- CAD
- h/o MSSA bacteremia after manipulation of fistula
- hospitalization in [**12-31**] for incarcerated inguinal hernia
complicated by ESBL Klebsiella bacteremia and PNA
- Hyperlipidemia
- GERD
- S/p SBO [**2109**]
- Hernia repair
- Hypoglycemia
Social History:
Patient lives in [**Location **] with his daughter, [**Name2 (NI) **], who is
a former [**Hospital1 18**] employee. He denies any recent use of alcohol,
tobacco, illicit drugs, or herbal medications. He has a distant,
but considerable smoking history per his daughter. [**Name (NI) **] uses
the toilet himself, but needs help cleaning himself, and does
not cook or manage his finances. He is at HD on MWF and spends
TU and [**Doctor First Name **] in an adult day program. His daughter does not leave
him alone by himself.
Family History:
Mother died at 45 with hypertension. Father died at 60 of
unknown causes. He has eight living siblings, many of whom have
hypertension. He has six children who are all healthy.
Physical Exam:
Admission Physical Exam:
Vitals: T: 101.7 PO 105/62 96 18 96%/2L NC
General: non-toxic appearing, no acute distress, attentive
[**Doctor First Name 4459**]: NC/AT, MMM.
Neck: reduced ROM to passive movement, no carotid bruit.
Pulmonary: B/L Crackles auscultated.
Cardiac: S1,S2 distant sounds.
Abdomen: soft, distended, hypoactive bowel sounds.
Extremities: No edema, left ankle contracture.
Skin: no rashes or lesions noted. dry skin.
GU: uncircumcised, retraction of foreskin reveal small amount of
dark clotted blood, no active bleeding or drainage, no ulcers or
skin breakdown, area is nontender
Neuro: AOX2, able to give me his first name, place of birth
([**Country **]), unable to relay date. Exhibited delayed reaction to
commands and verbal responses.
Pertinent Results:
[**2113-1-15**] 11:00AM BLOOD WBC-10.2 RBC-4.22* Hgb-12.7* Hct-40.8
MCV-97 MCH-30.2 MCHC-31.2 RDW-17.4* Plt Ct-96*
[**2113-1-16**] 04:13AM BLOOD WBC-12.8* RBC-3.29* Hgb-10.0* Hct-31.2*
MCV-95 MCH-30.3 MCHC-32.0 RDW-17.2* Plt Ct-92*
[**2113-1-18**] 07:30AM BLOOD WBC-7.4 RBC-3.22* Hgb-9.6* Hct-30.3*
MCV-94 MCH-29.9 MCHC-31.9 RDW-16.6* Plt Ct-119*
[**2113-1-18**] 06:30AM BLOOD WBC-7.3 RBC-3.14* Hgb-9.5* Hct-29.4*
MCV-94 MCH-30.1 MCHC-32.2 RDW-16.7* Plt Ct-119*
[**2113-1-17**] 03:35AM BLOOD WBC-5.4# RBC-3.59* Hgb-10.8* Hct-33.5*
MCV-93 MCH-30.0 MCHC-32.1 RDW-17.0* Plt Ct-97*
[**2113-1-16**] 04:13AM BLOOD WBC-12.8* RBC-3.29* Hgb-10.0* Hct-31.2*
MCV-95 MCH-30.3 MCHC-32.0 RDW-17.2* Plt Ct-92*
[**2113-1-15**] 11:00AM BLOOD WBC-10.2 RBC-4.22* Hgb-12.7* Hct-40.8
MCV-97 MCH-30.2 MCHC-31.2 RDW-17.4* Plt Ct-96*
[**2113-1-15**] 11:00AM BLOOD Neuts-86* Bands-0 Lymphs-9* Monos-3 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2113-1-18**] 06:30AM BLOOD PT-18.2* PTT-57.5* INR(PT)-1.7*
[**2113-1-15**] 11:00AM BLOOD PT-12.9* PTT-35.2 INR(PT)-1.2*
[**2113-1-18**] 07:30AM BLOOD Glucose-67* UreaN-39* Creat-7.9* Na-142
K-4.2 Cl-95* HCO3-34* AnGap-17
[**2113-1-18**] 06:30AM BLOOD Glucose-63* UreaN-41* Creat-7.9*# Na-139
K-4.2 Cl-94* HCO3-33* AnGap-16
[**2113-1-17**] 03:35AM BLOOD Glucose-106* UreaN-23* Creat-6.0*# Na-139
K-3.9 Cl-91* HCO3-33* AnGap-19
[**2113-1-16**] 04:13AM BLOOD Glucose-77 UreaN-41* Creat-9.5* Na-135
K-6.5* Cl-100 HCO3-22 AnGap-20
[**2113-1-15**] 10:43AM BLOOD Creat-9.7*
[**2113-1-16**] 12:45PM BLOOD ALT-15 AST-22 AlkPhos-113 TotBili-0.4
[**2113-1-16**] 04:13AM BLOOD ALT-15 AST-19 CK(CPK)-58 AlkPhos-105
TotBili-0.3
[**2113-1-15**] 11:00AM BLOOD ALT-14 AST-38 AlkPhos-168* TotBili-0.3
[**2113-1-15**] 11:00AM BLOOD Lipase-69*
[**2113-1-16**] 04:13AM BLOOD CK-MB-2 cTropnT-0.05*
[**2113-1-15**] 11:00AM BLOOD CK-MB-2 cTropnT-0.05*
[**2113-1-18**] 07:30AM BLOOD Calcium-8.8 Phos-5.0* Mg-2.2
[**2113-1-18**] 06:30AM BLOOD Calcium-8.6 Phos-5.3* Mg-2.1
[**2113-1-17**] 03:35AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.5*
[**2113-1-16**] 04:13AM BLOOD Calcium-8.4 Phos-3.5# Mg-1.8
[**2113-1-18**] 06:36AM BLOOD Vanco-16.1
[**2113-1-18**] 06:30AM BLOOD Vanco-14.7
[**2113-1-16**] 04:13AM BLOOD Vanco-18.1
[**2113-1-18**] 07:38AM BLOOD Lactate-1.0
[**2113-1-16**] 04:24AM BLOOD Lactate-1.8
[**2113-1-15**] 10:31PM BLOOD Lactate-2.8*
[**2113-1-15**] 10:44AM BLOOD Glucose-137* Lactate-2.7* Na-139 K-5.4*
Cl-95* calHCO3-21
C-PEPTIDE
Test Result Reference
Range/Units
C-PEPTIDE 8.23 H 0.80-3.10
ng/mL
INSULIN
Test Result Reference
Range/Units
INSULIN 6 <17 uIU/mL
Insulin analogues may demonstrate non-linear
cross-reactivity in this assay. Interpret results
accordingly.
BETA-HYDROXYBUTYRATE
Test Name Flag Results Units
Reference Value
--------- ---- ------- -----
---------------
Beta-Hydroxybutyrate, s 0.1 mmol/L
<0.4
[**Month/Day/Year 894**] LABS:
[**2113-1-30**] 07:00AM BLOOD WBC-4.8 RBC-3.43* Hgb-10.4* Hct-32.7*
MCV-95 MCH-30.4 MCHC-31.9 RDW-18.5* Plt Ct-155
[**2113-1-30**] 07:00AM BLOOD PT-27.5* PTT-143.8* INR(PT)-2.6*
[**2113-1-30**] 07:00AM BLOOD Glucose-72 UreaN-34* Creat-8.8* Na-135
K-4.9 Cl-91* HCO3-32 AnGap-17
MICRO (FINAL = NEGATIVE FOR GROWTH)
ALL CULTURES NEGATIVE
[**2113-1-18**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2113-1-18**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2113-1-18**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2113-1-17**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2113-1-16**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2113-1-16**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2113-1-16**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2113-1-15**] BLOOD CULTURE Blood Culture,
Routine-FINAL EMERGENCY [**Hospital1 **]
[**2113-1-15**] BLOOD CULTURE Blood Culture,
Routine-FINAL EMERGENCY [**Hospital1 **]
IMAGING
Chest xray [**1-16**] FINDINGS: Dialysis catheter over the left
internal jugular vein, the tip
projects over the right atrium.
No evidence of pneumonia. Mild interstitial fluid overload. No
pleural
effusions. Borderline size of the cardiac silhouette. Old right
clavicular
fracture. No pneumothorax.
CT head [**1-16**] Unchanged encephalomalacic changes from bilateral
right MCA territory infarct.
No evidence of new acute infarct.
KUB [**1-17**]
FINDINGS: Suboptimal positioning, please note diaphragms and
inferior pelvis and part of the right abdomen not included in
the radiograph. There are markedly distended loops of bowel
measuring up to 6.5 cm concerning for small-bowel obstruction.
Evaluation for free air is suboptimal.
IMPRESSION: Small-bowel obstruction.
KUB Study Date of [**2113-1-20**] 4:34 PM
IMPRESSION: Non-obstructive bowel gas pattern.
RUE duplex [**1-18**]
IMPRESSION:
1. Patent left-sided upper extremity vasculature.
2. Nonocclusive thrombus of the right internal jugular vein, and
occlusive
thrombus of the right axillary vein, right cephalic vein, one of
the right
brachial veins, and the right AV fistula.
KUB [**1-19**]
Wet Read: SJBj [**Month/Year (2) **] [**2113-1-17**] 10:11 PM
Dilated small bowel loop up to 5.5cm. Degree of distention has
improved since yesterday. Air in rectum indicates likely partial
obstruction. No
pneumoperitoneum.
Brief Hospital Course:
Mr. [**Known lastname **] is a 63 year-old man with a PMH notable for ESRD on HD
(MWF), chronic aspiration, seizure disorder, history of CVA with
residual left-sided weakness and dysarthria, who presented to
the ED with AMS and dehydration.
ACTIVE ISSUES
# Aspiration Pneumonia: Pt required transfer to the MICU from
[**1-17**] - [**1-18**] for management of aspiration. Pt was noted to be
in respiratory distress and hypoxia but did not require
intubation. Pt has a documented history of chronic aspiration
likely secondary to his CVA, and has been evaluated by speech
and swallow multiple times in the past with increased risk for
aspiration. Family in the past had insisted on continued
feeding, regardless of aspiration risk with preference for
quality of life to be considered to be the number one priority
by the family. Also hx of mucus plugging responsive to chest PT
and suction.
He was treated with vancomycin and zosyn initially for his
febrile illness but this was switched to vancomycin and
meropenem given concern for zosyn related rash on his abdomen.
When the rash worsened, he was switched to ceftaz and completed
an 8 day course with Vanc and Ceftaz given QHD which ended on
[**2113-1-23**]. The patient had no further aspiration events.
#) Chronic aspiration: Palliative care and ethics was consulted
to assist in facilitating the discussion about code status and
chronic aspiration. Ethics was consulted because of concerns
that the HCP may not be able to effectively make decisions as
the HCP. This discussion resulted in the family keeping the
patient full code knowing full-well the high aspiration risk the
patient poses by continuing to eat. They are aware of this high
risk and deferred other nutrition options. The patient's HCP
[**Name2 (NI) **] expressed a philosophical agreement with DNR/DNI but
could not come to decide to change his code status from Full
Code to DNR/DNI. After discussion with the patient's PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], the decision was made to respect the family's wishes and
to continue to remind the family that the patient's code status
will routinely be brought up at future hospitalizations as a
part of hospital policy. Support was also provided to the
family.
# SBO: Pt developed vomiting and aspiration symptoms on [**1-17**]
and a KUB showed small bowel obstruction, most likely [**2-23**] to an
adhesion. His NGT was placed to suction. He was kept NPO. He
denied persistent nausea, abd pain or distension. Repeat KUB on
[**1-21**] suggested resolution of the SBO and he tolerated his diet
without any further obstructive symtptoms.
# Hypoglycemia: Patient presented with hypoglycemia of unknown
etiology. The hypoglyemia would appear only when he was NPO
despite normal liver function and no administration of insulin.
He had an extensive work up for this last admission [**12-3**]
without clear etiology. This admission, c-peptide levels,
insulin, beta-hydroxybuturate, and proinsulin levels were sent
off but were unfortunately nondiagnostic. The timing of the
tests did not capture a moment of true hypoglyemia (BG <40 or
<60 with symptoms) and therefore could not rule out an
endocrinopathy. Work up was interrupted by resolution of his
hypoglyecmia after advancing his dysphagia diet. Caution is
advised the next time patient is made NPO to monitor his finger
sticks carefully.
# Access: He was admitted with 2 PIV: one in his R axilla and
the other in the R chest wall. Prior CVLs placed under fluoro.
Transplant surgery and the IV team were [**Month/Year (2) 653**] regarding
assistance with short and long term plans for his access issues
(see below on TRANSITIONAL ISSUES FOR DETAILS). Upper extremity
ultrasound showed clots in multiple RUE deep veins and the R IJ.
It was decided to heparinze the patient and bridge the patient
to coumadin. The patient's last 3 INRs were within [**2-24**] goal
range and the heparin gtt was discontinued on [**2113-1-30**].
# AMS: Appears to be at baseline currently. Per history pt
appears to have been doing poorly at home and noted to be more
unresponsive. Neuro evaluated patient and did not feel that AMS
was [**2-23**] CVA or active seizing. Felt to have AMS [**2-23**] metabolic
derangement. Not likely acute intracranial process as no changed
on CT head w/o. There was a delay in med administration as pt
hasn't had AEDs since yesterday. He was continued on keppra
1500mg daily, lacosamide 50mg [**Hospital1 **] wo incident. As his infection
cleared, he returned to his baseline of AOx2-3. In general, he
seems the most drowsy upon waking and after HD, and this usually
clears with time/meals.
INACTIVE ISSUES
# Penile bleeding: Very mild. Does not appear to be worsening
despite heparin gtt. Apparently persistent on/off since last
week in rehab. No issues in the week prior to [**Hospital1 **].
# Fistula thrombosis/Access: Following his stay in the ICU the
patient had a thrombosed RUE AVG in [**11/2112**] (the LUE AVG was
removed [**2-23**] infectin). Has been on coumadin but was
subtherapeutic on arrival and started on a heparin gtt until his
coumadin was therapeutic. Access was a very challenging problem
as his vasculature was either thrombosed on the right or being
salvaged for a future fistula on the left for new fistula
creation. He will follow up with transplant surgery as an
outpatient.
# ESRD on HD: MWF, received dialysis on schedule. Access is now
a tunneled line, given AVG thrombosis. He was continued on home
dose sevelamer, which was switched to Lanthanum and nephrocaps.
# thrombocytopenia: Pt with macroycytic anemia and
thrombocytopenia prior. This was stable during his stay.
# CAD/CVA history: ECG unchanged from prior. Hx of recent RP
bleed on [**11/2112**] hospitalization related to anticoagulation. He
was continued on home dose aspirin, statin, metoprolol, and
coumadin (which was titrated up for therapeutic INR).
# Depression: Was formerly on fluoxetine as listed [**Year (4 digits) **] med
but held on [**Year (4 digits) **] as it causes hypoglycemia and it can lower
the seizure threshold.
ISSUES OF TRANSITIONS IN CARE:
His left arm needs a fistula creation
He needs a better access issue next time he is hospitalized, but
unfortunately this is temporarily impossible. After consultation
with [**First Name4 (NamePattern1) 8817**] [**Last Name (NamePattern1) **] and the tranplant surgeons, his tunneled
line cannot be converted to a VIP port, and he has no other
veins available for central access given his multiple clots and
left arm reserved for fistulization. Best options are to use
antibiotics that use HD dosing such as vanc and ceftaz in order
to forgo IV access. The IV team can occasionally place
peripherals and re lab draws, art sticks can be used as a last
resort. Unfortunately, his anatomy does not allow for a better
access plan. The only other options would be to reevaluate his
goals of care, but the family is adamantly against this as well.
Very challenging situation as he will likely return to the
hospital for future aspiration events and the family is aware of
this.
# CODE: FULL - confirmed HCP daughter
# CONTACT: patient; [**Telephone/Fax (1) 63591**] [**Name2 (NI) **]/ Daughter's cell:
(h) [**Telephone/Fax (1) 63580**]. Adult Day Care Program is [**Last Name (un) 35689**] House in
[**Telephone/Fax (1) 63595**]
Medications on Admission:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1)
Capsule PO once a day.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
4. levetiracetam 500 mg/5 mL Solution Sig: 1500 (1500) mg
Intravenous twice a day.
5. LeVETiracetam 500 mg IV MWF Dose after HD
6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day: hold if SBP<90, HR<55.
7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO once a day as needed for constipation.
8. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
9. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO
three times a day.
10. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. heparin (porcine) 1,000 unit/mL Solution Sig: see below
Injection PRN (as needed) as needed for line flush: 4000-[**Numeric Identifier 2249**]
UNIT DWELL PRN line flush
Dialysis Catheter (Temporary 3-Lumen): DIALYSIS Lumens/ DIALYSIS
NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS
followed by Heparin as above according to volume per lumen.
12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: please titrate to INR, goal [**2-24**].
13. heparin (porcine) 1,000 unit/mL Solution Sig: see below
Injection PRN (as needed) as needed for dialysis: Heparin Dwell
(1000 Units/mL) [**2101**]-8000 UNIT DWELL PRN dialysis
Dwell to catheter volume
14. lacosamide 200 mg/20 mL Solution Sig: Fifty (50) mg
Intravenous [**Hospital1 **] (2 times a day).
15. heparin (porcine) in NS Intravenous
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
.
[**Hospital1 **] Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. B-complex with vitamin C Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
9. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. heparin (porcine) 1,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
12. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR): Dose after HD.
13. lacosamide 10 mg/mL Solution Sig: Fifty (50) MG PO BID (2
times a day).
14. lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
15. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
16. warfarin 2 mg Tablet Sig: Three (3) Tablet PO once a day.
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital **] LivingCenter - Heathwood - [**Location (un) 55**]
[**Location (un) **] Diagnosis:
Aspiration pneumonia
Chronic aspiration
Encephalopathy
Hypoglycemia
Deep venous thrombosis
[**Location (un) **] Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: [**Location (un) **] and interactive.
Activity Status: Bedbound.
[**Location (un) **] Instructions:
You were admitted to the hospital for fever and vomiting thought
to be related to an infection from aspiration. You were treated
with IV antibiotics. Your cultures were negative. You has an
episode of aspiration/choking that required admission to the
medical ICU. You had an nasal tube placed for medication
administration and drainage of your stomach fluids as you were
found to have a small bowel obstruction as well. This was
treated with bowel rest until the obstruction resolved.
A discussion was held between your daughter, palliative care
services, and the medical team about the safety of eating. The
likelihood that you will continue to choke is very high. The
decision was made to continue to allow you to eat, despite the
high risk of choking on foods. Your family was made aware of the
risks of choking on food, respiratory failure, infection, and
rehospitalization but still prefer you to be full code (meaning
undergo CPR and use of breathing machine if your heart would
stop). Fortunately, you ate your meals without difficulty for
the remainder of your hospitalization.
We also addressed your long term intravenous access needs. With
the help of the IV team and the transplant surgeons who have
evaluated you before, it was decided to try to avoid placing IVs
in the left arm for future fistula placements. Also, in the
future, using antibiotics only to be given at dialysis would
also benefit.
We restarted you on coumadin for your recent blood clot but we
had to increase your dose. This will likely fluctuate so you
should continue to have your INR monitored. Your current dose
of coumadin is 11 mg a day.
We also changed your sevelamer to Lanthanum.
We have not made any other significant changes to your
medications this hospitalization.
You are being discharged to rehab and should follow up with your
primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] to home.
Followup Instructions:
Please follow up with your primary care doctor after your
[**Last Name (Titles) **] from rehab. The rehab doctors [**Name5 (PTitle) **] help [**Name5 (PTitle) **] arrange
this.
|
[
"5070",
"51881",
"40391",
"41401",
"2875",
"311",
"53081",
"V5861"
] |
Admission Date: [**2145-6-23**] Discharge Date: [**2145-6-28**]
Service: MICU
CHIEF COMPLAINT: Hypotension and acidosis.
HISTORY OF PRESENT ILLNESS: Patient is an 84-year-old female
with severe coronary artery disease status post multiple
myocardial infarctions in the past with an ejection fraction
of 25% in [**2143**]. She is not a CABG or angioplasty candidate.
The patient was transferred from [**Hospital 4068**] Hospital on [**2145-6-23**] for right leg ischemia. The patient underwent
thrombectomy and embolectomy on [**6-24**], but suffered from
a perioperative myocardial infarction with troponins greater
than 50. In the PACU, the patient had a metabolic acidosis
and intermittent hypotension that was fluid responsive.
The patient was transferred to the MICU for observation at
the request of the Medical Floor team.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post catheterization in
[**2143**] which showed severe three vessel disease. The patient
is status post multiple myocardial infarctions.
2. Congestive heart failure with an ejection fraction of 25%
in [**2143**].
3. Type 2 diabetes mellitus.
4. Hypothyroidism.
5. Hyperlipidemia.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Levothyroxine.
2. Aspirin.
3. Metoprolol.
4. Insulin-sliding scale.
5. Lipitor.
HOSPITAL COURSE BY SYSTEMS:
1. Cardiovascular: Patient was admitted with a right
ischemic leg following thrombectomy on [**6-24**]. The
patient was found to have a creatinine kinase of 8,800 likely
secondary to rhabdomyolysis from ischemia. The patient also
had an elevated creatinine kinase, MB, and a troponin that
was greater than 50 postoperatively. The patient was not
given Heparin secondary to a left neck hematoma and
heme-positive stool, as well as a hematocrit of 24 on
presentation.
In addition, her platelets were found to be trending down.
Heparin-induced thrombocytopenia laboratories were sent off.
The patient was instead started on Coumadin on [**6-26**].
The patient was continued on metoprolol, aspirin, Lipitor,
and she was transfused to keep her hematocrit greater than
30. The patient was not considered to be a candidate to
return to the operating room for Vascular Surgery.
In terms of the patient's congestive heart failure, the
patient was thought to be euvolemic with a CVP of 4.
2. Renal: The patient was admitted with mild acute renal
failure and anion gap acidosis that was likely from lactic
acidosis. She was gently hydrated with intravenous fluids
and her medications were dosed for a creatinine clearance of
about 20 mL/minute.
3. Endocrine: The patient has type 2 diabetes mellitus and
hypothyroidism. She was continued on her insulin-sliding
scale and her levothyroxine.
4. GI: The patient was found to have heme-positive stool,
however, her hematocrit remained stable at 33. She was given
a proton-pump inhibitor for prophylaxis, and was followed
with twice daily hematocrits.
The patient was also given a swallow evaluation on [**6-25**],
which was repeated on [**6-28**], and she was found to
tolerate oral diet without any aspiration risk.
5. Heme: The patient was found to have a GI bleed and a left
cervical hematoma from an internal jugular access attempt in
the postoperative unit for which she received 5 units of
packed red blood cells and 2 units of fresh-frozen plasma
after Heparin was discontinued. Therefore, Heparin and
Plavix were both held postprocedure. The patient did
maintain a stable hematocrit through the rest of her hospital
stay.
6. Pulmonary: The patient, on admission to the MICU, had
sats of 98% on 2 liters nasal cannula. She did have moderate
bilateral pleural effusions on admission, but she maintained
a good oxygen saturations throughout her stay.
7. ID: The patient was continued on levofloxacin for empiric
urinary tract infection based on a urinalysis from an outside
hospital. The levofloxacin was to total a seven day course,
and was continued once the patient was transferred to the
floor. On the day prior to discharge, the patient was found
to have an INR of 3.5, and her Coumadin was subsequently
held.
LABORATORIES ON ADMISSION: The patient's laboratories on
admission were a sodium of 140, chloride of 104, glucose of
210, BUN of 38, and creatinine of 1.7 with a CK MB of 35, and
a troponin of 17.4.
The patient had a transthoracic echocardiogram on [**6-25**]
in order to rule out thrombus. The echocardiogram showed
that the left atrium was mildly dilated, left ventricular
wall thickness were normal. The left ventricular cavity size
was normal. Overall, left ventricular systolic function was
moderately to severely depressed with an ejection fraction of
30% secondary to akinesis of the inferior and posterior wall
and hypokinesis of the inferior septum and lateral wall. No
masses or thrombi were seen in the left ventricle. The
aortic valve leaflets were mildly thickened. Trace aortic
regurg was seen. Mitral valve leaflets were mildly
thickened. There was mitral valve prolapse, 1+ mitral
regurgitation was seen. There was a small pericardial
effusion primarily by the right atrial free wall. There were
no signs of tamponade.
DISCHARGE MEDICATIONS:
1. Coumadin 2 mg daily.
2. Metoprolol 50 mg half a tablet daily.
3. Levofloxacin 250 mg one tablet daily for two days.
4. Aspirin 81 mg one tablet daily.
5. Levothyroxine 75 mcg one tablet daily.
6. Isosorbide mononitrate 30 mcg one tablet daily.
7. Sertraline 50 mg one tablet daily.
8. Atorvastatin 10 mg one tablet daily.
DISCHARGE INSTRUCTIONS: The patient was discharged with
visiting nurse services in order to check her INR twice a
week with a goal INR of [**2-7**].5. VNA was also to take her
staples out in 14 days after the procedure. The patient has
insulin-sliding scale administered to her by her husband at
home. The patient is to followup with a primary care
physician in three weeks.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 5615**]
MEDQUIST36
D: [**2145-7-3**] 21:27
T: [**2145-7-9**] 10:57
JOB#: [**Job Number 37716**]
|
[
"41071",
"5849",
"5070",
"4280",
"5990",
"41401"
] |
Admission Date: [**2124-8-30**] Discharge Date: [**2124-9-5**]
Date of Birth: [**2044-1-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Differin / Coumadin / Adhesive Tape
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest discomfort
Major Surgical or Invasive Procedure:
[**2124-8-30**] Aortic valve replacement 25-mm Mosaic
tissue valve.
History of Present Illness:
80 yo male with known AS being
followed by serial echos. Has become symptomatic in past few
months and was referred for AVR. He presents today for surgical
management of his aortic valve stenosis.
Past Medical History:
aortic stenosis
avascular necrosis R hip
hypertension
hyperlipidemia
gastroesophageal reflux disease
prior ETOH dependen
Social History:
Lives with: wife
Occupation: works at supermarket deli 20h/week
Tobacco: quit 30 yrs. ago (20 pack year hx)
ETOH: 4 beers/day
Family History:
no FH of CAD
Physical Exam:
Pulse: 61 Resp: 16 O2 sat: 95%
B/P Left: 123/72
Height: 5'6" Weight: 175lb
General: NAD, WGWN, 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 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ (closure device s/p cath) Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit radiation of cardiac murmur vs. bruit
Pertinent Results:
[**2124-9-1**] 05:38AM BLOOD WBC-12.4* RBC-3.46* Hgb-11.1* Hct-31.6*
MCV-91 MCH-32.0 MCHC-35.0 RDW-13.5 Plt Ct-119*
[**2124-8-31**] 05:13AM BLOOD WBC-17.6*# RBC-3.75* Hgb-12.2* Hct-34.0*
MCV-91 MCH-32.5* MCHC-35.9* RDW-13.7 Plt Ct-147*
[**2124-8-30**] 01:10PM BLOOD PT-13.4 PTT-38.9* INR(PT)-1.1
[**2124-9-1**] 05:38AM BLOOD Glucose-117* UreaN-13 Creat-1.0 Na-135
K-4.0 Cl-101 HCO3-28 AnGap-10
PREBYPASS
No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage. No spontaneous echo contrast is
seen in the body of the right atrium or right atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. 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 is normal with normal free wall contractility. The
descending thoracic aorta is mildly dilated. There are complex
(>4mm) atheroma in the proximal descending thoracic aorta/distal
aortic arch. There are three aortic valve leaflets. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen.The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion.
POSTBYPASS
The patient is A-paced on a phenylephrine infusion.There is a
bioprosthetic aortic valve which appears well seated. The
peak/mean gradients across the valve are 19/8 mmHg at a CO of
3.91 L/min. The aorta is intact post decannulation. Dr.[**Last Name (STitle) **]
was notified in person of the results at the time of the study.
[**2124-9-5**] 04:30AM BLOOD WBC-6.4 RBC-3.21* Hgb-10.3* Hct-29.9*
MCV-93 MCH-31.9 MCHC-34.3 RDW-13.3 Plt Ct-286
[**2124-9-4**] 05:45AM BLOOD WBC-6.7 RBC-3.25* Hgb-10.5* Hct-30.1*
MCV-93 MCH-32.2* MCHC-34.8 RDW-13.4 Plt Ct-218
[**2124-9-5**] 04:30AM BLOOD Glucose-96 UreaN-21* Creat-1.0 Na-139
K-4.0 Cl-103 HCO3-27 AnGap-13
Brief Hospital Course:
The patient was brought to the operating room on [**2124-8-30**] where
the patient underwent aortic valve replacement with a 25mm
tissue valve. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Cefazolin was
used for surgical antibiotic prophylaxis.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery. He
did develop post-op a-fib briefly and converted to sinus rhythm
with amiodarone. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility. By
the time of discharge on POD 6 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to rehab (TCU, [**Hospital 1474**]
Hospital) in good condition with appropriate follow up
instructions.
Medications on Admission:
ASA 325 mg daily
metoprolol XL 50 mg daily
MVI daily
fish oil
simvastatin 10 mg daily
quinapril 5 mg daily
zolpidem 10 mg daily
omeprazole 20 mg [**Hospital1 **]
percocet 5/325 mg prn TID
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/temp.
10. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg [**Hospital1 **] x 7 days, then 400mg daily x 7 days, then
200mg daily until further instructed.
12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
14. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
16. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
17. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
18. diphenhydramine HCl 25 mg Capsule Sig: [**11-27**] Capsules PO Q6H
(every 6 hours) as needed for itching.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 1474**] Hospital TCU (Signature)
Discharge Diagnosis:
Aortic Stenosis
PMH:
avascular necrosis R hip
hypertension
hyperlipidemia
gastroesophageal reflux disease
prior ETOH dependency
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, [**Known lastname **], 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:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2124-9-28**] 1:00
Cardiologist Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] [**10-2**] @ 12:20 pm
Please call to schedule the following:
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] H. [**Telephone/Fax (1) 14331**] in [**2-28**] weeks
Completed by:[**2124-9-5**]
|
[
"4241",
"42731",
"4019",
"2724",
"53081"
] |
Admission Date: [**2147-1-5**] Discharge Date: [**2147-1-10**]
Date of Birth: [**2102-3-9**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4760**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 44 year-old female with a history of alcohol abuse
and psychosis N.O.S who was transferred to the ED with altered
mental status. Pt arrived hypertensive and tachycardic. She was
admitted to an inpatient psychiatric facility today with a
Section 12. She was sent from the psych facility for question of
D.T.'s.
.
In the ED, initial vitals were T 99.6 BP 160/90 HR 120 RR 20
97%RA. She was given a total of 180 mg of IV valium without much
effect. Because of her altered mental status, discussion about a
diagnosis of meningitis was begun. She was given appropriate
doses of vancomycin and ceftriaxone. No LP was able to be
obtained given the patient's behavior. Head CT was negative for
any acute pathology. CXR was WNL. She was given a banana bag and
NS. EKG notable for just sinus tachycardia.
.
Upon arrival to the ICU, she was quite agitated and had to be
restrained. Her records were reviewed. She initially was brought
to [**Hospital6 10353**] on [**2147-1-4**] by EMS when she was found
outside her house, agitated and hallucinating. She is s/p
assault several days ago, having been punched in the face by
someone whose house she was staying at. She admitted to being
"off her meds." At [**Hospital1 392**], she was medically cleared for an
inpatient psych facility. She continued to have confused speech
at [**Hospital1 392**]. She was then transported to [**Hospital1 **] and was given the
diagnosis of psychotic disorder N.O.S.
.
ROS: Unable to be obtained.
Past Medical History:
(per records):
Depression
HTN
Alcohol abuse
Social History:
She was recently assaulted about 3 weeks ago per records.
Family History:
Unable to obtain
Physical Exam:
On presentation:
Vitals: 98 180/107 107 15 98% on RA
GEN: Agitated, not able to follow commands, thrashing in bed.
HEENT: Old, healing B/L periorbital ecchymosis, L > R. PERRLA,
EOMI, MMM, OP clear.
NECK: No JVD.
CV: RRR, no M/G/R, normal S1 S2, radial pulses +2.
PULM: Lungs CTAB, no W/R/R.
ABD: Soft, NT, ND, +BS, no HSM, no masses.
EXT: No C/C/E, no palpable cords.
NEURO: Agitated, thrashing in bed. Unable to cooperate with
exam.
SKIN: Periorbital ecchymoses as above.
Pertinent Results:
HEAD CT: No acute process
Brief Hospital Course:
MICU COURSE:
44 y/o female admitted from an inpatient psych unit for concern
for EtOH withdrawal. Patient received 180 mg valium in the ED
without effect. Concern for acute psychosis vs. alcohol
withdrawal.
# Altered mental status: Transferred here for concern for acute
alcohol withdrawal. Patient with unknown prior psychiatric
history though per OSH record, has psychosis NOS. Per patient,
last drink was 6 days prior to admission though she was
delirious at time of admission so history unreliable. Also had
transaminitis and hyperbilirubinemia on admission. Patient had
no fevers per records and no leukocytosis, cultures were sent
and were negative. She received one dose of meningitis
treatment in ED which was not continued on the floor. Patient
was delirious and combative on admission to ICU. Emergent
psychiatric consult obtained who recommended continuing CIWA
scale with valium for likely EtOH withdrawal. Morning after
admission patient continued to be delirious and psychiatry was
concerned about benzodiazapine intoxication and valium was held.
Agitation treated with haldol standing and prn with good effect.
Day prior to transfer from ICU pt's mentation improved, she was
fully orientated with no hallucinations, psychiatry recommended
discontinuing Diazepam and restarting pt's Buspirone and
Paroxetine, Haldol was also changed to PRN. Pt's altered mental
status most likely due to Etoh withdrawal with psychosis. Per
psychiatry, they felt more of her inpatient issues were related
to substance abuse, and did not requiring inpatient psychiatric
admission. The patient was seen by social work and given follow
up options. The patient has follow up with her psychiatrist
arranged the week after discharge and with her PCP. [**Name10 (NameIs) **] pt did
not want her d/c summary sent to her psychiatrist for unclear
reasons.
.
# Abuse: Pt had sustained a punch to the face several weeks
prior to admission, still has eccymosis over bilateral cheeks.
The person who punched her was her reported roommate who is in
jail. The patient will be staying with one of her friends after
discharge, and the safety of the situation was assessed by
social work prior to discharge.
.
# Pancytopenia: On admission was pancytopenia, thought to be
secondary to chronic alcohol use. No prior values for
comparison. No evidence of hemolysis on labs. Her pancytopenia
had resolved with just mild anemia with hct of 34 at discharge.
.
# Hyperbilirubinemia: Total bili was 3 on admission and slowly
trended down. Likely [**1-23**] EtOH use. RUQ u/s showing
cholelithaisis but no cholestasis. Bilirubin was normal at
discharge.
.
# Transaminitis: Very mildly elevated on admission, normalized.
RUQ ultrasound as above.
# HTN: Per OSH record, had been on clonidine 0.1mg po tid, had
not taken recently. Given hypertension to 200's systolic and
tachycardia to 110's clonidine withdrawal could have contributed
and so patient was started on clonidine patch 0.3g/day. BP's
decreased after clonidine and valium/haldol dosing as above.
Medications on Admission:
Home Medications (per records):
Trazadone 100 mg PO QHS
Clonidine 0.1 mg PO TID
Klonopin 1 mg PO BID and 2 mg PO QHS
Buspar 15 mg PO TID
Wellbutrin SR 150 mg PO daily
Prozac 40 mg PO daily
Medications given in ED at [**Hospital1 392**]:
Ativan, Haldol, Clonazepam, Fluoxetine.
Medications at [**Hospital 1680**] Hospital:
Trazadone 100 mg PO QHS
Clonidine 0.1 mg PO TID
Klonopin 1 mg PO BID and 2 mg PO QHS
Buspar 15 mg PO TID
Wellbutrin SR 150 mg PO daily
Prozac 40 mg PO daily
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
Disp:*4 Patch Weekly(s)* Refills:*2*
2. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a
day).
Disp:*270 Tablet(s)* Refills:*2*
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Delirium tremens
Acute alcohol withdrawl
Discharge Condition:
stable
Discharge Instructions:
You were admitted with acute alcohol withdrawl and delirium
tremens (hallucinations related to alcohol withdrawl). You were
admitted initially into the intensive care unit for treatment.
Your symptoms resolved. You were also followed by psychiatry
while you were here.
.
You need to stop drinking alcohol, as this is dangerous for your
health and you can die if you continue to drink. Your liver
function may also worsen.
.
Please follow up with your psychiatrist and primary care doctor
as scheduled.
.
Call your doctor or return to the ER for recurrent withdrawl,
hallucinations, confusion, chest pain, dehydration,
nausea/vomiting, tremors, or any other concerning symptoms
Followup Instructions:
Please follow up with your primary care doctor or a new one of
your choosing. You can call [**Telephone/Fax (1) 250**] to schedule an
appointment here with a primary care doctor if you need one.
.
Please follow up with Dr. [**Last Name (STitle) 43712**] this Friday morning 1/23/009
at 10:30 AM
.
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 43713**] (psychiatrist) and
Ms. [**First Name8 (NamePattern2) 2563**] [**Last Name (NamePattern1) **] (therapist), N. [**University/College 7709**] [**Location (un) **] Counseling
Center: [**2147-1-17**], Tuesday, 2:30 PM.
.
Please call the following for outpatient substance abuse
counseling:
* [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 2678**] Substance Abuse Clinic ([**Telephone/Fax (1) 43714**], [**Location (un) 43715**], Unit [**Unit Number **]) Wednesday and Thursday 11 AM, group tx.
* N. [**University/College 7709**] Mental Health ([**Telephone/Fax (1) **]) for intake appt. Tx
will be [**Location (un) **] Counseling Center.
|
[
"311"
] |
Admission Date: [**2113-9-26**] Discharge Date: [**2113-9-28**]
Date of Birth: [**2050-4-17**] Sex: M
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
s/p carotid stenting
Major Surgical or Invasive Procedure:
carotid stenting of right carotid artery
History of Present Illness:
63 yo male with history of HTN, HL, and claudication who is s/p
carotid stenting for 90% stenosis on right admitted for
monitoring.
.
Approximately 3 months ago, he had a stress echo (nl, EF >50%,
negative for ischemia), and at that time, a carotid bruit was
heard. Carotid US and CT neck with contrast were done (results
not available on admission). Per patient, he had 90% stenosis
on right and 50-60% stenosis on left. He has been asymptomic
and scheduled an elective surgery today.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis. he
denies recent fevers, chills or rigors. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
cardiac catheterization - [**2111-3-26**]: 30% mid plaque lesion in
the LAD at the diagnoals and only minimal disease in the other
vessels
3. OTHER PAST MEDICAL HISTORY:
Hyperlipidemia
GERD
claudication s/p left SFA stent
distant h/o gastric ulcer
hydrocele s/p indigo laser procedure
tobacco abuse
adenocarcinoma of the rectosigmoid [**Month/Day/Year 499**] s/p surgery
BPH
Social History:
Currently smokes tobacco since age 15 at least 1ppd
(45pack-year), now smokes approximately 0.5-1 ppd. He drinks 1
alcoholic drinks per week. Married and works as engineer.
Family History:
His family history is significant for a mother with MI in her
50s and pacemaker. Mother had [**Name2 (NI) 499**] cancer and DM too. Not in
touch with father
Physical Exam:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. EOMI. no oral lesions.
NECK: Supple, bruit on left
CARDIAC: RRR
LUNGS: CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no pedal edema, distal pulses intact, right groin
nontender, without brusing or bruits
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: CN II-XII intact, nl strength and sensation in upper and
lower extremities bilaterally, nl rapid alternating movements of
hands
Pertinent Results:
[**2113-9-26**] 07:55AM BLOOD WBC-7.1 RBC-4.36* Hgb-12.5* Hct-36.4*
MCV-84 MCH-28.8 MCHC-34.5 RDW-15.0 Plt Ct-269
[**2113-9-27**] 05:24AM BLOOD WBC-9.1 RBC-4.05* Hgb-11.4* Hct-34.3*
MCV-85 MCH-28.2 MCHC-33.3 RDW-15.0 Plt Ct-300
[**2113-9-26**] 07:55AM BLOOD Glucose-101* UreaN-10 Creat-0.9 Na-140
K-4.5 Cl-104 HCO3-27 AnGap-14
[**2113-9-27**] 05:24AM BLOOD Glucose-104* UreaN-17 Creat-1.0 Na-140
K-4.3 Cl-105 HCO3-26 AnGap-13
[**2113-9-27**] 05:24AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.1
Brief Hospital Course:
63 yo male with history of HTN, HL, and claudication who
presents after carotid stenting for monitoring.
# Carotid stenting - The patient tolerated the procedure well.
Post procedure, the patient was hypotensive and bradycardic to
the 40s. He was started on dopamine and transferred to the CCU
for monitoring. The dopamine drip was able to be weaned after
one night and the patient's blood pressure rose to 120s without
any medication. He ambulated around the unit without difficulty
and tolerated PO intake well. He was started on a full dose
aspirin. Plavix and statin were continued. Lisinopril and
amlodipine were held due to hypotension.
# Smoking cessation - The patient said he was trying to cut back
his smoking habit. He was counseled that smoking cessation
would be the best thing to do to lower his stroke risk.
Medications on Admission:
AMLODIPINE [NORVASC] - 5 mg Tablet - daily
DICYCLOMINE -10 mg Capsule - 1 Capsule(s) by mouth three times a
day
DIPHENOXYLATE-ATROPINE - 2.5 mg-0.025 mg Tablet as needed
DUTASTERIDE [AVODART] - 0.5 mg - 1 Capsule(s) by mouth qpm
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth twice a day
PANTOPRAZOLE - 40 mg Tablet, - 1 Tablet(s) by mouth every
afternoon
PROCHLORPERAZINE MALEATE -10 mg-every 6 hours as needed for
nausea
ROSUVASTATIN [CRESTOR] -10 mg by mouth afternoon
ASPIRIN - 81 mg Tablet - qam
plavix 75 daily - started recently
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for s/p R carotid artery stent.
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
s/p R carotid artery stent.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
4. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) as needed for diarrhea.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
7. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO qpm ().
Discharge Disposition:
Home
Discharge Diagnosis:
s/p carotid stenting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 59744**],
It was a pleasure taking care of you during your
hospitalization.
You were admitted for carotid stenting of the right carotid
artery. After the procedure, your heart rate and blood pressure
were low. You were treated with IV dopamine, a medication that
raises blood pressure and heart rate. We were able to wean the
dopamine and your blood pressure and heart rate stayed stable.
Please make the following changes to your medications:
INCREASE aspirin to 325 mg daily
Please follow-up with your scheduled appointments.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **]: [**Last Name (LF) 766**], [**10-2**] at 3:45. You
can reach the office at ([**Telephone/Fax (1) 32215**].
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2113-11-23**] 3:40. They will try go get you sooner and
call you. You are in the urgent waiting list.
|
[
"4019",
"2724",
"53081",
"3051",
"42789"
] |
Admission Date: [**2144-6-26**] Discharge Date: [**2144-6-29**]
Date of Birth: Sex:
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old
male with bipolar disorder admitted to [**Hospital 10073**] Hospital for
psychotic depression on [**6-3**]. The patient also reported
being suicidal at that time. On [**6-25**] at 11:40 p.m., the
patient requested Ambien 10 mg in addition to his usual 10
mg. Around 12:30 a.m., the patient fell out of bed with
continued snoring. His heart rate was 120-140 with variable
respiratory rate. The patient seemed to be short of breath.
Oxygen was given, and the ambulance was called.
In the Emergency Department, the patient's heart rate was
130, blood pressure 150/74, respirations was agonal. He had
decreased oxygen saturation, and fingerstick was 125.
Arterial blood gas was with a pH of 7.15, pCO2 of 75, pO2 45
on room air. The patient was intubated. He had an upper GI
lavage which showed no evidence of toxins. Also, the patient
had food in his stomach. The patient was obtunded and
unresponsive. He received Clindamycin and Ceftriaxone.
PAST MEDICAL HISTORY: 1. Bipolar disorder. 2. Question of
history of coronary artery disease.
SOCIAL HISTORY: The patient is unemployed and homeless. He
lives with his parents. His house burned down about six
weeks ago. No alcohol or drug abuse.
ALLERGIES: NO KNOWN DRUG ALLERGIES..
MEDICATIONS ON ADMISSION: Topamax 100 mg p.o. q.h.s.,
Zyprexa 10 mg p.o. q.h.s., Effexor XR 150 mg p.o. b.i.d.,
Prozac 40 mg p.o. q.d., Nexium 40 mg p.o. q.d., Ambien 10 mg
p.o. q.h.s., ................. 40 mg p.o. t.i.d., Clozaril
350 mg p.o. q.h.s.
PHYSICAL EXAMINATION: Vital signs: The patient was
afebrile, heart rate 106, blood pressure 110/52. He was on
assist control at 750 with a respiratory rate of 14, FI02
100%, PEEP 5. The patient had good oxygen saturation on
these settings. General: He was a responsive, obese white
male, intubated, cool, and not sweating. HEENT: Sclerae
clear. Oropharynx moist. Pupils 2 mm and reactive
bilaterally. Neck: Obese. Chest: Clear to auscultation
bilaterally. No crackles. No wheezes. Cardiovascular:
Faint tachycardia. No S1 and S2. No murmurs. Abdomen:
Positive bowel sounds. Soft and nontender. Extremities: No
lower extremity edema. Fair dorsalis pedis pulses
bilaterally. No cyanosis. Neurological: Unable to assess
secondary to his intubation.
LABORATORY DATA: On admission white count was 11.4,
hematocrit 40.4, platelet count 244, neutrophils 66,
lymphocytes 0.6, monocytes 4, eosinophils 4; PTT 24.8, INR
1.2; sodium 141, potassium 4.4, chloride 112, bicarb 22, BUN
17, creatinine 1.2, glucose 171; serum for Aspirin, alcohol,
.............., Benzodiazepines, barbiturates, tricyclics
were negative.
Electrocardiogram showed sinus tachycardia at 115, normal
axis, normal intervals, no ST-T changes. Chest x-ray showed
small lung volumes, ETT at the carina and the right bronchus
which was subsequently ..................
HOSPITAL COURSE: The patient was admitted to the MICU
initially intubated. He was continued on Zyprexa and Haldol
p.r.n.. The patient had a head CT which did not demonstrate
bleed, edema, or mass affect. He woke up shortly after
transfer to MICU. He was violently agitated. He was started
on Propofol. The patient was shortly extubated. He did well
from a respiratory point of view; however, he has been
fatigued.
The patient's psychiatric symptoms have been followed by the
Psychiatry Service. He has been placed on Haldol p.r.n. and
Olanzapine 10 mg p.o. q.h.s. This is being followed by the
Psychiatry Service.
The patient will be likely discharged to [**Hospital 42339**] Hospital
on [**2144-6-29**].
DISCHARGE MEDICATIONS: Tylenol 325-650 mg p.o. q.4-6 hours
p.r.n., Protonix 40 mg p.o. q.24 hours, Heparin 5000 U subcue
q.12 hours, Haldol 5-25 mg IV q.4 hours p.r.n., Olanzapine 10
mg p.o. q.h.s., Colace 100 mg p.o. b.i.d., Dulcolax 10 mg
p.o. p.r. q.d. p.r.n.
DISPOSITION: The patient will be discharged back to
Bournwood and will receive an outpatient sleep study for
evaluation of obstructive sleep apnea.
CONDITION ON DISCHARGE: The patient is being discharged in
stable condition.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2144-6-29**] 10:12
T: [**2144-6-29**] 10:16
JOB#: [**Job Number 42989**]
|
[
"51881",
"2762"
] |
Admission Date: [**2175-4-14**] Discharge Date: [**2175-4-26**]
Date of Birth: [**2105-12-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
left heart catheterization, coronary angiogram, left
ventriculogram
Coronary artery bypass grafting x 4 & Mitral Valve Repair (28mm
Ring) [**2175-4-20**]
History of Present Illness:
This 69 year old gentleman has no past medical history has had
four or five months of dyspnea on exertion. The patient was
noted to be tachycardic with atrial tachycardia with 2:1
conduction at an outpatient visit. He was noted to be in
congestive heart failure. Lisinopril and digoxin were started
(held on beta blocker because he had heart failure). With
digoxin, he had much less dyspnea on exertion. He was noted to
have a LVEF of 10 to 15% with mitral regurgitation.
Dr.[**Doctor Last Name 3733**] felt his dilated cardiomyopathy was secondary to
tachycardia and underwent cardiac catheterization to evaluate
for coronary disease. this revealed left main disease and mitral
regurgitation. He underwent further evaluation to determine if
he was a good surgical candidate.
Past Medical History:
Dilated cardiomyopathy (LVEF 10-15%)
Severe mitral regurgitation
Atrial arrhythmia
Social History:
The patient lives with his wife. Denies any current smoking,
alcohol
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS - T: 97.7, BP: 103/70, HR: 87, RR: 18, O2 sat: 98%
Gen: Elderly 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. JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Tachycardia. Regular rate. normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Limited to anterior
auscultation with crackles at bases. No wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
Cardiac MRI: Impression:
1. Severely increased left ventricular (LV) volume and global LV
systolic
dysfunction. The LVEF was severely decreased at 26%. Severe
global
hypokinesis with mild sparing of the LV apex. The effective
forward LVEF was severely decreased at 16%. No CMR evidence of
prior myocardial
scarring/infarction. This pattern of LV dysfunction (global
hypokinesis with apical sparing) and lack of LGE is more
consistent with a non-ischemic
cardiomyopathy. However, if myocardial hibernation due to severe
CAD is the
etiology of this patient's LV dysfunction, these findings are
consistent with high likelihood of functional recovery following
mechanical revascularization.
2. Normal right ventricular cavity size with mild global
systolic dysfunction. The RVEF was mildly decreased at 41%.
3. Severe mitral and tricuspid regurgitation..
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
5. Moderate left atrial enlargement. Mild right atrial
enlargement
6. Small pericardial effusion.
7. Aortic atheroma.
8. Small, bright signal seen in the liver on scout images which
likely
represents a hepatic cyst.
[**2175-4-23**] 06:05AM BLOOD WBC-8.4 RBC-3.77* Hgb-11.4* Hct-32.6*
MCV-86 MCH-30.2 MCHC-35.0 RDW-14.1 Plt Ct-109*
[**2175-4-17**] 05:40AM BLOOD WBC-8.3 RBC-4.13* Hgb-12.5* Hct-36.0*
MCV-87 MCH-30.4 MCHC-34.8 RDW-13.3 Plt Ct-196
[**2175-4-23**] 06:05AM BLOOD Glucose-98 UreaN-10 Creat-1.0 Na-136
K-3.9 Cl-98 HCO3-27 AnGap-15
[**2175-4-14**] 11:45AM BLOOD Glucose-125* UreaN-15 Creat-1.1 Na-139
K-4.1 Cl-104 HCO3-26 AnGap-13
Brief Hospital Course:
[**4-20**] Mr.[**Known lastname **] was taken to the operating room and underwent
coronary artery bypass grafting x4 and mitral valve repair.
Please see operative note for details. He tolerated the
procedure well and was transferred to the CVICU in stable but
critical condition, intubated, sedated, on milrinone, and
pressors to optimize cardiac function. He awoke neurologically
intact and was extubated on POD#1 without difficulty. Inotropes
and pressors were weaned off, he was started on diuretics and
carvedilol. Plan to start ACE-I when BP tolerates. His chest
tubes and epicardial pacing wires were removed per protocol. He
was transferred from the ICU on POD#4 for further monitoring.
Physical therapy was consulted for evaluation of strength and
mobility. He continued to progress and was cleared for discharge
to home by Dr. [**Last Name (STitle) **] on POD# 6. All follow up appointments were
advised.
Medications on Admission:
DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet daily
LISINOPRIL - (Prescribed by Other Provider) - 2.5 mg Tablet
daily
PRAVASTATIN - (Prescribed by Other Provider) - 80 mg Tablet
daily
TERBINAFINE - (Prescribed by Other Provider) - 250 mg Tablet
daily
.
Medications - OTC
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1
daily
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D-3]
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
2. Pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
s/p mitral valve repair
acute exacerbation of systolic heart failure
dilated cardiomyopathy
severe mitral regurgitation
atrial arrythmia
hyperlipidemia
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:
Surgeon: Dr [**Last Name (STitle) **] on [**2175-5-24**] at 1PM ([**Telephone/Fax (1) 170**])
Please schedule appointments with:
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] in [**1-21**] weeks ([**Telephone/Fax (1) 65542**])
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**1-21**] weeks ([**Telephone/Fax (1) 62**])
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2175-4-26**]
|
[
"41401",
"4280",
"4240",
"2875",
"2724",
"4168",
"2720",
"2859",
"42731",
"42789"
] |
Admission Date: [**2201-8-10**] Discharge Date: [**2201-8-13**]
Date of Birth: [**2136-7-28**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
"Foley catheter repalcement, UTI, ?pneumonia"
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
Foley placement by Urology [**8-10**]
History of Present Illness:
This is a 65 year old male with history of CVA (non-verbal at
baseline), multiple pneumonias (s/p trach/PEG [**3-/2200**]), atrial
fibrillation on coumadin, C diff s/p colectomy, type 2 diabetes
mellitus, peripheral vascular disease and recent admissions for
UTI and pneumonias who presents after his Foley catheter came
out and he needs it replaced. The nursing home mentioned that he
has an elevated WBC count and a chest x-ray that showed a
"slight infiltrate" but did not start antibiotics as pt has been
afebrile. They state that the patient's current mental status
presentation is at his baseline. EMS brought him in for further
evaluation.
.
In the ED, initial vs were: 98.5 77 92/58 20 96%. On PE, patient
was non-verbal but could answer yes/no questions, trach with
some yellow-ish discharge, lungs difficult to auscultate due to
gurgling breath sounds, abdomen soft/nontender to palpation,
G-tube and colostomy visualized. Labs were notable for K 5.5,
BUN 54 but Cr 0.9. WBC was elevated at 22 with 81% neut, no
bands. Lactate was wnl. UA was with lg leuk, >182 WBC, many
bact. Blood cx were sent. Pt was given CTX and IL IVF. CXR
revealed trace bilat effusions and left base opacity likely
atelectasis but infection could not be ruled out. Has a condom
cath on, as unable to replace Foley. Vitals on transfer were BP
109/65 T 97.5 O2 sat 100% on 35% trach mask RR 13 HR 58. Has PIV
x1.
.
On arrival to the ICU, pt appears comfortable, nonverbal. Is
able to follow simple commands like squeezing hand. Denies
chest pain, abd pain. Does seem to endorse back/flank pain.
.
Review of systems:
unable to obtain
Past Medical History:
* Hypertension
* Hypothyroidism
* H/o CVA (bilateral embolic cerebellar [**2188**], hemorrhagic left
thalamic [**2190**])
* Type II Diabetes mellitus
* Peripheral neuropathy
* Depression
* h/o DVT (? - no [**Hospital1 18**] records)
* Atrial fibrillation (on coumadin)
* Peripheral vascular disease
* Hyperlipidemia
* Anemia of chronic disease
* Tracheostomy and GJ tube for chronic aspiration ([**3-/2200**]) -
Portex Bivono, Size 6.0
* C.diff colitis in [**1-29**] requiring total abdominal colectomy
with end ileostomy [**1-29**], repeat positive C diff toxin [**2200-5-20**]
(outside facility, [**12/2198**] here)
Social History:
Prior resident of [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **], now at [**Hospital 16662**] Nursing Home.
Family very involved in care. Patient does not take anything by
mouth due to history of aspiration. Spanish-speaking. Patient is
a former 60 pack year smoker but quit in [**2183**].
Family History:
Patient has a mother with diabetes and brother with heart
disease.
Physical Exam:
Vitals: T: 97.2 BP: 137/89 P: 68 R: 15 O2: 100% on 35% trach
mask
General: Alert, noncommunicative, follows simple commands
HEENT: Sclera anicteric, MMM, oropharynx clear, no dentition
Neck: supple, JVP not elevated, no LAD, trach in place with
secretions in gauze
Lungs: Clear to auscultation anteriorly, +upper airway sounds
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, +G-tube,
+colostomy
GU: no foley
Ext: warm, well perfused, no edema
Neuro: EOMI, PERRL, unable to verbalize, unable to move
extremities, wiggles fingers in left hand, endorses sensation in
all ext
Pertinent Results:
Labs at Admission:
[**2201-8-12**] 08:10AM BLOOD WBC-10.8 RBC-5.12 Hgb-11.9* Hct-37.9*
MCV-74* MCH-23.3* MCHC-31.5 RDW-15.3 Plt Ct-229
[**2201-8-11**] 07:17AM BLOOD WBC-16.3* RBC-5.51 Hgb-12.8* Hct-39.9*
MCV-72* MCH-23.3* MCHC-32.2 RDW-15.5 Plt Ct-237
[**2201-8-10**] 05:30PM BLOOD WBC-22.0*# RBC-5.94 Hgb-13.3* Hct-41.4
MCV-70* MCH-22.4* MCHC-32.1 RDW-16.1* Plt Ct-270#
[**2201-8-12**] 08:10AM BLOOD Neuts-72.3* Lymphs-16.2* Monos-6.4
Eos-4.6* Baso-0.5
[**2201-8-10**] 05:30PM BLOOD Neuts-81.9* Lymphs-10.5* Monos-4.7
Eos-2.5 Baso-0.5
[**2201-8-11**] 07:17AM BLOOD PT-28.7* PTT-32.9 INR(PT)-2.8*
[**2201-8-12**] 08:10AM BLOOD Glucose-162* UreaN-32* Creat-0.6 Na-147*
K-3.5 Cl-109* HCO3-30 AnGap-12
[**2201-8-11**] 07:24PM BLOOD Glucose-111* UreaN-34* Creat-0.5 Na-148*
K-3.9 Cl-110* HCO3-28 AnGap-14
[**2201-8-11**] 07:17AM BLOOD Glucose-124* UreaN-45* Creat-0.7 Na-146*
K-4.5 Cl-107 HCO3-28 AnGap-16
[**2201-8-10**] 05:30PM BLOOD Glucose-157* UreaN-54* Creat-0.9 Na-141
K-5.5* Cl-102 HCO3-29 AnGap-16
[**2201-8-10**] 05:30PM BLOOD ALT-24 AST-42* LD(LDH)-383* AlkPhos-76
TotBili-0.4
[**2201-8-12**] 08:10AM BLOOD Phos-2.7 Mg-2.3
[**2201-8-11**] 07:24PM BLOOD Calcium-8.3* Phos-3.4 Mg-2.4
[**2201-8-11**] 07:17AM BLOOD Calcium-8.6 Phos-4.1 Mg-2.5
[**2201-8-10**] 05:30PM BLOOD Albumin-3.9
[**2201-8-10**] 05:38PM BLOOD Lactate-1.2
Micro:
[**2201-8-11**] URINE Legionella Urinary Antigen -FINAL
INPATIENT
[**2201-8-11**] 11:18 am URINE Source: Catheter. URINE CULTURE
(Preliminary):
GRAM NEGATIVE ROD #1. >100,000 ORGANISMS/ML..
GRAM NEGATIVE ROD #2. >100,000 ORGANISMS/ML..
Imaging:
[**8-10**] CXR: FINDINGS: Single supine AP portable view of the chest
was obtained. The patient is rotated to the right. Tracheostomy
tube is again noted. There is blunting of the bilateral
costophrenic angles, which could be due to trace effusions.
Bibasilar atelectasis is seen. Patchy left base opacity most
likely relates to atelectasis, although underlying aspiration or
infection cannot be excluded, however, has improved in the
interval. No overt pulmonary edema is seen. Cardiac and
mediastinal silhouettes are stable.
Labs at Discharge:
[**2201-8-13**] 05:40AM BLOOD WBC-8.3 RBC-5.51 Hgb-12.5* Hct-41.1
MCV-75* MCH-22.8* MCHC-30.5* RDW-15.3 Plt Ct-251
[**2201-8-13**] 05:40AM BLOOD PT-35.3* INR(PT)-3.5*
[**2201-8-13**] 05:40AM BLOOD Glucose-170* UreaN-25* Creat-0.5 Na-146*
K-4.1 Cl-106 HCO3-30 AnGap-14
Brief Hospital Course:
#Pt's Foley was difficult to be replaced. Urology was consulted
and they were successful. They recommended outpatient f/u with
Dr. [**Last Name (STitle) 770**].
.
#Sepsis: WBC = 22,000 on admission. He had an impressive pyuria,
so the source was most likely UTI. He was started empirically on
Ceftriaxone and improved. He should receive 2 more days of IV
Ceftriaxone, then swithch to PO Cipro for 5 more days. His urine
from admission is growing out 2 strains of Gram negative rods
(>100K each) [**Last Name (un) 80454**] have not been speciated yet. Sensitivities
pending.
.
Hypernatremia: clinically euvolemic. Needs more free water. His
free water PEG flushes were increased to 250ml Q6hrs and his
serum sodium is slowly dropping.
.
#Possible bronchitis - patient initially had thich yellow sputum
from his trach, but otherwise no evidence of pulmonary
infection. It is possible but unlikely that this was causing his
leukocytosis. With antibiotics his sputum did become thinner
(and rusty in color, probably due to aggressive deep
suctioning).
.
# Atrial fibrillation: Pt was in sinus, not on any meds at home.
He iss supratherapeutic on Coumadin (likely due to
antibiotics), and his coumadin is being held. It should be
restarted once his INR is below 3
.
# Sacral decubitus ulcer: present on admission. Pt was
continued with appropriate wound care.
.
# Hypothyroidism: Pt was continued on home Levothyroxine.
.
# Tyle 2 diabetes mellitus: well-controlled, with complications
- continued on 34U [**Last Name (un) 8472**] + insulin sliding scale
.
# Peripheral neuropathy: Pt was continued on home Gabapentin,
Fentanyl patch. He continued to complain of this (by nodding yes
and pointing to area on body chart). In fact, this was his only
complaint. We did not give him Cymbalta as our pharmacy told us
it should not be crushed, but we did increase his Fentanyl patch
dose to 125 mcg/hr
Medications on Admission:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (un) **]: One (1) unit Inhalation four times a day.
2. acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (un) **]: One (1)
Miscellaneous four times a day.
3. ipratropium bromide 0.02 % Solution [**Last Name (un) **]: One (1) Inhalation
four times a day.
4. baclofen 10 mg Tablet [**Last Name (un) **]: 1.5 Tablets PO QID (4 times a
day): Please give through G tube.
5. duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Last Name (un) **]: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day): Please
give through the G tube.
6. docusate sodium 100 mg Capsule [**Last Name (un) **]: Two (2) Capsule PO at
bedtime: Please give through the G tube.
7. fentanyl 100 mcg/hr Patch 72 hr [**Last Name (un) **]: One (1) Transdermal
every seventy-two (72) hours.
8. ferrous sulfate 220 mg (44 mg iron)/5 mL Solution [**Last Name (un) **]: One
(1) PO once a day: Please give through the G tube.
9. gabapentin 300 mg Capsule [**Last Name (un) **]: One (1) Capsule PO Q8H (every
8 hours): Please give through the G tube.
10. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): Please give through
the G tube.
11. [**Last Name (STitle) 8472**] 100 unit/mL Solution [**Last Name (STitle) **]: Thirty Four (34) units
Subcutaneous at bedtime.
12. levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily): Please give through the G tube.
13. mirtazapine 15 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime): Please give through the G tube.
14. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: Please give through the G
tube.
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) vial Inhalation q2h as needed for
shortness of breath or wheezing.
16. ipratropium bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) vial
Inhalation q2h as needed for shortness of breath or wheezing.
17. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
18. ascorbic acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily): Please give through the G tube.
19. miconazole nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
20. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation: Please give through the G tube.
21. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension [**Hospital1 **]:
Thirty (30) ML PO QID (4 times a day) as needed for stomach
upset: Please give through the G tube.
22. Milk of Magnesia 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30) mL
PO once a day as needed for constipation: Please give through
the G tube.
23. Glucerna Liquid [**Hospital1 **]: One (1) Application PO once a day:
1.2 via feeding pump at 75 mL/hr. Up at 2pm down at 10am.
24. Novolin R 100 unit/mL Solution [**Hospital1 **]: One (1) unit Injection
qac: Please refer to sliding scale for additional information.
25. multivitamin Liquid [**Hospital1 **]: Five (5) mL PO once a day:
Please give through the G tube.
26. warfarin 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO daily at 4pm:
Please adjust dose to keep INR between [**1-22**]. Please give through
G-tube.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 16662**] Skilled Nursing Facility
Discharge Diagnosis:
Sepsis, urinary source, catheter-related, with gram-negative
rods (facility-acquired)
Discharge Condition:
Mental Status: Complete expressive aphasia (non-verbal)
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted for Foley catheter re-insertion (by
urology)and noted to have a complicated urinary tract infection.
You responded well to Ceftriaxone IV, and should complete a 10
day course of antibiotics. The exact bacteria and sensitivities
in the urine are still pending, so your current treatment is
empiric.
Followup Instructions:
Please contact Dr.[**Name2 (NI) 825**] office to make an poointment to
follow up for the indwelling Foley catheter. [**Name8 (MD) 770**], M.D., [**Doctor First Name 1158**]
P
Department:Surgery
Division:Urology
Organization:[**Hospital1 18**]
Office Location:[**Hospital1 **]. 5th FL: [**Location (un) 86**] [**Numeric Identifier **]
Office Phone:([**Telephone/Fax (1) 5278**]
|
[
"2760",
"5990",
"42731",
"V5861",
"2859",
"2449",
"4019"
] |
Admission Date: [**2167-8-25**] Discharge Date: [**2167-8-30**]
Date of Birth: [**2115-12-11**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 51-year-old man with a
past medical history of metastatic esophageal cancer and
recent back surgery, who presented with new onset shortness
of breath. Per the family since Sunday, the patient had
becoming increasingly short of breath. He had not been able
to get out of a chair or exert himself secondary to this
shortness of breath. He feels that he is able to take a deep
breath. He also described increasing lower extremity edema.
Four-to-five pillow orthopnea. He has not had any recent
fevers, chills, and cough, but he has been "gurgling" and
sounding congested per his family. He has had no nausea or
vomiting. He has had diarrhea, had three episodes of large
volume loose stool since Sunday. He took Imodium for two
days, and has not had a bowel movement since.
On date of admission, his oxygen saturation was 82%, so the
patient was taken to the Emergency Room. He was found to
have a new pleural effusion, which was drained. The
preliminary results looked like an exudate with 26 atypical
cells likely from a malignancy. The patient feels that his
breathing has improved since the tap.
REVIEW OF SYSTEMS: The patient has not eaten since [**Month (only) 205**]. He
has had a 45 pound weight loss. He has taken occasional sips
of Gatorade, but the patient describes the sense of not being
able to swallow. The family states that he does not cough
while swallowing.
PAST MEDICAL HISTORY:
1. Esophageal cancer.
2. Nephrostomy tube infection. He had started taking Cipro
on [**Month (only) 2974**]. Today is day 4 of 10.
3. Back surgery.
4. Depression.
5. Normocytic anemia likely secondary to anemia of chronic
disease.
6. Hypertension.
7. Hypercholesterolemia.
8. Acute renal failure.
MEDICATIONS:
1. Zoloft 100 mg p.o. q.d.
2. Protonix 40 mg p.o. q.d.
3. Lisinopril 10 mg p.o. q.d.
4. Colace 100 mg p.o. b.i.d.
5. Magnesium two tablets p.o. q.d.
6. MS Contin 15 mg p.o. b.i.d.
7. Nystatin swish and swallow.
8. Calcium carbonate and ergocalciferol 50,000 units q week
being held secondary to hypercalcemia.
9. Sertraline 100 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is a former smoker.
FAMILY HISTORY: He has a sister with [**Name (NI) 4278**] disease and a
mother with breast cancer.
PHYSICAL EXAM ON ADMISSION: His vitals: In the Emergency
Room, his temperature was 95.0, heart rate of 110, blood
pressure 102/76, respiratory rate of 20. He was 91% on room
air. He was put on a nonrebreather, given Lasix, and he was
93% on nonrebreather. In general, he was a somnolent white
male lying in bed. HEENT: His oropharynx was clear.
PERRLA. EOMI. He had mild exophthalmus. Mucous membranes
were slightly dry. Neck was supple. He had 9 cm of JVD, no
lymphadenopathy. Heart: He had a loud S1, S2. He had a
regular, rate, and rhythm, no murmurs, rubs, or gallops.
Lungs were clear to auscultation bilaterally except decreased
breath sounds half way up bilaterally. Abdomen was soft,
nontender, nondistended. Bowel sounds were present. He had
bilateral nephrostomy tubes in place. Extremities are warm
and well perfused. He had 3+ pitting edema, 2+ pulses
throughout.
LABORATORY DATA: Significant for a white count of 19.4 on
admission. His Chem-7 was within normal limits. His coags
on admission were significant for a PT of 17.6, INR of 2.1.
His urinalysis showed large blood, moderate leukocyte
esterase, small bilirubin, 100 protein, trace ketones, [**11-12**]
white blood cells, and many bacteria. His LFTs were within
normal limits. His LDH was 390.
EKG showed sinus tachycardia at 100 beats per minute.
STUDIES IN THE EMERGENCY ROOM: He had a CT of the head which
showed no hemorrhage.
A chest x-ray showed increased interval bilaterally and
pleural effusions right greater than left.
A urine culture from [**8-23**] showed Pseudomonas which was
sensitive to ciprofloxacin.
The patient was admitted to Medicine for further workup of
his shortness of breath.
REVIEW OF HOSPITAL COURSE BY SYSTEMS:
1. Pulmonary: Shortness of breath. The patient had improved
after paracentesis. It was felt that this was likely a
malignant effusion. He was continued on oxygen by nasal
cannula. The fluid was monitored for growth. It was felt
that it was unlikely to be an empyema, and Interventional
Pulmonology was consulted regarding whether or not his
effusion could be pleurodesed.
However, on the morning after admission, the patient
clinically deteriorated. He became hypoxic, hypotensive, and
tachypneic. He had increasing JVD almost to his ears. He
had a pulsus of 14. A STAT echocardiogram was done which was
negative for tamponade. A chest x-ray was done which showed
increasing right pleural effusion. At this time, the patient
was transferred to the ICU for further treatment.
In the ICU, a chest tube was placed by Interventional
Pulmonology. A central line was also placed for access. The
patient was intubated and placed on a ventilator.
On the 5th, CT was done to rule out pulmonary embolus, which
was negative. On the 6th, his endotracheal tube cuff
ruptured and Anesthesia was consulted, and they replaced the
endotracheal tube and the patient remained on the ventilator
until the time of his demise, at which time the endotracheal
tube was pulled.
2. Oncology: The patient was to have had a restaging CT on
admission. However, this was deferred due to his
deteriorating clinical status.
3. Cardiovascular: Patient had a history of hypertension.
He was initially maintained on his lisinopril for blood
pressure control. However, on the 4th, when he became
hypotensive, he was started on pressors in the unit. He was
initially weaned somewhat, however, he required increased
pressor support on the 7th, at which time, they decided to
call a family meeting, and it was decided at this time that
the patient should be made comfort measures only.
4. ID: Sepsis. While on the Intensive Care Unit blood
cultures grew gram-positive cocci. He was continued on
ciprofloxacin and Zosyn. During his ICU stay, Vancomycin was
added on the 5th as he had spiked a fever.
5. Renal: His creatinine was rising during his ICU stay
possibly secondary to the sepsis, versus hypotension, versus
the dye load from the CTA. He was volume repleted and close
monitoring was made of his renal status.
6. Cardiovascular: Patient had multifocal atrial tachycardia
and frequent ectopy during his unit stay. His electrolytes
were repleted, and they tried to avoid hypoxia.
7. GI: The patient had a nasogastric tube placed. Nutrition
was consulted. The patient received tube feeds during his
unit stay.
A family meeting was held on the 7th to discuss the patient's
deteriorating condition due to septic shock and his poor
prognosis especially given the metastatic esophageal
carcinoma. The family decided at the time to make the
patient comfort measures only. The pressor support was
withdrawn and the endotracheal tube was pulled.
At 7:45 p.m., on [**8-30**], there was no pulse, no
spontaneous respirations, no corneal or pupillary reflexes.
The patient's family was present. The attending was notified
and the family refused a postmortem exam.
DISCHARGE DIAGNOSES:
1. Metastatic esophageal cancer.
2. Nephrostomy tube infection.
3. Back surgery.
4. Depression.
5. Normocytic anemia.
6. Hypertension.
7. High cholesterol.
8. Acute renal failure.
9. Sepsis secondary to gram-positive cocci.
10. Hypoxia, respiratory distress requiring intubation.
11. Cardiac arrhythmias including multifocal atrial
tachycardia.
MARK [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3282**]
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2167-9-18**] 14:57
T: [**2167-9-21**] 06:08
JOB#: [**Job Number 46436**]
|
[
"5849",
"51881",
"0389",
"2720",
"4019"
] |
Admission Date: [**2131-7-7**] Discharge Date: [**2131-7-24**]
Date of Birth: [**2131-7-7**] Sex: M
Service: NB
HISTORY: Baby boy [**Known lastname **] [**Known lastname **] is twin B who was born at
25 1/7 weeks gestation by repeat C-section for intractable
preterm labor of a 34 year old G2, P2-3 mom. Pregnancy was
complicated by exploratory lap at 5 weeks to rule out ovarian
torsion. Otherwise, this was an unremarkable pregnancy until
the morning of [**7-7**] when mother experienced uterine
contractions. She presented to L&D approximately 4 cm
dilated. She received magnesium and betamethasone but labor
ultimately progressed resulting in need for C-section.
This infant emerged with good cry but electively intubated in/
the DR [**Last Name (STitle) **] inability to sustain adequate respirations. His
apgars were 7 at one and 7 at five.
Prenatal screens included O+ antibody negative, RPR
nonreactive, Rubella immune, hep-B surface antigen negative
and GBS unknown.
PHYSICAL EXAMINATION: The birth weight was 720 gm (25th
percentile). The length was 35 cm (50th percentile). The head
circumference was 23.5 cm (35th percentile). General -
preterm infant, small but appropriate for gestational age.
HEENT - minimal molding present, anterior fontanelle open and
soft, eyes fused, palate intact, EG tube in oropharynx, nares
clear. Chest - coarse inspiratory rales bilaterally with mild
respiratory distress including grunting, flaring and
retractions, symmetrical breath sounds. Cardiovascular -
regular rate and rhythm, normal S1 and S2, no murmur present.
Abdomen - nontender, nondistended, soft with no
hepatosplenomegaly, three vessel cord. Testes - nonpalpable.
Extremities - warm and well-perfused with 2+ pulses. Hips are
stable. Spine is intact. Neuro - moving all extremities
symmetrically. Tone is appropriate for gestational age.
HOSPITAL COURSE BY SYSTEM: Respiratory: [**Known lastname **] was
intubated at resuscitation with subsequent administration of
surfactant for HMD. He received a total of three doses of
surfactant with reasonable response. [**Known lastname **] was started on
HIFI at the time of NICU admit. His vent settings were
gradually weaned until transitioned to conventional on day of
life 4. We have continued to make gradual weaning of his vent
but at times requires increased support for hypercapnia. The
present settings are 20/5 with a rate of 30. His vent
settings have gone up in the last 24 hours with concerns for
possible reopening of his duct. [**Known lastname **] was briefly on
caffeine when his vent settings seemed low enough that he
might end up extubated. At present, we have discontinued the
caffeine as he still receives significant vent support.
Now that his PDA has reopened, he has required more support.
Currently, vent settings are 22/5 x 34 30-40%
Cardiovascular: [**Known lastname **] has had two courses of indomethacin
already for presence of a PDA. The first course was
administered on [**7-11**] with presence of a murmur. The second
course was administered on [**7-14**] when echo confirmed presence
of persistent duct. Follow-up study on [**7-16**] suggested that
the PDA was closed. However, in the past 24 hours, we have
had recurrent concerns with presence of a murmur, increasing
vent support and metabolic acidosis. An ECHO on [**7-23**] demonstrated
moderate-large PDA. In setting of twin with perforation
following third course of indocin and [**Known lastname 58558**] increasing
respiratory instability with rising creatinine, he is scheduled
to have PDA ligation this afternoon at [**Hospital3 1810**].
Throughout his hospitalization, [**Known lastname **] has been quite stable from
a hemodynamic standpoint with only early need of dopamine for
approximately 48 hours of life. He has had no further signs
of hypotension.
FEN: [**Known lastname 58558**] early course was significant for significant
weight loss with weight down well over 20 percent from birth
weight. With this significant weight loss, his fluids were
pushed all the way to 200 cc/kg per day. At present, we have
backed off on fluids and he receives 150 cc/kg per day. He has
received a maximum of 20 cc/kg of feeds but this has been d/ced
on [**7-20**] when he developed a significant metabolic acidosis.
[**Known lastname **] has been relatively stable from an electrolyte
standpoint with exception of early hypernatremia, now
resolved. His electrolytes on [**7-24**] are 138/3.6/100/22/38/0.8 (his
highest creatinine was 1.0 yesterday).
GI: [**Known lastname **] has had a prolonged course of hyperbilirubinemia
with almost a week of phototherapy. His most recent levels
have been within reason although we plan to continue
following them. The last bilirubin on [**7-20**] was 2.8 and 0.4.
HEME: Initial crit=49.8% Received first PRBC transfusion on
[**7-14**]. Hematocrit on [**7-23**] was 18% prompting a total of 35 cc/kg
PRBC. His last CBC was 18WBC, crit=33, plt=413 (~1 1/2 hours
after most recent transfusion). He will be transported to
[**Hospital1 **] OR with 50cc PRBC.
ID: [**Known lastname **] had an early rule-out sepsis with negative blood
cultures and a relatively reassuring CBC (white count of 4.4
of which 14 percent were polys and 0 percent bands). We
discontinued antibiotics after negative blood culture at 48
hours. With clinical decompensation on [**7-14**], blood culture
and CBC were again obtained. This culture ultimately grew
staph epi which was methicillin sensitive. [**Known lastname **] is
currently finishing a week long course of antibiotics for
this blood culture. We treated through the PICC line that was
present at the time of decompensation. He originally received
vancomycin and gentamicin but ultimately was switched to
oxacillin. Negative follow-up culture on [**7-16**] never
demonstrated presence of bacteria.
Neuro: [**Known lastname **] has had three normal head ultrasounds on [**7-9**]
and [**7-16**] and [**7-23**].
DIAGNOSES: Premature infant at 25 1/7 weeks gestation, twin
B.
HMD status post surfactant times three.
PDA status post indomethacin times two now requiring ligation.
Hypotension, resolved.
Hyperbilirubinemia, resolved.
Staph epi sepsis, [**7-14**], (treated with one week of
antibiotics).
Rule-out sepsis, negative cultures.
anemia. s/p PRBC transfusions.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31759**], MD
Dictated By:[**Name8 (MD) 58559**]
MEDQUIST36
D: [**2131-7-20**] 15:00:35
T: [**2131-7-20**] 16:23:46
Job#: [**Job Number **]
|
[
"7742",
"V053"
] |
Admission Date: [**2130-10-23**] Discharge Date: [**2130-10-27**]
Date of Birth: [**2083-8-25**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 3012**] is a 47 year old homeless male with alcohol abuse,
history of complicated withdrawl, seziures, PFO s/p CVAs with
most recent left middle frontal stroke in [**8-17**] as well as
pyomyositis/clavicular osteo treated with 6 weeks of vanco
completed in [**10-6**] who is transferred from [**Hospital1 882**] with altered
mental status. The patient left [**Hospital1 18**] AMA late last night
during treatment for ETOH intoxication/seizures, transaminitis.
He was reportedly found this morning in a train station and
brought to [**Hospital 882**] hospital. At [**Hospital1 882**] he was noted to be
delerious, his BAL was ???, he was treated with ativan for
presumed ETOH withdrawl. Their ICU was full so he was
transferred to [**Hospital1 18**]. CT head was first reported as normal, but
[**Hospital1 882**] called the [**Hospital1 18**] ED to say that there was ? hypodense
lesion in the right frontal lobe. Of note, during his previous
admission, he patient was seen by neuro for seizures and started
on Keppra with a plan to taper lamictal, there was some concern
that his seizures were related to a new CVA rather than ETOH.
He also had a resolving transaminitis of unclear etiology, [**Name (NI) 5283**]
U/S showed fatty infiltrate and no sign of cholelithiasis. His
lipase was elevated at 70, but patient refused to be NPO. He
also complained of right arm pain, Xrays revealed a
non-displaced fracture, [**Name (NI) **] saw him and did a nerve block. He
has known residual left arm weakness from prior osteo.
.
In the [**Hospital1 **] ED, V/S were HR: 103, BP: 126/85, RR:15 02 sa98% on
RA. He was agitated and required 4 point restraints. He was
treated for presumed ETOH withdrawl with Diazepam and Ativan x
???. His BAL was 79 and he was NOT noted to have seizure. He
had a FAST scan due to abraison on his abdomen which did not
show free fluid. OSH Head CT was reviewed by radiology and
preliminarily negative, repeat head CT w/o contrast was also
done and this showed no acute intracranial process.
.
On the floor, the patient was calm, alert and oriented x2, and
with prompting x3. He intermittently fell asleep during the
interview and his speech was somewhat garbled but he was easily
rousable and could relate details of the previous day. He is
unsure what happened after he left the hospital last night.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, headache, rhinorrhea, cough, shortness
of breath. Denied chest pain or tightness, palpitations. Denied
nausea, vomiting, diarrhea, constipation or abdominal pain. No
dysuria. Denied arthralgias or myalgias except in the left upper
extremity, unchanged from prior.
.
Past Medical History:
Past Medical History:
- Hepatitis C - untreated
- Alcohol Abuse with previous withdrawal seizures and DT's
- Depression
- C6-C7 disk degeneration spondylosis s/p C6-C7 anterior
diskectomy [**7-18**], fusion C6-7, anterior instrumentation C6-C7
with Dr. [**Last Name (STitle) 65184**].
- recent left frontal CVA as above with aphasia
- C6/7 spinal cord contusion [**4-17**] admission
- Thrombocytopenia, since [**4-17**]
- Anemia
- Leukopenia
- Medial orbital wall fracture [**3-19**]
- Panic attack [**6-17**]
Social History:
Social History: (per OMR notes)
He is homeless and lives in shelters or at his sister's home in
[**Location (un) **], NH. He smokes half a pack of cigarettes per day and
denies any drug use. Drinks alcohol daily, varies from 1 pint
to [**2-10**] gallon of vodka.
Family History:
Family History: (per OMR notes)
mother and father with stroke and hypertension.
.
Physical Exam:
Admission
Vitals: T: BP: P:114 R: 18 O2: 98% on RA
General: Alert, NAD
HEENT: Several small abraisons on face, no scalp tenderness,
sclera anicteric, MM dry, oropharynx clear.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, no murmurs, rubs.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
[**2130-10-27**] 0755:
At time pt left AMA, pt was AAOx3, was able to clearly state the
risks of leaving AMA even prior to being told the risks,
including possible death. Pt ackowleded these risks and chose
to sign AMA paperwork and leave AMA.
Pertinent Results:
WBC: 6.1
N:62.3 L:30.8 M:5.8 E:0.8 Bas:0.4
HCT: 36.5
PLT: 74
U/A with mod bact, [**4-13**] WBC.
Urine cx neg
Serum ETOH: 79
Serum Tox, Urine Tox: negative
ALT 345 AST 345 LDH 384
CK 3468 -> 1163
.
Images:
CT head w/o contrast (here [**10-23**]) and CT head [**Hospital1 882**]: prelim:no
acute intracranial process.
CT c-cpine: no acute fracture
[**2130-10-26**] 04:17AM BLOOD WBC-5.0 RBC-3.84* Hgb-11.3* Hct-33.7*
MCV-88 MCH-29.5 MCHC-33.7 RDW-16.0* Plt Ct-129*
[**2130-10-27**] 07:40AM BLOOD WBC-PND RBC-PND Hgb-PND Hct-PND MCV-PND
MCH-PND MCHC-PND Plt Ct-PND
[**2130-10-26**] 04:17AM BLOOD Glucose-101 UreaN-8 Creat-0.9 Na-139
K-3.7 Cl-106 HCO3-18* AnGap-19
[**2130-10-27**] 07:40AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND
K-PND Cl-PND HCO3-PND
[**2130-10-22**] 05:20AM BLOOD ALT-345* AST-345* LD(LDH)-384*
CK(CPK)-175* AlkPhos-62 TotBili-0.5
[**2130-10-23**] 06:27PM BLOOD ALT-387* AST-401* CK(CPK)-3042*
AlkPhos-62 TotBili-0.8
[**2130-10-25**] 03:57AM BLOOD ALT-289* AST-281* LD(LDH)-454*
CK(CPK)-3468* AlkPhos-55 TotBili-0.8
[**2130-10-26**] 04:17AM BLOOD ALT-273* AST-223* LD(LDH)-358*
CK(CPK)-1163* AlkPhos-58 TotBili-0.7
[**2130-10-26**] 04:17AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.9
[**2130-10-27**] 07:40AM BLOOD Calcium-PND Phos-PND Mg-PND
[**2130-10-23**] 08:30AM BLOOD ASA-NEG Ethanol-79* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2130-10-26**] 05:27AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.021
[**2130-10-26**] 05:27AM URINE Blood-LG Nitrite-POS Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
[**2130-10-26**] 05:27AM URINE RBC-379* WBC-214* Bacteri-NONE Yeast-NONE
Epi-0
[**2130-10-24**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2130-10-23**] URINE URINE CULTURE- NO GROWTH. FINAL.
[**2130-10-23**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
Brief Hospital Course:
[**Hospital Unit Name 153**] course:
# Altered mental status: most likely due to ETOH withdrawl that
he didn??????t finish during last admission when he left AMA. Also,
with pt??????s h/o seizure and stroke, both could also cause AMS.
Stroke is unlikely bc neuro exam was intact except for chronic
weakness in left arm s/p infection there. Seizure also less
likely bc pt??????s AMS persisted too long. Pt was maintained on CIWA
protocol. Initially, the scores were >20, requiring heavy doses
of IV Ativan and Valium. Code Purple was called during the
night of admission and pt was put in 4 pt restraints. Since
then, pt has imrpoved clinically over time, requiring less and
less of the benzos. Pt is currenlty on PO Valium PRN. Also,
Neuro was following, as per their recs, Keppra dose was inc to
1000mg [**Hospital1 **] and Lamictal was continued. A Lamictal level from
[**10-20**] is still pending. Medications that may reduce his seizure
threshold (i.e., fluoroquinolones, flagyl, antipsychotics) need
to be avoided. Also, they recommended to use zyprexa or
seroquel over halodol if needed for agitation. Also, pt has an
outpatient f/u appt with Neuro.
.
# Thrombocytopenia: Patient intermittently thrombocytopenic over
the last year. Most likely related to ETOH. His plts were
monitored daily. HIT seemed unlikely so SC Heparin was used for
ppx. Pt showed no acute signs of bleeding.
.
# Elev CK: Likely [**3-13**] to injury/ETOH. Hypothyroidism is a
possible cause as well, however TSH wnl recently. CK trending
down since admissionwith IVF hydration.
.
# Transaminitis: During Likely [**3-13**] ETOH abuse. Also, recent Hep
serologies indicate pt is HCV positive. Pt is HIV negative.
Recent [**Month/Day (2) 5283**] U/S with fatty infiltrate but no other abnormality.
Home meds Remeron and Simvastatin were held. Pt could benefit
from an outpatient f/u with liver service.
.
# History of PFO: Pt was continued full dose aspirin.
.
Pt was initially NPO when agitated/disoriented. Once more
stable, was advanced to clears, and ultimately a regular diet.
Pt was maintained on SC Heparin for DVT ppx.
.
On morning following MICU call out, pt signed out against
medical advice. Pt was able to clearly state the risks of
leaving the hospital, including possible death. Patient signed
the AMA form and left the hospital.
Medications on Admission:
Medications: (per D/C summary dated [**10-22**])
Keppra 750mg [**Hospital1 **], then increase to 1000mg [**Hospital1 **] on [**2130-10-25**]
Ativan 1mg [**Hospital1 **], then decrease to 1mg daily on [**2130-10-26**] for 3 days
then stop
Multivitamin Daily
Protonix 40mg Daily
Folate 1mg Daily
Thiamine 100mg Daily
Remeron 30mg QHS
Aspirin 325mg Daily
Fluoxetine 40mg Daily
Lamictal 200mg Daily
Chantix--unsure of dose, patient has been on for 4-6 weeks and
is still smoking
Discharge Medications:
1. Patient left AMA; instructed to resume previous medications,
as would not wait for medication update.
Discharge Disposition:
Home
Discharge Diagnosis:
# Seizures
# Epilepsy
# Alcohol withdrawl
# Left hospital AMA
Discharge Condition:
Against medical advice.
Discharge Instructions:
You were admitted with seizures which may be related to alcohol
withdrawl, and required an admission to the ICU. You have
chosen to leave the hospital against medical advice, which is
extremely dangerous, and you have been warned that you may die.
You acknowledged this risk, and exhibited understanding of this
risk, and signed the Against Medical Advice form.
Please seek medical attention if you develop more seizures or
alcohol withdrawl symptoms.
.
Please resume your medications as per prior to this
hospitalization. Your medications were not able to be updated,
as you refused to complete this hospitalization, and would not
stay for updating.
Followup Instructions:
outpatient epilepsy appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 877**] on [**11-24**].
We have made an appointment for you to see a neurologist on
[**2130-11-24**] at 1:30pm.
|
[
"2875"
] |
Admission Date: [**2155-10-27**] Discharge Date: [**2155-11-2**]
Date of Birth: [**2091-10-21**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 101878**] is a 63-year-old
female with a past medical history significant for
Methicillin-resistant Staphylococcus aureus pneumonia,
end-stage renal disease secondary to Lithium toxicity,
papillary thyroid cancer status post tracheostomy complicated
by vocal cord paralysis, and Crohn's disease who was admitted
to the Emergency Department on [**2155-10-27**] with hypotension
and fever after dialysis. This is the third week in a row
that this has happened.
She has been worked up for bacteremia in the past, and so far
only one of many blood cultures grew out Stenotrophomonas.
She has been on intravenous vancomycin and more recently
gentamicin for this blood culture. A recent TEE on
[**2155-10-21**] was without vegetation, and patient had an
ejection fraction of 55%.
REVIEW OF SYSTEMS: Patient denies cough, night sweats, or
sick contacts. She also denied nausea, abdominal pain,
vomiting, dysuria, hematuria, chest pain, or shortness of
breath. Her only other complaint was of hand/arm pain, which
is a chronic issue.
PAST MEDICAL HISTORY:
1. Methicillin-resistant Staphylococcus aureus of the left
lower lobe diagnosed 11/[**2152**]. MRSA screen in [**2154**] was
positive.
2. End-stage renal disease on hemodialysis for 11 years.
3. Papillary thyroid cancer status post tracheostomy that
was complicated by vocal cord paralysis.
4. Intention tremor secondary to Lithium.
5. Osteoporosis.
6. Crohn's disease status post ileostomy with history of
chronic diarrhea. History of perineal abscess status post
colectomy and a history of perineal abscesses.
7. Basal cell carcinoma of the right lower extremity.
8. History of recurrent right upper extremity AV graft
thromboses and pseudo aneurysm formation.
9. History of upper GI bleed secondary to NSAIDs.
10. Hypothyroidism.
MEDICATIONS ON ADMISSION:
1. Remeron 45 mg p.o. q. h.s.
2. Ambien 5 mg p.o. q. h.s.
3. Digoxin 0.125 mg p.o. q.o.d.
4. Synthroid 0.125 mg q.d.
5. Nephrocaps one q. Tuesday through Saturday, [**Year (4 digits) 1017**].
6. Protonix 40 mg p.o. q. day.
7. Premarin 0.625 mg p.o. q. Tuesday, Thursday, Saturday,
[**Year (4 digits) 1017**].
8. Oxycodone 10 mg q. Monday, Wednesday, [**Year (4 digits) 2974**] with
dialysis.
9. Oxycodone 10 mg q. 4 hours p.r.n.
10. Remegel 800 mg t.i.d.
11. Atrovent b.i.d.
12. Salmeterol q.d.
13. Phos-Lo 667 mg b.i.d. Tuesday, Thursday, [**Last Name (LF) 2974**], [**First Name3 (LF) 1017**].
14. Humibid two b.i.d.
15. Mucinex 600 b.i.d.
16. Heparin subcutaneously.
17. Lithium 700 mg with hemodialysis.
18. Fentanyl patch 125 mg q. 72 hours.
19. Elavil 75 mg q. h.s.
20. Mirtazapine 30 mg p.o. q. h.s.
21. Loperamide p.r.n.
22. Maprotiline 125 mg q. Tuesday, Thursday, Saturday,
[**First Name3 (LF) 1017**].
PHYSICAL EXAMINATION ON ADMISSION: Temperature 101.1 F,
blood pressure 91/53, pulse 78, respirations 17, satting 100
brisk sound and a high flow trach mask. Generally, patient
is in no acute distress. She is alert and oriented times
three. Patient has no voice but is able to clearly mouth
words. Neck: Trachea in place with thick white secretions.
HEENT: Pupils equal, round, reactive to light. Extraocular
movements intact. Heart sounds are normal. Lungs are clear.
Abdomen is diffusely tender; no rebound or guarding; no bowel
sounds. Extremities: No edema; with good pulses.
SIGNIFICANT LABORATORY DATA ON ADMISSION: White blood cell
count with 94% neutrophils and 0% bands, hematocrit 34.6.
Chemistries are within normal limits aside from the
creatinine of 3.8 based on creatinine and BUN between 5 and
8. Lactate is 2.20.
SUMMARY OF HOSPITAL COURSE:
1. Line sepsis: Patient was initially admitted to the
Medical Intensive Care Unit secondary to her hypotension and
concern about sepsis. She was stabilized with fluids and was
transferred to the floor the next morning. She has been
hemodynamically stable since. Blood cultures this
hospitalization were drawn daily and are still negative to
date. However, she was started empirically on vancomycin and
gentamicin which were dosed at dialysis.
Since this is the third week this has happened, she was
suspected to have a line infection from her Perm-A-Cath.
When this was removed and cultured, it grew out
Stenotrophomonas sensitive to Bactrim. Vancomycin and
gentamicin were discontinued and Bactrim started on
[**2155-11-1**]. Patient was afebrile after the first day, and
her white blood cell count came down nicely. She needs to
continue taking Bactrim to be dosed at dialysis for the next
two weeks.
2. End-stage renal disease: Patient continued to have
dialysis while an inpatient. As her Perm-A-Cath was removed,
a temporary catheter was placed in her groin for dialysis use
only. This was removed the day of discharge. Another
Perm-A-Cath was placed during this admission and is working
fine.
3. Chronic hand pain: This is a big issue with this patient
and is causing her to lose function of her hand. She is to
follow up in Pain Clinic on Tuesday, [**2155-11-4**]. She is to
continue to receive Fentanyl patch and Oxycodone p.r.n. and
also before dialysis as dialysis exacerbates her pain.
4. Bipolar disorder: Patient is to continue on her meds
which she was on prior to admission. The dosing of the
medication maprotiline was questioned, however, and this
needs to be readdressed by her primary doctor. In the
meantime it has been discontinued.
5. Trach and ostomy care: Continue as before admission. No
issues, needs, regards during this admission.
DISCHARGE DIAGNOSES:
1. Bacteremia from line infection.
2. Chronic renal failure.
3. Chronic hand/arm pain.
DISCHARGE MEDICATIONS:
1. Heparin 5000 units subcutaneous q. 8 hours.
2. Oxycodone 15 mg p.o. Monday, Wednesday, and [**Year (4 digits) 2974**] prior
to hemodialysis.
3. Atrovent two puffs b.i.d.
4. Salmeterol 50 mcg, one inhalation q. day.
5. PhosLo 667, one tablet, b.i.d. Tuesday, Thursday,
Saturday, [**Year (4 digits) 1017**].
6. Dextromethrophan-guaifenesin 5 to 10 ml q. 6 hours as
needed.
7. Ambien 5 mg p.o. q. h.s.
8. Amitriptyline 75 mg p.o. q. h.s.
9. Loperamide one p.o. q. 8 hours p.r.n.
10. Oxycodone 10 mg p.o. q. 3 hours p.r.n.
11. Estrogen 0.625 mg, one, p.o. q. Tuesday, Thursday,
Saturday, [**Year (4 digits) 1017**].
12. Protonix 40 mg, one, p.o. q. day.
13. Multivitamin, one, p.o. q. Tuesday, Thursday, Saturday,
[**Year (4 digits) 1017**].
14. Synthroid 125 mcg, one, p.o. q.d.
15. Digoxin 0.125 mg, one, p.o. q.o.d.
16. Mirtazapine 45 mg, one, p.o. q.h.s.
17. Lithium 600 mg three times a week following hemodialysis.
18. Tylenol p.r.n.
19. Simethicone p.r.n.
20. Fentanyl 125 mcg per hour; change every 72 hours.
21. Sevelamer 1600 mg t.i.d.
DISCHARGE INSTRUCTIONS:
1. Patient is to follow up with Pain Management on
[**2155-11-4**] at 10:30 a.m.
2. She is also to follow up with Dr. [**Last Name (STitle) 217**]
[**2155-11-18**] at 11 a.m.
3. She is also to follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], her primary
doctor, within the next week. She needs to call to make this
appointment.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To [**Hospital3 2558**].
DR.[**First Name (STitle) **],[**First Name3 (LF) 275**] 11-498
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2155-11-2**] 12:13
T: [**2155-11-3**] 22:01
JOB#: [**Job Number 108190**]
|
[
"0389",
"2449"
] |
Admission Date: [**2113-4-7**] Discharge Date: [**2113-4-19**]
Date of Birth: [**2039-4-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
73 year old man with history of HIV (last CD4 [**12-20**], VL<48, on
HAART), COPD, dCHF, a fib, PE on coumadin presents with 4 days
of increasing SOB and cough with green sputum. His symptoms have
been going on for about 4 days. He denied any fevers, chills,
sweats. He also denied any chest pain, nausea, vomitting. He did
report acute on chronic abdominal pain, which has had an
extensive and negative outpatient work up. Of note, he was
recently discharged from [**Hospital1 18**] in early [**2113-3-10**] for UTI,
superficial ulcer. Because his symptoms worsened over time, he
developed
.
In the ED, the patient presented with the following vital signs:
96.8 147/70 94 34 96%12L NRB. He was thought to be
initially with acute COPD was given 500cc NS and duonebs when he
became acutely dyspneic and was thought to have acute pulmonary
edema. He was given nitro SL to no avail. He was given nitro
paste again with no significant help. He then was given lasix
20mg IV ONCE but made no urine from this. He then was given
nitro gtt, which per ED resident seemed to help him, as did
bipap. He was given morphine for abdominal pain and respiratory
distress. He was also given levofloxacin 750mg IV ONCE,
azithromycin 500mg PO ONCE, ceftriaxone 1gm IV ONCE. His last
set of vitals were 67 111/76 21 98% on CPAP FIO2 60, PEEP
of 10.
Past Medical History:
# HIV disease, dx [**9-15**] likely secondary to heterosexual
transmission. ATRIPLA started [**12-17**]. Self-d/c meds due to side
effects. Last CD4 count [**2112-9-9**] was 123.
# Chronic kidney disease (baseline cr 1.0)
# Atrial fibrillation - off coumadin due to GI bleed
# Prostate cancer - Diagnosed 15 yrs ago, in remission s/p
hormonal and radiation therapy
# COPD, long ex-tobacco history, severe emphysema on radiography
# Pumonary Nodule: 2mm LUL lung nodule detected on CT chest
[**9-15**]
# GERD
# PUD, Had 'surgery' 40 yrs ago, likely a Billroth
# Anemia
# Lumbar radiculopathy, spinal stenosis
# Left shoulder rotator cuff tear with repair in [**10/2105**]
# Trichomonas
# Gout
# Hx of esophageal candidiasis
# Chronic left-sided abdominal pain, follows with GI here,
extensive negative workup as an outpatient
# Infrarenal abdominal aneurysm, measuring 3.6 cm on [**2111-12-31**]
Social History:
(per OMR and patient) He lives with his wife in [**Location (un) 686**] at an
[**Hospital3 **] and denies alcohol or drug use. He smoked for 60
years and quit recently.
Family History:
per OMR) No history of lung disease, cancer or CAD.
Physical Exam:
On admission:
GEN: Elderly man in moderate distress, tachypneic, diaphoretic
HEENT: anicteric,
RESP: CTA b/l with good air movement throughout, scattered
crackles, no wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, mild LUQ tenderness, no masses or
hepatosplenomegaly
EXT: no c/c 2+ edema bilaterally
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3.
Pertinent Results:
On admission:
[**2113-4-7**] 07:05PM BLOOD WBC-9.7# RBC-3.43* Hgb-11.7* Hct-35.9*
MCV-105* MCH-34.1* MCHC-32.6 RDW-16.5* Plt Ct-213
[**2113-4-7**] 07:05PM BLOOD Neuts-89.8* Lymphs-8.5* Monos-1.4*
Eos-0.1 Baso-0.3
[**2113-4-7**] 07:05PM BLOOD PT-23.5* PTT-23.9 INR(PT)-2.2*
[**2113-4-7**] 07:05PM BLOOD Glucose-127* UreaN-32* Creat-2.0* Na-138
K-4.9 Cl-105 HCO3-22 AnGap-16
[**2113-4-8**] 02:25AM BLOOD Glucose-165* UreaN-38* Creat-2.5* Na-136
K-5.4* Cl-106 HCO3-19* AnGap-16
[**2113-4-7**] 07:05PM BLOOD ALT-22 AST-21 LD(LDH)-397* AlkPhos-54
TotBili-0.5
[**2113-4-8**] 02:25AM BLOOD CK-MB-6 cTropnT-0.15*
[**2113-4-7**] 10:51PM BLOOD Type-ART Temp-37.8 PEEP-8 FiO2-60 pO2-32*
pCO2-51* pH-7.23* calTCO2-22 Base XS--7 Intubat-NOT INTUBA
[**2113-4-8**] 12:10AM BLOOD Type-ART PEEP-10 pO2-77* pCO2-33* pH-7.36
calTCO2-19* Base XS--5 Intubat-NOT INTUBA Vent-SPONTANEOU
[**2113-4-8**] 06:11AM BLOOD Type-ART pO2-83* pCO2-42 pH-7.29*
calTCO2-21 Base XS--5
[**2113-4-7**] 07:53PM URINE RBC-50* WBC->182* Bacteri-MANY Yeast-NONE
Epi-2
[**2113-4-7**] 07:53PM URINE CastGr-4* CastHy-21*
CXR on admission:
IMPRESSION: Given profound low lung volumes, it is difficult to
definitively diagnose a superimposed acute process above the
extensive linear reticular scarring seen at the lung bases.
Conceivably, there may be a superimposed consolidation at the
left lung base although this is not entirely clear. If clinical
management is dependent on determination, consider repeat x-ray
or CT for further characterization.
INDICATION: History of HIV, intubated in ICU for respiratory
failure.
COMPARISON: CT available from [**2113-3-13**] and [**2112-12-22**].
TECHNIQUE: MDCT-acquired 5-mm axial images of the chest were
obtained without the use of IV contrast. Coronal and sagittal
reformations were performed at 5-mm slice thickness. 1.25-mm
axial reconstructions were also obtained for further evaluation
of the pulmonary parenchyma.
FINDINGS: Again seen is severe centrilobular emphysema with
paraseptal blebs, the largest measuring 21 mm in diameter
located at the right base (3:32). There is increased
ground-glass opacity and atelectasis within the right upper and
middle lobes, partially obscuring a right upper lobe mass (3:22)
better seen on prior examinations. Increased septal thickening,
predominantly at the lung bases (3:34) are reflective of
mild-to-moderate pulmonary edema, worse since the [**2113-3-13**]
examination. A left lower lobe consolidation (3:37) is new.
Trace bilateral pleural effusions are present. The heart is
mildly enlarged. There is no pericardial effusion. The great
vessels are normal in caliber, re-demonstrating mild
atherosclerotic calcifications. Crescentic narrowing of the
trachea is reflective of tracheomalacia.
Prominent prevascular nodes measure up to 9 mm in diameter
(2:17), increased since the prior examination. Other scattered
axillary lymph nodes do not meet CT criteria for
lymphadenopathy.
Included views of the upper abdomen demonstrate transesophageal
catheter
terminating within the stomach lumen. Non-contrast enhanced
images of the
liver, gallbladder, pancreas, kidneys, spleen, small splenule
(2:43), and
adrenal glands are normal.
IMPRESSION:
1. Left lower lobe pneumonia.
2. Bilateral pleural effusions.
3. Increase in right upper and middle lobe atelectasis and
diffuse
mild-to-moderate pulmonary edema.
4. Spiculated right upper lobe nodule, obscured by neighboring
atelectasis
and edema, better appreciated on the [**2113-3-13**] examination,
remains
concerning for neoplasm.
MICRO:
URINE CULTURE (Final [**2113-4-11**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- =>64 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ 8 I
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- =>512 R
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
.
Blood Cultures: [**4-7**] and [**4-8**]: negative
.
CRYPTOCOCCAL ANTIGEN (Final [**2113-4-8**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
.
Legionella Urinary Antigen (Final [**2113-4-9**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
.
MRSA SCREEN (Final [**2113-4-10**]): No MRSA isolated.
.
Respiratory Viral Culture (Final [**2113-4-12**]):
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final [**2113-4-10**]):
Less than 60 columnar epithelial cells;.
Specimen inadequate for detecting respiratory viral
infection by DFA
testing.
Interpret all negative results from this specimen with
caution.
Negative results should not be used to discontinue
precautions.
Refer to respiratory viral culture results.
Recommend new sample be submitted for confirmation.
Reported to and read back by DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4091**] [**2113-4-10**] AT
12:18.
.
BAL: GRAM STAIN (Final [**2113-4-8**]):
RESPIRATORY CULTURE (Final [**2113-4-10**]):
>100,000 ORGANISMS/ML. Commensal Respiratory Flora.
YEAST. ~3000/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
LEGIONELLA CULTURE (Final [**2113-4-15**]): NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2113-4-8**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2113-4-9**]): NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary): YEAST.
ACID FAST SMEAR (Final [**2113-4-10**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
.
STOOL:
MICROSPORIDIA STAIN (Final [**2113-4-12**]): NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final [**2113-4-12**]): NO CYCLOSPORA SEEN.
FECAL CULTURE (Final [**2113-4-13**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2113-4-13**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2113-4-12**]):
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
Cryptosporidium/Giardia (DFA) (Final [**2113-4-12**]):
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2113-4-12**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
Catheter tip CULTURE (Final [**2113-4-17**]): No significant growth.
.
BDGlucan and Galactomman: NEGATIVE
.
Labs on Discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2113-4-19**] 04:05 7.2 2.63* 9.2* 28.0* 106* 35.0* 32.9 17.5*
307
DIFFERENTIAL Neuts Bands Lymphs Monos Eos
[**2113-4-19**] 04:05 87.1* 9.7* 2.4 0.7 0.1
BASIC COAGULATION PT PTT INR(PT)
[**2113-4-19**] 04:05 21.0* 24.9 1.9*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2113-4-19**] 04:05 104*1 24* 1.3* 137 4.3 104 25 12
Brief Hospital Course:
73 year old man with history of HIV (last CD4 [**12-20**], VL<48, on
HAART), COPD, dCHF, a fib, PE on coumadin.
.
# Hypoxic respiratory failure: Patient presented with 4 days of
increasing SOB and cough with green sputum and admitted to the
MICU on a NRB. CXR appeared to have LLL infiltrate so he was
empirically started on treatment for hospital acquired pneumonia
with Vanc/Cefepime/levofloxacin. On the night of admission, he
was intubated for clinically worsening respiratory failure. CT
chest showed consolidation in the LLL and emphysematous changes
throughout the rest of the lung. [**Last Name (un) **] and BAL was performed
which revealed frank pus in the left lower lobe which was
plugging the distal bronchioles. BAL sent for infectious
organisms but did not grow any bacteria, it did grow yeast but
B-glucan and galactomman were negative so this was felt to be a
contaminant. PCP and viral cultures were negative. ESBL
Klebsiella grew from the patient's urine (taken in the ED prior
to antibiotics) and this was presumed to be the cause of his
pneumonia as well. Therefore ABX were changed to
Vanc/[**Last Name (un) **]/Levoflox and he completed an 8 day course. Patient
was weaned from the vent and successfully extubated on HD #9.
He did well post-extubation and was weaned down to 4L-5L 02 via
NC by HD #12. He was continued on nebs post-extubation.
-patient will require pulmonary rehab
-patient will follow up with his outpatient pulmonologist as he
missed an appointment in the hospital.
-volume overload was contributing to his hypoxia in the hospital
and he was diuresed with 40 IV lasix daily for several days. He
appears to be more euvolemic now and has been restarted on his
home lasix 20mg po daily but may require additional doses of 40
IV lasix for volume overload
-Patient should remain on 1.5L Fluid restriction
.
#. UTI: Culture grew Klebsiella resistant to all ABX except
meropenem. He completed 8 days of meropenem.
.
#. Acute Kidney injury: On admission, creatinine was 2.6. This
resolved with IVF in the ICU and remained 1.1 to 1.3 for the
rest of his stay. His lamivudine and valganciclovir were
initially renally dosed and then changed back to full dose as
his creatinine improved.
-patient should have weekly chem7 particularly if he is
requiring diuresis with IV lasix.
.
#. Atrial fibrillation: Patient was admitted in afib with rates
<100. The patient developed a wide complex tachycardia and
cardiology looked at his strips and felt it was consistent with
Afib with RVR and abberence. He was started on diltiazem and
his rate improved and he had no more wide complex tachycardia.
When patient stabilized he was restarted on his home coumadin
1mg PO daily (restarted [**2113-4-18**])
-patient will need daily INRs until stabilized (INR on the day
of discharge is 1.9)
-patient should be monitored closely for bleeding as he
developed hemoptysis in the ICU while on heparin.
.
# Hemoptysis: Patient was put on heparin gtt given his history
of afib and PE. However he developed hemoptysis. Bronch did
not reveal a source of bleeding. Heparin was held and the
patient's hemoptysis slowly resolved. Patient was restarted on
his home coumadin on HD 11 and he had no more hemoptysis.
.
# HIV: Patient was continued on his home HAART, initially dose
adjusted Lamivudine for renal failure. Also continued on
Bactrim prophylaxis and valgancyclovir for CMV prophylaxis.
Patient's outpatient ID provider was [**Name (NI) 653**].
.
# Depression: Patient's home fluoxetine and mirtazipine held due
to his intubation. These medications were not initially
restarted after extubation due to delerium. Mirtazipine and
fluoxetine restarted on discharge.
-can uptitrate fluoxetine as needed as an outpatient
.
# Hyperglycemia: Patient is not a known diabetic. He was
intermittently hyperglycemic in the setting of acute illness and
has required a small dose of sliding scale insulin with humalog.
-He should be worked up for diabetes as an outpatient and may
reqiore oral hypoglycemics.
.
# Thrush: Patient noted to have oral thrush. Given his
immunocompromised status he was started on fluconazole for 14
days starting [**4-19**]
-needs LFTs checked in 1 week
-monitor INR very closely while patient on fluconazole
Medications on Admission:
1. abacavir-lamivudine 600-300 mg Tablet Sig: One (1) Tablet PO
once a day.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**12-11**] puff Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
3. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO at bedtime.
4. DILT-CD 120 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day. Capsule, Ext Release
24 hr(s)
5. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
8. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
9. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: Twenty
(20) mL PO QID (4 times a day).
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H as needed
for pain.
16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
18. ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*16 Tablet(s)* Refills:*0*
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. ergocalciferol (vitamin D2) 400 unit Tablet Sig: One (1)
Tablet PO once a day.
Discharge Medications:
1. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. abacavir 300 mg Tablet Sig: Two (2) Tablet PO once a day.
3. lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO once a
day.
5. atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR ([**Month/Day (2) 766**] -Wednesday-Friday).
8. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
11. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for abdominal pain.
13. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
14. insulin lispro 100 unit/mL Cartridge Sig: One (1) unit
Subcutaneous four times a day as needed for hyperglycemia: per
sliding scale.
15. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day.
16. mirtazapine 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 14 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Acute Respiratory Failure secondary to Pneumonia
Afib w/RVR and abherency
COPD
HIV
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with difficulty breathing. We believe
this was from pneumonia and we treated you with antibiotics.
You required intubation and mechanical ventilation. You were
able to wean off the ventilator. You also had a urinary tract
infection that we also treated with antibiotics.
.
Please follow up with your doctors as below.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2113-5-4**] at 4:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2113-5-4**] at 4:30 PM
With: DR. [**Last Name (STitle) 11071**] / DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Hospital Ward Name **], [**Name8 (MD) **] MD
Location: [**Hospital1 **]
DIVISION OF INFECTIOUS DISEASE
Address: [**Doctor First Name **], STE GB, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 457**]
*Please call the above number to schedule an appointment to see
Dr. [**Last Name (STitle) **] within 2 weeks.
Completed by:[**2113-4-19**]
|
[
"51881",
"5849",
"2761",
"5990",
"42731",
"V5861",
"5859",
"53081",
"311",
"4280",
"2767"
] |
Admission Date: [**2185-3-27**] Discharge Date: [**2185-4-2**]
Date of Birth: [**2131-9-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
s/p stroke
Major Surgical or Invasive Procedure:
PFO closure
History of Present Illness:
53 y/o male s/p R MCA stroke. Work-up was significant for a PFO
and Intra-atrial Septal Aneursym.
Past Medical History:
1. s/p Cerebrovascular Accident
2. Hypertension
3. Gastroesophageal Reflux Disease
4. Chronic shoulder pain
Social History:
Lives with his wife, has 2 children. Works as a contractor (has
been unable to go to work since Tuesday). No tob, etoh, or
drugs
Family History:
Mother-DM
[**Name2 (NI) 6419**] maternal grandparents had strokes. His grandfather was in
his 50's.
Physical Exam:
VS: 88SR 140/90 70" 283lb
General: WD/WN in NAD
Neuro: A&O x 3, no focal deficits noted. Strength 5/5
Skin: Warm, dry
HEENT: NCAT, PERRL, EOMI, anicteric sclera
Neck: Supple, -JVD, -Carotid bruits
Chest: CTAB, -w/r/r
Heart: RRR, -c/r/m/g
Abd: Soft, Obese, NT/ND, NABS
Ext: -c/c/e, -varicosities, 2+ pulses throughout
Pertinent Results:
[**2185-3-27**] 08:15PM BLOOD WBC-4.8 RBC-5.23 Hgb-15.7 Hct-44.3 MCV-85
MCH-29.9 MCHC-35.3* RDW-13.3 Plt Ct-162
[**2185-4-1**] 07:20AM BLOOD WBC-8.8 RBC-3.81* Hgb-11.4* Hct-32.9*
MCV-87 MCH-30.0 MCHC-34.6 RDW-13.6 Plt Ct-147*
[**2185-3-27**] 08:15PM BLOOD PT-13.8* PTT-25.1 INR(PT)-1.2
[**2185-4-2**] 06:00AM BLOOD PT-13.2 INR(PT)-1.1
[**2185-3-27**] 08:15PM BLOOD Glucose-92 UreaN-19 Creat-0.9 Na-140
K-4.0 Cl-106 HCO3-28 AnGap-10
[**2185-3-31**] 06:20AM BLOOD Glucose-128* UreaN-19 Creat-0.8 Na-137
K-4.0 Cl-102 HCO3-26 AnGap-13
[**2185-3-27**] 08:15PM BLOOD ALT-88* AST-59* AlkPhos-58 Amylase-36
TotBili-0.7
[**2185-3-31**] 06:20AM BLOOD Mg-1.9
[**2185-3-28**] 06:40AM BLOOD %HbA1c-5.7 [Hgb]-DONE [A1c]-DONE
[**2185-3-27**] 07:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026
[**2185-3-27**] 07:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
Pt. was admitted prior to surgery secondary to patient taking
Coumadin. Once admitted Heparin was started (Coumadin was
stopped before hospitalization). Pt. had Cardiac Cath on HD #2
which revealed normal coronaries. Pt was experiencing some
hematuria and a Urology consult was performed. On HD #3 pt was
brought to the operating room where she underwent a PFO Closure.
Please see op not for surgical details. Pt. tolerated the
procedure well and was transferred to the CSRU in stable
condition with a Neo and Propofol gtt. Later on op day, pt was
weaned from mechanical ventilation and propofol and was
successfully extubated. He was weaned off of Neo by POD #1. Also
on POD #1 pt was started on diuretics and b-blockade and
transferred to telemetry floor. On POD #2 pt was on Coumadin,
Chest tubes, epicardial pacing wires, and Foley were removed. Pt
quickly recovered, had an uneventful post-op course and by POD
#4 was at level 5 and was discharged. He would need to follow up
with neuro for homocysteine and cont. need for Coumadin.
Medications on Admission:
1. ASA 35mg qd
2. Coumadin
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Packet(s)* Refills:*0*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: then check with Dr.[**Name (NI) 58936**] office for continued
dosing.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Patent Foramen Ovale s/p Patent Foramen Ovale Closure
s/p Cerebrovascular Accident
Hypertension
Gastroesophageal Reflux Disease
Chronic shoulder pain
Discharge Condition:
good
Discharge Instructions:
no lifting > 10# or driving for 1 month
no creams, lotions or powders to incision
may shower, no bathing or swimming for 1 month
[**Last Name (NamePattern4) 2138**]p Instructions:
with Dr. [**First Name (STitle) **] in [**1-13**] weeks
with Dr. [**Last Name (STitle) **] when able
with Dr. [**Last Name (Prefixes) **] in 4 weeks
Completed by:[**2185-7-6**]
|
[
"4019",
"53081",
"V5861"
] |
Admission Date: [**2114-3-14**] Discharge Date: [**2114-3-22**]
Date of Birth: [**2055-12-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
[**2114-3-16**] Aortic Valve Replacement utilizing a 21mm St. [**Male First Name (un) 923**]
mechanical valve
History of Present Illness:
Mr. [**Known lastname 45480**] is a 58 year old male with known aortic stenosis.
Over the last year, he experienced worsening exertional chest
pain and shortness of breath. Cardiac catheterization in
[**2114-1-4**] confirmed aortic stenosis with an aortic valve
area of 1.09 cm2. Coronary angiography showed normal coronary
arteries. His most recent echocardiogram was from [**2114-3-4**]
which showed an aortic valve area of 0.8cm2 with peak/mean
gradients of 81/47 mmHg respectively. His LVEF was estimated at
60% with mild symmetric left ventricular hypertrophy. Based upon
the above results, he was admitted for surgical intervention.
Past Medical History:
Aortic Stenosis
Hypertension
Hypercholesterolemia
Social History:
Denies tobacco. Admits to one scotch drink per day. He is
single, lives with roommates. Spanish speaking, originally from
[**University/College **]. Came to United States about 15 years ago.
Family History:
Denies premature CAD.
Physical Exam:
Vitals: T 97.9, BP 122/80, HR 100, RR 20, SAT 96 on room air
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 2-3/6 systolic ejection murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2114-3-22**] 07:02AM BLOOD WBC-10.1 RBC-3.41* Hgb-9.9* Hct-28.9*
MCV-85 MCH-29.2 MCHC-34.4 RDW-13.9 Plt Ct-313
[**2114-3-22**] 07:02AM BLOOD PT-21.9* PTT-98.4* INR(PT)-2.1*
[**2114-3-21**] 06:40PM BLOOD PT-21.2* PTT-74.8* INR(PT)-2.1*
[**2114-3-21**] 07:25AM BLOOD PT-16.1* PTT-80.9* INR(PT)-1.5*
[**2114-3-21**] 12:32AM BLOOD PT-14.7* PTT-66.1* INR(PT)-1.3*
[**2114-3-20**] 04:02PM BLOOD PT-13.2* PTT-42.4* INR(PT)-1.1
[**2114-3-22**] 07:02AM BLOOD Glucose-104 UreaN-14 Creat-0.8 Na-138
K-4.4 Cl-103 HCO3-26 AnGap-13
[**2114-3-21**] 07:25AM BLOOD UreaN-13 Creat-0.7 K-3.8
[**2114-3-20**] 10:35AM BLOOD Glucose-145* UreaN-12 Creat-0.8 Na-139
K-3.9 Cl-103 HCO3-28 AnGap-12
[**2114-3-20**] 10:35AM BLOOD Calcium-7.9* Phos-3.7 Mg-2.6
Brief Hospital Course:
Mr. [**Known lastname 45480**] was admitted and first underwent dental extractions.
This was performed on [**3-15**] by Dr. [**Last Name (STitle) 2866**] without
complications. He was pretreated with Clindamycin. On [**3-16**], Dr. [**Last Name (STitle) **] performed an aortic valve replacement. For
surgical details, please see seperate dictated operative note.
Following the operation, he was brought to the CSRU for invasive
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated without incident. Low dose beta blockade was
resumed and diuretics were initiated. He maintained stable
hemodynamics and transferred to the SDU on postoperative day
one. He remained in a normal sinus rhythm as beta blockade was
advanced as tolerated. Warfarin anticoagulation was started and
dosed for a goal INR between 2.0 - 3.0 for his mechanical aortic
valve. He temporarily required Heparin for a subtherapuetic INR.
Over several days, he continued to make clinical improvments and
was cleared for discharge to home on postoperative day six.
Prior to discharge, arrangements were made with Dr. [**Last Name (STitle) **] to
monitor his Warfarin as an outpatient.
Medications on Admission:
Toprol XL 25 qd, Lipitor 20 qd, Aspirin 81 qd
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO qpm: Take daily
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic Stenosis - s/p Aortic Valve Replacement
Hypertension
Hypercholesterolemia
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Dr. [**Last Name (STitle) 45481**]' office will monitor Warfarin as outpatient. INR
should be checked within 48-72 hours of discharge. Warfarin
should be adjusted for goal INR between 2.0 - 3.0. VNA should
fax results to Dr. [**Last Name (STitle) **](Attn: [**First Name4 (NamePattern1) 717**] [**Last Name (NamePattern1) 20788**] RN) at
[**Telephone/Fax (1) 1989**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**3-8**] weeks, call for appt
Dr. [**Last Name (STitle) **], appt on [**2114-4-25**] @ 3PM
Dr. [**Last Name (STitle) 1789**] in [**1-6**] weeks, call for appt
Completed by:[**2114-3-22**]
|
[
"4019",
"2720"
] |
Admission Date: [**2173-12-8**] Discharge Date: [**2173-12-11**]
Date of Birth: [**2145-6-12**] Sex: M
Service: MEDICINE
Allergies:
Zinc Oxide
Attending:[**First Name3 (LF) 17865**]
Chief Complaint:
Intentional insulin overdose
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
28-year-old homeless man with DM1 admitted after an intentional
insulin overdose. He reports having taken 425U lantus and 100U
humalog around 345 pm today in an attempt to secure pain
medication and shelter given that it was raining. He denies
suicidality or a history of suicide attempt, psychiatric
disease, or psych hospitalization. He has admittedly done this
repeatedly in the past at other institutions. He reports having
being admitted at NYU 5 days ago, at which time he was treated
for insulin overdose, as well as for xanax withdrawal with
barbiturates. He was hospitalized at [**Hospital6 **]
yesterday and discharged with a list of shelters but he reports
that they were full. He has felt lightheaded and sweaty today
but has not lost consciousness. No fever, chills, cough,
shortness of breath, abdominal pain, nausea, or diarrhea. He
took a city bus to the [**Hospital1 18**] ED.
In the ED, initial V/S 97.4 103 170/102 16 100%RA. L EJ placed.
Started on D5 gtt. FS 333-209-133 at which point D10 gtt
started. FS then 66, given amp D50. Also given morphine 8 mg IV
for back pain. Vital signs prior to transfer 99 165/108 20 97%
RA.
On arrival in the MICU, complains of lower back pain radiating
down the left leg.
Past Medical History:
DM type 1
MSSA pneumonia complicated by empyema requiring chest tube
placement
MVA complicated by chronic back pain
hypothyroidism
Social History:
Homeless. Smokes 1 ppd. No ETOH. Rare MJ use. Former injection
drug user, none in 6 years.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals T 99.2 BP 148/104 HR 101 RR 18 02sat 100%RA FSG 103
GENERAL: Well-appearing, NAD
HEENT: PERRL
NECK: supple no JVD
CARDIAC: reg rate nl S1S2 no m/r/g
LUNGS: CTAB no w/r/r
ABDOMEN: soft NTND normoactive BS
EXT: warm, dry full distal pulses no c/c/e
NEURO: AA&Ox3, conversing appropriately
DERM: multiple tattoos
Pertinent Results:
[**2173-12-8**] 09:57PM BLOOD WBC-9.9 RBC-3.92* Hgb-11.9* Hct-35.0*
MCV-89 MCH-30.4 MCHC-34.0 RDW-17.2* Plt Ct-293
[**2173-12-10**] 01:37PM BLOOD WBC-7.5 RBC-3.81* Hgb-11.5* Hct-34.8*
MCV-91 MCH-30.2 MCHC-33.1 RDW-17.2* Plt Ct-267
[**2173-12-8**] 09:57PM BLOOD Glucose-67* UreaN-11 Creat-0.9 Na-141
K-3.9 Cl-107 HCO3-25 AnGap-13
[**2173-12-10**] 01:37PM BLOOD Glucose-137* UreaN-20 Creat-0.9 Na-136
K-4.7 Cl-99 HCO3-29 AnGap-13
[**2173-12-8**] 09:57PM BLOOD Calcium-8.9 Phos-4.8* Mg-2.0
[**2173-12-10**] 01:37PM BLOOD Calcium-9.4 Phos-4.7* Mg-2.0
[**2173-12-8**] 04:58PM BLOOD Type-ART pH-7.53* Comment-GREEN TOP
[**2173-12-8**] 10:26PM BLOOD Type-[**Last Name (un) **] pO2-45* pCO2-40 pH-7.43
calTCO2-27 Base XS-1
[**2173-12-8**] 04:58PM BLOOD Glucose-314* Lactate-2.9* Na-139 K-4.5
Cl-107 calHCO3-20*
[**2173-12-8**] 10:26PM BLOOD Lactate-1.0
[**2173-12-8**] 04:58PM BLOOD freeCa-0.93*
[**2173-12-8**] 10:26PM BLOOD freeCa-1.18
Cardiology Report ECG Study Date of [**2173-12-8**] 7:26:36 PM
Sinus tachycardia. Otherwise, normal tracing. No previous
tracing available for comparison.
Brief Hospital Course:
#Intentional insulin overdose - Treated with dextrose infusion
and maintained on hourly finger sticks. Glucose normalized and
patient transitioned to SC sliding scale insulin on hospital day
3. Evaluated by psychiatry who did not feel that 1:1
supervision, suicide precautions, or inpatient psychiatry
transfer were indicated.
Eloped on [**12-11**] and refused to sign AMA form, despite
acknowledging the risk of doing so, including brain injury,
coma, and death.
Medications on Admission:
insulin glargine 30 U
humalog sliding scale
oxycontin 80 mg TID
xanax 2 mg TID
Discharge Medications:
1. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous once a day.
2. Humalog 100 unit/mL Solution Sig: per sliding scale units
Subcutaneous at meals and bedtime.
3. OxyContin 80 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO three times a day as needed
for pain: do not drive or drink alcohol while taking this
medication.
4. Xanax 2 mg Tablet Sig: One (1) Tablet PO three times a day:
do not drive or drink alcohol while taking this medication.
Discharge Disposition:
Home
Discharge Diagnosis:
Intentional insulin overdose
Discharge Condition:
Eloped, refused to sign AMA form.
Discharge Instructions:
You were admitted to the hospital following an insulin overdose.
Your blood sugar rose to a normal range with a dextrose
infusion.
You left the hospital against medical advice despite
acknowledging the risk of doing so, including brain injury,
coma, and death.
Please feel free to contact Traveler??????s Aid at [**Telephone/Fax (1) 83756**]
for assistance with travel resources.
Followup Instructions:
If you remain in the [**Location (un) 86**] area, you may call [**Hospital1 771**] [**Hospital3 **] at ([**Telephone/Fax (1) 1300**]
for a primary care appointment at your earliest convenience.
Completed by:[**2173-12-11**]
|
[
"311",
"2449",
"3051"
] |
Admission Date: [**2111-9-13**] Discharge Date: [**2111-10-10**]
Date of Birth: [**2111-9-13**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] was the 3.050
kilogram product of a 34 week gestation born to a 38 year-old
G7 P4 mom with [**Name2 (NI) **] types O positive, antibody negative, RPR
nonreactive, Rubella immune, hepatitis surface antigen
negative. Mother with a placenta accreta prompting C section
on [**2111-9-13**]. Apgars were 7 and 8. The infant was
brought to the Neonatal Intensive Care Unit for further
management of prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Active, anterior fontanel
open and flat. Normal S1 and S2. Soft 1/6 systolic murmur.
Breath sounds coarse. Abdomen soft, nontender, nondistended.
Extremities warm and well perfuse. Tone appropriate for
gestational age.
HOSPITAL COURSE: 1. Respiratory: Baby boy [**Known lastname **] presented
on admission to the Neonatal Intensive Care Unit with
increased respiratory distress. Initial CPAP was attempted
and infant continued to progress. The decision was made to
intubate the infant. He received a total of one dose of
Surfactant and was extubated by 12 hours of life. He
remained on nasal cannula O2 for approximately 24 hours and
has been in room air without any further issues since that
date. [**Known lastname **] never received Methylxanthine therapy,
although has had mild desaturations associated with feedings.
No apnea per say. His last desaturation episode was on [**10-4**]
five days prior to discharge.
2. Cardiovascular: No issues during this hospital course.
3. Fluid and electrolytes: Birth weight was 3.050
kilograms. He was initially started on 60 cc per kilogram
per day of D10W. Enteral feedings were initiated on day of
life number one. Infant advanced to full enteral feedings by
day of life number three and is currently ad lib feeding
Enfamil 20 calorie taking in about 230 per kilogram per day
demonstrating adequate weight gain with his discharge weight
being 3820 grams.
4. Gastrointestinal: Peak bilirubin was on day of life
number three of 15.0/0.3. The infant received a total of
three days of single phototherapy and this issue has since
resolved.
5. Hematology: Hematocrit on admission was 45.8. He has
not required any [**Month/Year (2) **] transfusions or further hematocrit
checks.
6. Infectious disease: CBC and [**Month/Year (2) **] culture were obtained
on admission. CBC was benign. [**Month/Year (2) **] cultures remained
negative. At 48 hours Ampicillin and Gentamycin were
discontinued. He has had no further issues with sepsis
during this hospital course.
7. Neurological: Infant has been appropriate for
gestational age.
8. Sensory: Audiology screening has been performed and the
infant passed both ears.
9. Psycho/social: A social worker has been involved with
the family and can be contact[**Name (NI) **] at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital 1426**] Pediatrics,
telephone number is [**Telephone/Fax (1) 37802**].
CARE AND RECOMMENDATIONS: Feeds at discharge, continue ad
lib feeding Enfamil 20 calorie. Medications, not applicable.
Car seat position screening has been performed and the infant
passed. State newborn screens have been sent per protocol
and have been within normal limits. Immunizations received,
the infant received hepatitis B vaccine on [**2111-9-16**].
DISCHARGE DIAGNOSES:
1. Premature male infant born at 34 weeks.
2. Mild respiratory distress syndrome.
3. Mild hyperbilirubinemia.
4. Mild feeding coordination issues resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 37156**]
MEDQUIST36
D: [**2111-10-9**] 01:28
T: [**2111-10-9**] 13:53
JOB#: [**Job Number 51710**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2188-8-19**] Discharge Date: [**2188-8-22**]
Date of Birth: [**2124-2-3**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT:
Increasing shortness of breath at rest and dyspnea on
exertion.
Chest pain and increasing fatigue.
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old
gentleman with a questionable history of a myocardial
infarction in his 40s, which was medically managed. Over the
past three months, he has developed worsening shortness of
breath and anginal symptoms. In [**2188-6-11**], the patient
underwent an exercise tolerance thallium test which revealed
a left ventricular ejection fraction of 32%, down from a left
ventricular ejection fraction of 60% in [**2181**].
The patient was subsequently evaluated with a cardiac
catheterization on [**2188-7-23**], which revealed left main
20%, left anterior descending artery 50%, diagonal 50%,
diagonal two 80%, circumflex 100%, right coronary artery
100%, and left ventricular ejection fraction 41%. He was
subsequently evaluated for cardiac surgery.
PAST MEDICAL HISTORY: 1. Myocardial infarction. 2.
Insulin dependent diabetes mellitus. 3. Hypertension. 4.
Hyperlipidemia. 5. Chronic obstructive pulmonary disease.
6. Chronic right sided headache. 7. Gastroesophageal
reflux disease. 8. Peripheral vascular disease. 9.
Bilateral carotid endarterectomies. 10. Removal of penile
implant status post infection. 11. Left total knee
replacement. 12. Colonoscopy with polyp removal. 13.
Cataract, right eye.
SOCIAL HISTORY: The patient has a remote history of alcohol
abuse. He has an 80 pack year history of smoking.
MEDICATIONS ON ADMISSION: Aspirin 81 mg p.o.q.d., Prevacid
30 mg p.o.b.i.d., Zocor 20 mg p.o.q.d., Zestril 10 mg
p.o.q.d., atenolol 50 mg p.o.q.d., Procardia 60 mg p.o.q.d.,
and insulin Novolin 70/30 15 units q.a.m. and 16 units q.p.m.
ALLERGIES: Naprosyn and Vioxx (gastrointestinal distress).
REVIEW OF SYSTEMS: The patient denies weight loss, rash,
sinusitis. He has chronic obstructive pulmonary disease,
palpitations, orthopnea and paroxysmal nocturnal dyspnea. He
has no gastrointestinal symptoms. He has chronic left knee
pain, status post total knee replacement. He has bilateral
claudication in his legs and a history of bilateral carotid
disease. He has no history of cerebrovascular accident. He
has insulin dependent diabetes mellitus, no thyroid or
psychiatric history.
PHYSICAL EXAMINATION: On physical examination, the patient
had a heart rate of 54, respiratory rate 10, blood pressure
148/82. General: Well nourished gentleman appearing his
stated age, in no acute distress. Head, eyes, ears, nose and
throat: Normocephalic, atraumatic, pupils equal, round, and
reactive to light and accommodation. Neck: Supple, no
jugular venous distention. Lungs: Clear to auscultation
bilaterally. Cardiovascular: Occasionally irregular without
murmur, rub or gallop. Abdomen: Soft, nontender,
nondistended, positive bowel sounds. Extremities: Well
perfused with no cyanosis, clubbing or edema.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2188-8-19**] for coronary artery bypass grafting times
four. Grafts included a left internal mammary artery to the
left anterior descending artery, saphenous vein graft to the
diagonal, saphenous vein graft to the ramus and saphenous
vein graft to the posterior descending coronary artery. The
operation was performed without complication and the patient
was subsequently transferred to the Cardiothoracic Intensive
Care Unit.
The patient was weaned off drips and extubated. He was
adequately fluid resuscitated. On postoperative day number
one, the patient was felt stable for transfer to the floor.
The patient recovered well and uneventfully on the floor.
His Foley catheter and chest tubes were discontinued on
postoperative day number two. He was tolerating an oral
diet. He was ambulating well and his pain was under good
control on oral medications. On [**2188-8-22**], the patient
was felt stable for discharge to home.
Physical examination on discharge: Vital signs: Temperature
99.3, pulse 80, blood pressure 139/66, respiratory rate 20
and oxygen saturation 93% on three liters. Cardiovascular:
Regular rate and rhythm. Lungs: Clear to auscultation
bilaterally. Incision: Clean, dry and intact. Abdomen:
Soft, nontender, nondistended, positive bowel sounds.
Extremities: Without cyanosis, clubbing or edema.
DISCHARGE MEDICATIONS:
Simvastatin 20 mg p.o.q.d.
Atenolol 50 mg p.o.q.d.
Aspirin 325 mg p.o.q.d.
Prevacid 30 mg p.o.b.i.d.
Percocet one to two tablets p.o.q.4-6h.p.r.n.
Docusate 100 mg p.o.b.i.d.
Zestril 10 mg p.o.q.d.
Novolin insulin 70/30 15 units q.a.m. and 15 units q.p.m.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to home.
FOLLOW-UP: The patient was instructed to follow up with Dr.
[**Last Name (STitle) **] in four weeks and with Dr. [**Last Name (STitle) **] in three to four
weeks.
DISCHARGE DIAGNOSIS:
Status post coronary artery bypass grafting times four.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 11235**]
MEDQUIST36
D: [**2188-8-22**] 17:45
T: [**2188-8-22**] 18:59
JOB#: [**Job Number **]
|
[
"41401",
"4019",
"53081",
"2720",
"412",
"V1582"
] |
Admission Date: [**2176-2-26**] Discharge Date: [**2176-3-1**]
Date of Birth: [**2104-10-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
Upper endoscopy performed on [**2176-2-29**] showing no ulcerative
lesions.
History of Present Illness:
Mr. [**Known lastname 10840**] presented to the [**Hospital1 18**] ED after 2 days of nausea.
Upon arrival to the Emergency room, he began to vomit. He was
denying abdominal pain, back pain, and lightheadedness. He has
continued to have bowel movements. He has no history of
abdominal surgery.
Past Medical History:
PMHx/PSurgHx:
--a fib w/ tachy-brady syndrome s/p pacemaker placement on
[**2174-2-1**] by Dr. [**Last Name (STitle) 284**] @ [**Hospital1 18**]
--AAA s/p endovascular repair by Dr. [**Last Name (STitle) 1111**] [**2-10**] with known
endoleak per records.
--Type II diabetes, insulin-dependent
--Bilateral LE fx s/p fixation 20 yrs ago
--Morbid obesity
--Sleep apnea
--HTN
--diabetic retinopathy
--CHF most likely diastolic as has preserved EF 55%
--Pulmonary artery hypertension
--Hyperlipidemia
--Chronic venous stasis
--Prior syncope
--Arthritis
-- Cardiac Cath [**4-11**] [**2-9**] to abnormal stress which showed no
significanty blockage. One vessel coronary artery disease.
Normal LV systolic function. Mild LV diastolic dysfunction.
No significant subclavian stenosis on the right or left.
Angioseal of right femoral artery.
- Restrictive pattern on PFT's [**3-11**]
Social History:
Social Hx: lives w/ wife, no tobacco for 25 yrs (>100 pack-year
hx), social EtOH, former heavy drinker, retired realtor/salesman
Family History:
non-contributory
Physical Exam:
In the emergency room:
Vital signs: T 97.6, HR 81, BP 175/94, RR 16, Sat 100 % room air
Alert and oriented x3, no acute distress
Lungs clear to auscultation bilaterally
Cardio: Clear S1, S2
Abdomen: Obese, non-tender
Rectal: Guiac negative
Palpable femoral and popliteal pulses bilaterally
Pertinent Results:
[**2176-2-26**] 11:40AM BLOOD WBC-10.9 RBC-5.22 Hgb-13.3* Hct-40.0
MCV-77* MCH-25.4* MCHC-33.2 RDW-16.4* Plt Ct-246
[**2176-2-26**] 11:40AM BLOOD Glucose-212* UreaN-26* Creat-1.4* Na-137
K-7.2* Cl-103 HCO3-25 AnGap-16
[**2176-2-26**] 07:20PM BLOOD K-4.1
[**2176-2-26**] 11:40AM BLOOD ALT-22 AST-69* CK(CPK)-77 AlkPhos-82
Amylase-31 TotBili-0.4
[**2176-2-26**] 11:40AM BLOOD CK-MB-2 cTropnT-<0.01
[**2176-2-26**] 07:20PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2176-2-27**] 03:50AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2176-2-27**] 05:00AM BLOOD CK-MB-2 cTropnT-<0.01
[**2176-2-29**] 10:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2176-2-29**] 07:04PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2176-3-1**] 02:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
RADIOLOGY:
[**2-26**]: RUQ U/S: No prior studies for comparisons. The study is
significantly limited by patient habitus. The hepatic parenchyma
is not well visualized. Multiple shadowing gallstones are
present. The gallbladder is not significantly distended.
Allowing for the technical limitations of the study, no wall
edema is appreciated. There is diffuse right upper quadrant
pain, but no focal son[**Name (NI) 493**] [**Name (NI) **] sign. Main portal vein is
patent with appropriate hepatopetal flow and wave form.
IMPRESSION: Very limited study. Cholelithiasis.
[**2-26**]: KUB: Films are not specifically labeled as upright or
supine. Gas and stool are seen throughout the colon. No
air-filled dilated loops of large or small bowel are identified.
Possible small scattered fluid levels, but no findings to
suggest obstruction. No obvious intraperitoneal air, although
subtle abnormalities would be difficult to exclude on these
films, due to patient body habitus and technical factors. There
is scattered vascular calcification, with a stent in the lower
aorta and proximal common iliac vessels. There is osteopenia and
degenerative change of the lumbar spine. Apparent non-acute rib
fracture involving the left tenth rib. In addition, there is
deformity of the left iliac crest, not fully evaluated, but most
suggestive of sequela of remote trauma.
IMPRESSION: Bowel gas pattern within normal limits. No evidence
of obstruction. Stool noted.
[**2-27**]: CT ABD/PELVIS: There are ill-defined, focal opacities in
the visualized portion of the right middle lobe, with a
tree-in-[**Male First Name (un) 239**] appearance. This is a nonspecific finding and is
most likely infectious or inflammatory in etiology. There is
mild left base atelectasis. No pleural or pericardial effusions.
There is a nasogastric tube in place.
The stomach is distended, with gastric contents mixed with
contrast. There is a 5.5 x 2.7 cm duodenal diverticulum at the
third portion of the duodenum (sequence 2, image #35), as seen
on prior studies. There is stranding adjacent to the fourth
portion of the duodenum near the junction with proximal
(sequence 2, image #34). An ill-defined heterogeneous
hypoattenuating structure in the duodenal lumen most likely
represents intestinal contents. No abrupt narrowing is seen to
explain the gastric distension.
There are gallstones. The liver is unremarkable. No intra- or
extra-hepatic biliary ductal dilatation. The pancreas, spleen
and adrenal glands are normal. There are multiple bilateral
renal cysts, the largest in the left kidney. Otherwise, the
kidneys are unremarkable, without hydronephrosis. No abdominal
lymphadenopathy or free fluid.
An endovascular AAA stent graft is again seen with a stable
endoleak present. There are extensive vascular calcifications,
including involving the celiac and SMA, however there are
secondary signs of bowel ischemia.
CT PELVIS: The urinary bladder is decompressed and contains a
Foley catheter. There are prostatic calcifications. The rectum
and sigmoid colon are unremarkable.
No suspicious osseous lesions.
Multiplanar reformatted images were essential in the delineation
of the above findings.
IMPRESSION:
1. Gastric distention without features to suggest a distal
obstruction.
2. Mild stranding involving the fourth portion of the duodenum
of uncertain significance. Clinical correlation recommended to
exclude possibility of duodenitis.
3. focal right middle lobe lung opacities consistent with
infectious or inflammatory process.
4. Endovascular stent graft within aortic aneurysm, with stable
endoleak.
5. Extensive vascular calcifications
Brief Hospital Course:
Mr. [**Known lastname 10840**] was admitted to the Vascular service complaining of
nausea and vomiting one day prior to a scheduled repair of his
Type 1 endoleak. Overnight HD1, he had a few episodes of
emesis, and a large emesis on HD2. A nasogastric tube was
placed and over the following 16 hours, 5600 cc of gastric
contents were evacuated. He was maintained NPO with his
nasogastric tube to suction. A total of 1600 cc was evacuated
from his stomach on HD3. Gastroenterology was consulted, and a
plan was formulated to perform an upper endoscopy on HD4 in the
ICU, as he had prior complications with endoscopy. He was
transferred to the TSICU on the evening of HD3.
On HD4, he was intubated, and his heart rhythm converted to
rapid atrial fibrillation. Cardiology was involved, and he was
stabilized with a diltiazem drip and an amiodarone drip. The
upper endoscopy was performed, and demonstrated no lesions. The
diltiazem drip was discontinued. His nasogastric tube was
removed, he was extubated, and he recovered well overnight with
an amiodarone drip in the TSICU. On the morning of HD5, his
amiodarone drip completed, and per his cardiologist, Dr.
[**Last Name (STitle) 73**], his amiodarone drip was stopped, and there was no
need for a taper. Mr. [**Known lastname 34858**] diet was advanced, and he
tolerated solid foods well. He is to have close follow up with
Cardiology, Vascular Surgery, and his PCP.
Medications on Admission:
lasix 20', ASA 325', humalin - 28U QD, lopressor 50",
simvastatin 10', lisinopril 5'
Discharge Medications:
1. Reglan 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
Disp:*120 Tablet(s)* Refills:*2*
2. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. Humulin N 100 unit/mL Suspension Sig: Twenty Eight (28) units
Subcutaneous once a day.
5. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Type 1 endoleak of aorto-bifemoral stent
Gastroparesis
Discharge Condition:
Good
Discharge Instructions:
Please call the office or return to the emergency room if you
experience:
--fever greater than 101.5 F
--nausea and/or vomiting that will not stop
--cold, numb feet
--new, severe back pain or abdominal pain
--fainting
Followup Instructions:
Call Dr.[**Name (NI) 5695**] office on Monday at ([**Telephone/Fax (1) 18181**] in
order to make an appointment to follow up, or to reschedule your
surgery.
Follow up with your PCP within the week.
Follow up with your cardiologist in [**1-9**] weeks. You may call Dr. [**Name (NI) 29964**] office at ([**Telephone/Fax (1) 12468**].
PACEMAKER CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2176-3-19**] 9:45
CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2176-5-8**] 10:00
[**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2176-5-14**] 10:00
|
[
"4280",
"V5867",
"4168",
"2724"
] |
Admission Date: [**2108-6-13**] Discharge Date: [**2108-6-14**]
Date of Birth: [**2026-9-20**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81 year-old Russian speaking male with a history of HTN, HL, DM,
CAD s/p CABG/PCI, CHF, PVD, multiple CVAs, and CRF who presents
with acute dyspnea from [**Hospital 100**] Rehab. It is unclear when the
dyspnea started, but nursing found him short of breath at 4am
and called EMS. His O2sats were 70-80 on RA, and he was put on
a NRB and brought to our ED.
.
Initial vs in our ED were: T 101.8 (rectal), P 101, BP 145/54,
RR 20, O2sat 92% on NRB. He was noted to be agitated and
tachypneic with bilateral rales on exam. Labs notable for a WBC
of 15.4 (82 N, 4 bands). CK 255 with mildly elevated CK-MB 17
(MBI 6.7) but trop 0.41; Cr 2.6 up from baseline 1.8-2 but
previous trops in OMR peaked at 0.17. BNP 3798. CXR showed
bilateral infiltrates consistent with pulmonary edema with
possible superimposed RLL pneumonia. ECG showed ST depressions
in the precordial leads with a RBBB. Cardiology was called due
to his history of CAD but felt this was demand in the setting of
tachycardia and renal failure. ASA was given. He was noted to
have a GI bleed in [**2104**] but Hct stable from baseline and guaiac
negative so started on heparin gtt. He also was also given
vancomcyin, levofloxacin, flagyl, and tylenol. BPs remained in
the 100s and patient appearing better after starting positive
pressure ventilation. He was confirmed DNR/DNI per documentation
and discussion with family. On transfer, VS: P 93 BP 108/36, RR
22, O2sat 94% on CPAP 8/5, 50%.
.
On the floor, pt appears uncomfortable and complains of
restraints. With Russian interpreter present, he reports feeling
short of breath as well as vague chest pain. He denies fevers,
cough. However, obtainment of history is limited given
dysarthria. Of note, he was recently admitted in [**5-/2108**] for
evaluation of chest pain and dyspnea. He ruled out for MI and
was felt to have angina and decompensated CHF in the setting of
poorly controlled and treated for CHF thought secondary to
poorly controlled hypertension. He refused cardiac cath.
.
Review of systems:
As above, otherwise limited history. Denies fever, chills.
Denies headache. Denies cough. Denies nausea, abdominal pain.
Past Medical History:
- Hypertension
- Hyperlipidemia
- Diabetes mellitus
- CAD s/p CABG (LIMA->LAD, SVG->OM, SVG->R-PDA) in [**12/2097**] and
BMS to SVG-PDA and DES to EIA and SVG-PDA ISR in [**12/2106**]
- CHF EF 45-50% in [**11/2106**], likely ischemic
- PVD s/p R fem-[**Doctor Last Name **] bypass, L fem-DP bypass, L SFA angioplasty
and patch
- History of multiple CVAs with right sided weakness, maintained
on aspirin and Plavix
- Chronic renal insufficiency
- Depression
- Anemia, melananic bleed in [**2104**] s/p negative EGD and
colonoscopy
- S/p appendectomy
- Previous ETOH abuse
- ?Gout, on allopurinol
Social History:
Per old d/c summary, patient is originally from [**Country 10363**].
Widowed. Has 4 children, 3 in [**Country 532**]/[**State 3908**] and one daughter in
U.S. Living at [**Hospital 100**] Rehab since [**2103**].
- Tobacco: 60 pack-year
- Alcohol: H/o EtOH abuse but none now
Family History:
Unable to elicit
Physical Exam:
On admission:
Vitals: T 98.2, BP 93/55, P 91, RR 20, O2sat 93% on 100% face
tent
General: Oriented to [**Hospital1 **] and [**Month (only) 116**], agitated, dysarthric,
tachypneic and using accessory muscles
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, unable to assess JVP
Lungs: Bilateral rales and coarse breath sounds, no wheezes
CV: Regular rate with no appreciable murmur butdifficult to
asuculate Abdomen: Soft, obese, non-tender, bowel sounds
present, no rebound tenderness or guarding
GU: Foley in place
Ext: Distal feet slightly cool, unable to palpate DP/TP pulses,
trace LE edema
Neuro: Pt responding to questions and simple commands but exam
limited by cooperation
.
On discharge:
General: appears comfortable, in NAD, AOx2, speech is dysarthric
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, thick
Lungs: Bibasilar rales and coarse breath sounds
CV: Regular rate, nl S1/S2
Abdomen: Soft, obese, non-tender, BS+ normoactive, no rebound
tenderness or guarding
GU: Foley in place
Ext: feet cool, pulses appreciated with doppler, trace LE edema
Neuro: awake, alert, speech dysarthric, AOx2
Pertinent Results:
Admission labs:
===============
[**2108-6-13**] 05:30AM BLOOD WBC-15.4*# RBC-3.60* Hgb-10.6* Hct-31.6*
MCV-88 MCH-29.4 MCHC-33.5 RDW-16.3* Plt Ct-214
[**2108-6-13**] 05:30AM BLOOD Neuts-82* Bands-4 Lymphs-8* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2108-6-13**] 05:30AM BLOOD PT-15.5* PTT-25.9 INR(PT)-1.4*
[**2108-6-13**] 05:30AM BLOOD Glucose-105* UreaN-61* Creat-2.6* Na-144
K-3.4 Cl-113* HCO3-19* AnGap-15
[**2108-6-13**] 06:10PM BLOOD Glucose-245* UreaN-64* Creat-3.2* Na-142
K-5.3* Cl-108 HCO3-17* AnGap-22*
[**2108-6-13**] 05:30AM BLOOD CK-MB-17* MB Indx-6.7* proBNP-3798*
[**2108-6-13**] 05:30AM BLOOD cTropnT-0.41*
[**2108-6-13**] 12:16PM BLOOD CK-MB-72* MB Indx-9.3* cTropnT-2.80*
[**2108-6-13**] 06:10PM BLOOD CK-MB-83* MB Indx-9.7* cTropnT-3.56*
[**2108-6-13**] 07:39PM BLOOD CK-MB-88* MB Indx-9.6* cTropnT-4.03*
[**2108-6-14**] 02:01AM BLOOD CK-MB-80* MB Indx-9.5* cTropnT-4.15*
[**2108-6-13**] 05:30AM BLOOD Calcium-8.7 Phos-0.7*# Mg-1.6
[**2108-6-13**] 05:58AM BLOOD Lactate-2.3*
.
Discharge labs:
===============
[**2108-6-14**] 02:01AM BLOOD WBC-28.3*# RBC-3.40* Hgb-10.0* Hct-30.3*
MCV-89 MCH-29.4 MCHC-32.9 RDW-16.2* Plt Ct-216
[**2108-6-14**] 02:01AM BLOOD Neuts-74* Bands-13* Lymphs-2* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-0
[**2108-6-14**] 02:01AM BLOOD PT-17.5* PTT-93.9* INR(PT)-1.6*
[**2108-6-14**] 02:01AM BLOOD Glucose-137* UreaN-72* Creat-3.5* Na-145
K-5.2* Cl-110* HCO3-19* AnGap-21*
[**2108-6-14**] 02:01AM BLOOD CK(CPK)-839*
[**2108-6-14**] 02:01AM BLOOD Calcium-8.7 Phos-5.6* Mg-2.6
[**2108-6-14**] 02:01AM BLOOD Vanco-9.2*
.
Imaging:
========
CXR [**6-13**]:
1. Findings concerning for recurrent chronic edema, with
possible superimposed infection at the right base.
2. Stable cardiomegaly.
.
CXR [**6-14**]:
As compared to the previous radiograph, there is no substantial
progression of the pre-existing severe pulmonary edema. Massive
cardiomegaly. No evidence of left pleural effusion, on the
right, the presence of mild-to-moderate pleural effusion cannot
be excluded. The lung parenchyma shows no evidence of newly
appeared focal parenchymal opacities suggesting pneumonia.
.
Brief Hospital Course:
81 year-old man with HTN, HL, DM, CAD, CHF, PVD, CVA, and CRF
p/w dyspnea and hypoxia with evidence of decompensated CHF,
pneumonia, and elevated troponins.
.
# Acute on chronic systolic CHF - pt has EF 40-45% (on TTE in
[**2106**]) and had significant pulmonary edema on admission with
elevated BNP. CXR showed pulmonary edema with possible RLL
opacity. Exacerbation of CHF likely in setting of pneumonia and
NSTEMI, as below. He was started on a lasix drip for diuresis
and Cr began to rise to 3.5 at time of discharge. We discussed
goals of care with the patient's family who did not want any
aggressive measures of care and lasix drip was continued for
comfort. His beta blocker was restarted on discharge given
improvement in blood pressure, but [**Last Name (un) **] continued to be held
given renal dysfucntion.
.
# Pneumonia - Patient had fever, leukocytosis with left shift,
and possible RLL opacity which was concerning for HCAP given
that he is a long-term facility resident with recent
hospitalization 1 month ago. Aspiration pneumonia also on
differential given he is s/p CVA, dysarthric, and found to be
aspirating on speech/swallow evaluation. Legionella was
negative. He was started on vancomycin, zosyn, and levofloxacin
for HCAP coverage including double coverage of pseudomonas.
Sputum sample was contaminated. His WBC was rising at time of
discharge but he was afebrile and breathing comfortably on
shovel mask (100%) which he wore intermittently. He should
complete an 8-day course of his antibiotic regimen (last day =
[**2108-6-20**]). Though patient did not pass speech/swallow evaluation,
he expressed desire to eat and was continued on feeding for
comfort, despite risk of aspiration. Should have CBC trended at
rehab.
.
# NSTEMI: Pt reported vague chest and left arm pain on admission
and had elevated troponins above previous baseline which
continued to rise (had not peaked at time of discharge). His ECG
showed diffuse ST depressions consisted with NSTEMI. Discussion
was held with his family who did not want any aggressive
measures (i.e. cardiac cath) for management of his ACS and he
was placed on heparin drip for 24 hrs, full dose ASA and plavix.
Simvastatin was changed to atorvastatin and beta blocker
restarted prior to discharge.
.
# Acute on chronic renal failure: Cr 2.6 on admission above most
recent baseline of 1.8, increased to 3.5. [**Month (only) 116**] be related to
decreased renal perfusion in setting of decompensated CHF which
is worsened given MI. We continued gentle diuresis with lasix
drip for comfort of breathing given significant pulmonary edema
and Cr should be trended on discharge. Antibiotics and other
medications should be renally dosed. Should have Chem 7 trended
at rehab.
.
# Goals of care: As per discussion with patient and family
patient does not want escalation of care and is DNR/DNI. Family
wanted to focus on making patient comfortable and there should
be discussion of avoiding further hospitalizations given patient
has clearly stated that he does not wish to be treated and feels
that he is being "tortured" by medical care. As above, despite
aspiration risk patient was continued on feeding for comfort.
.
# DM: Continude home Lantus 70 units daily and sliding scale
.
# s/p CVA: Continue ASA and plavix
.
# PAD: Continued ASA and plavix
.
Medications on Admission:
Allopurinol 100 mg daily
Oxycodone 10 mg [**Hospital1 **]
Clopidogrel 75 mg daily
Pantoprazole 40 mg daiy
Simvastatin 80 mg qhs
Aspirin 325 mg daily
Zolpidem 10 mg qhs
Artificial tears 1 gtt qhs
Bisacodyl 10 mg daily
Docusate 250 mg qhs
Tobramycin-dexamth 1 gtt qhs
Isosorbide mononitrate 90 mg daily
Glargine 70 units daily
NPH 15 units AC?
Regular SS
Torsemide 10 mg daily
Losartan 50 mg id
Acetamminophen 650mg q6h prn
Hydralazine 100mg tid
Metoprolol succinate 150 mg daily
Guaifenesin 600 mg tid prn
Discharge Medications:
1. furosemide 10 mg/mL Solution Sig: [**3-15**] ml/hour Injection
INFUSION (continuous infusion): please titrate for comfort of
breathing or ~100cc/hr.
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. insulin aspart 100 unit/mL Solution Sig: per sliding scale
Subcutaneous four times a day.
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
8. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-5**]
Drops Ophthalmic HS (at bedtime).
9. tobramycin-dexamethasone 0.3-0.1 % Drops, Suspension Sig: One
(1) Drop Ophthalmic HS (at bedtime).
10. atorvastatin 80 mg Tablet Sig: One (1) ML PO DAILY (Daily)
as needed for cough.
11. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
12. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Imdur 60 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet
Extended Release 24 hrs PO once a day.
15. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) g
Intravenous Q48H (every 48 hours): last day = [**2108-6-20**].
16. piperacillin-tazobactam 2.25 gram Recon Soln Sig: 2.25 g
Intravenous Q8H (every 8 hours): last day = [**2108-6-20**].
17. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day: last day = [**2108-6-20**].
18. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
20. insulin glargine 100 unit/mL Solution Sig: Seventy (70)
units Subcutaneous once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary:
Acute on chronic systolic heart failure
Health care associated pneumonia
NSTEMI
Acute on chronic renal failure
Secondary:
DM2
s/p CVA
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 29901**],
You were admitted to [**Hospital1 18**] with an infection in your lungs which
may be due to aspiration of food. You were also found to have a
heart attack which likely worsened your heart failure and
resulted in fluid in your lungs, which made it difficult for you
to breathe. We gave you antibiotics and a medication to remove
fluid and your breathing imrpoved. We discussed with you and
your family that you did not want aggressive measures of care
and your heart attack was managed with medical therapy.
We have made the following changes to your medications:
- START lasix drip at the MACU (2-5mg/hour) for a goal urine
output of 100ml/hour to help your breathing. You can restart
your torsemide 10mg daily after you have enough fluid removed
with the lasix drip.
- START vancomycin, zosyn, and levofloxacin for a total of 8
days (last day = [**2108-6-20**])
- STOP your losartan until your kidney function improves
- DECREASE your allopurinol to 100mg every other day until your
kidney function improves
- DECREASE your metoprolol to 25mg [**Hospital1 **] until your blood pressure
improves
- STOP your hydralazine until your blood pressure improves
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You will follow up with the physicians at [**Hospital 100**] Rehab.
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2108-10-31**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2108-6-14**]
|
[
"486",
"41071",
"5849",
"4280",
"40390",
"5859",
"25000",
"2724",
"V4581"
] |
Admission Date: [**2129-8-10**] Discharge Date: [**2129-8-27**]
Date of Birth: [**2076-1-1**] Sex: F
Service: Medicine, [**Location (un) **] Firm
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
female with steroid-dependent asthma admitted to Medical
Intensive Care Unit on [**8-10**] directly from the Emergency
Department after presenting with rhinorrhea, and cough, and
severe hypoxia to low 70% on room air. Chest CT in the
Emergency Department showed multilobar infiltrates. CT
angiogram was negative for pulmonary embolus. The patient
was sent to the Medical Intensive Care Unit and treated with
Levaquin for community-acquired pneumonia, Solu-Medrol for
severe reactive airway disease, and albuterol and Atrovent
nebulizers. The patient was transferred to the medical floor
on [**8-15**], but persistent hypoxemia with a worsened
arterial blood gas forced the patient to be transferred back
to Medical Intensive Care Unit on 100% nonrebreather. The
patient was again treated with intravenous Solu-Medrol,
nebulizers, and continued on Levaquin. The patient did not
require intubation at any point during this hospital period;
however, was maintained on oxygen by face mask for more or
less the first week and a half of this admission and did not
seem to be improving significantly despite treatment. A
chest CT was repeated on [**8-17**] which showed a total left
lower lobe collapse and partial right lower lobe collapse
likely secondary to mucous plugging. The patient under
bronchoscopy on [**8-21**] which revealed significant diffuse
mucous plugging and partial left lower lobe collapse. The
patient improved significant after bronchoscopy and removal
of significant mucous plugs with increased aeration of lower
lobes on repeat chest x-ray and improved oxygenation on
decreased face mask oxygen. The patient was placed on
humidified oxygen via nasal cannula and transferred to the
medical floor on [**2129-8-23**].
PAST MEDICAL HISTORY:
1. Severe reactive airway disease first noted in [**2118**] at the
age of 43.
2. Atopic dermatitis.
3. Chronic idiopathic urticaria.
4. Samter's triad.
5. Gastroesophageal reflux disease.
6. Obstructive sleep apnea.
7. Osteoarthritis.
8. Status post sinus surgery in [**2122**].
9. Osteopenia.
ALLERGIES: The patient is allergic to NONSTEROIDAL
ANTIINFLAMMATORY DRUGS, ASPIRIN producing anaphylactic
response; also allergic to BIAXIN, PENICILLIN, and DONNATAL.
SOCIAL HISTORY: No tobacco. No alcohol. No intravenous
drug use.
FAMILY HISTORY: Daughter with reactive airway disease.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.6,
pulse 64 to 90, blood pressure 122/60, respirations 18,
oxygenation 96% on 4 liters humidfied oxygen via nasal
cannula. General appearance revealed Cushingoid female in no
acute distress, talking in full sentences with nasal cannula
oxygen. HEENT revealed pupils were equal, round, and
reactive to light. Tongue and mucous membranes with whitish
plaque not consistent with thrush. Mucous membranes were
moist. Sclerae were anicteric. Neck was obese with midline
trachea. No carotid bruits. Cardiovascular had a regular
rate and rhythm with normal S1 and S2. No murmurs.
Pulmonary revealed chest was clear to auscultation
bilaterally with decreased breath sounds at the right base.
No wheezes, crackles or rhonchi. Abdomen was obese, soft,
nontender, and nondistended, positive bowel sounds. No
striae. Extremities revealed no clubbing, cyanosis or edema,
2+ distal pulses. Neurologically, alert and oriented times
three; otherwise nonfocal. Skin revealed multiple ecchymoses
at intravenous and injection sites, positive "buffalo hump."
REVIEW OF SYSTEMS: No dysuria. No nausea, vomiting, or
diarrhea. No chest pain or palpitations, intermittent
dyspnea on exertion. Good appetite with excellent p.o.
intake. No fevers or chills.
LABORATORY DATA ON ADMISSION: White blood cell count 12.8,
with 91% neutrophils, no bands, and 11% eosinophils;
hematocrit 39.4, with MCV of 98, platelets 185. Sodium 137,
potassium 3.8, chloride 99, bicarbonate 28, BUN 18,
creatinine 0.6, glucose 89. Microbiology laboratories
revealed Legionella antigen negative. Sputum culture on
[**8-19**] with no excessive growth, likely oropharyngeal
contamination. Urine culture with multiple organisms
consistent with skin contamination. Blood cultures were
negative. Stool studies were Clostridium difficile negative.
RADIOLOGY/IMAGING: Chest x-ray on [**8-22**] with improved
right lower lobe aeration. No change in left lower lobe,
grossly clear, improved significantly from prior studies.
Chest CT on [**8-17**] showing complete left lower lobe
collapse secondary to mucous plugging with air/fluid levels
in bronchi, partial right lower lobe and right middle lobe
collapse; no pulmonary embolus, 2.1-cm low density lesion in
the right lobe of liver not consistent with simple cyst,
question hemangioma versus malignancy. Recommend follow-up
ultrasound for further evaluation.
Arterial blood gas on [**8-15**] revealed pH 7.45, PACO2 27,
PAO2 58.
HOSPITAL COURSE: This is a 53-year-old woman with severe
steroid-dependent reactive airway disease and greater than 10
hospital admissions for asthma in the past; now status post
Medical Intensive Care Unit admission secondary to acute
asthma flare likely secondary to community-acquired
multilobar pneumonia.
1. CARDIOVASCULAR: Echocardiogram showing greater than 55%
left ventricular ejection fraction. No focal wall motion
abnormalities. Normal left ventricle and right ventricle.
Elongated left atrium. Normal pulmonary artery pressures.
Trace tricuspid regurgitation. Trace mitral regurgitation.
Blood pressure was stable throughout admission.
2. PULMONARY: The patient with resolving asthma
exacerbation and resolving community-acquired pneumonia.
Solu-Medrol was decreased from 80 mg intravenously t.i.d.,
and eventually the patient was discharged on a prednisone
taper. The patient on 120 mg p.o. at the time of discharge,
to be tapered down to likely no less than 20 mg p.o. q.d., as
this is the lowest dose the patient has been able to achieve
in the last four years. The patient was continued on
Levaquin for community-acquired pneumonia. The patient will
complete a 21-day course of Levaquin. The patient was weaned
from humidified face mask oxygen to room air with occasional
p.r.n. use of humidfied nasal cannula oxygen. The patient
desaturated to 89% with walking two flights of stairs on room
air and was given home oxygen for p.r.n. use. Although the
patient is able to oxygenate around 96% on room air, she does
have intermittent desaturations not necessarily associated
with asthma exacerbations. The etiology of this dyspnea and
desaturation is rather unclear in light of normal
echocardiogram and no evidence of congestive heart failure.
The patient does not always associate shortness of breath
with asthma flare. The patient will continue albuterol
nebulizers p.r.n. as well as Flovent, Serevent, [**Last Name (LF) 103121**],
[**First Name3 (LF) **], Beconase, and prednisone at home. The patient with
Samter's triad and severe history of atopy. The patient was
to follow up with outpatient primary care doctor as well as
pulmonologist, Dr. [**Last Name (STitle) **]. Recommended the patient be
evaluated by an allergist specializing in pulmonary
allergies.
3. INFECTIOUS DISEASE: Multilobar community-acquired
pneumonia resolving on Levaquin. The patient was afebrile
with a white count of 10.3 at the time of discharge. Urine
cultures and blood cultures were negative. Extended course
of Levaquin prescribed due to delicate pulmonary status of
the patient.
4. ENDOCRINE: As the patient on high-dose steroids, a
regular insulin sliding-scale was written for; however, the
patient did not require insulin as blood sugars never
exceeded 167 during this admission. Likely glucose will
decrease as steroid taper continues.
The patient is osteopenic found at bone density some point in
the last 10 years. The patient was on Fosamax at one point
in time. The patient was given a prescription for
Fosamax 10 mg p.o. q.d. at the time of discharge.
Recommended the patient follow up with Dr. [**Last Name (STitle) **]
regarding this new medication.
5. PROPHYLAXIS: The patient was placed on heparin and
Protonix during this admission. Heparin was discontinued
once the patient began ambulating.
6. FLUIDS/ELECTROLYTES/NUTRITION: The patient taking
excellent p.o. throughout admission requiring no intravenous
fluids or electrolyte repletion.
MEDICATIONS ON DISCHARGE:
1. Prednisone 120 mg p.o. q.d. and steroid taper.
2. [**Last Name (STitle) 103121**] 20 mg p.o. b.i.d.
3. Serevent 2 puffs p.o. b.i.d.
4. Flovent 4 puffs p.o. b.i.d.
5. [**Doctor First Name **] 60 mg p.o. b.i.d.
6. Beconase 2 puffs to each nostril b.i.d.
7. Levaquin 500 mg p.o. q.d. times three days, to complete
a 21-day course.
8. Celexa 40 mg p.o. q.d.
9. Albumin nebulizers p.r.n.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: The patient to be discharged to home with
p.r.n. home oxygen.
DISCHARGE FOLLOWUP: Follow up with Dr. [**Last Name (STitle) **], primary
care physician. [**Name10 (NameIs) **] up with Dr. [**Last Name (STitle) **],
pulmonologist. Follow up with allergist. Pulmonary physical
therapy, steroid taper, Levaquin.
DISCHARGE DIAGNOSES:
1. Severe asthma exacerbation secondary to
community-acquired pneumonia with complete left lower lobe
collapse, partial right lower lobe collapse, significant
mucous plugging.
2. Steroid-dependent reactive airway disease.
3. Atopic dermatitis.
4. Chronic idiopathic urticaria.
5. Osteopenia.
6. Atopic dermatitis.
7. Samter's triad.
8. Gastroesophageal reflux disease.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 10996**]
MEDQUIST36
D: [**2129-8-27**] 15:13
T: [**2129-8-31**] 07:15
JOB#: [**Job Number 38856**]
|
[
"486",
"5180",
"53081",
"2720"
] |
Admission Date: [**2163-10-8**] Discharge Date: [**2163-10-9**]
Date of Birth: [**2101-5-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 3556**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Intubation attempted
Central line placed
History of Present Illness:
Patient is a 62 yo M w/PMHx of NSCL and SCC recently admitted at
the VA and treated for pneunomia in [**8-/2163**], who presents with
hemoptysis of one day's duration. Patient relates that he awoke
at 2:30 am and noted a small amount of blood when he coughed. At
approximately 6:30 am, the amount of blood had increased, and he
sought medical attention at the [**Hospital3 **] ED. He relates that
he coughed up about 100cc of bright red blood at that time. He
was transferred to [**Hospital1 18**] for further evaluation and management.
.
In the [**Hospital1 18**] ED, his vitals were T 97.6, HR 120, BP 102/64, and
oxygen saturation of 100% on 4L NC. He received 1 L NS, as well
as levaquin 750 mg.
.
In the setting of a recent admission to the [**Hospital **] hospital for a
pneumonia, and apparently in light of abnormal findings there,
patient underwent a bronchoscopy on [**2163-9-22**] at [**Hospital1 18**] through
interventional pulmonology which showed normal upper airways.
The right main stem and right upper lobe were normal and the
right lower lobe ended in a large cavity filled with purulent
secretions. Biopsies were taken and eventually showed extremely
scant fragments of atypical squamous epithelium and bronchial
tissue with necrotic debris and necrotic bronchial cartilage.
The left lower lobe demonstrated a long main stem stump with
surgical clips. Biopsies were also taken and showed scant
bronchial tissue and necrotic debris; no viable malignancy was
identified.
.
A CT done on [**9-29**] showed a cavitary lesion continuous with an
ulcerated bronchus intermedius.
.
ROS: Denies fever, chills, chest pain, N/V, palpitations, HA,
lightheadedness, dizziness. Notes he did feel SOB, has noted
some weight loss and increasing fatigue.
.
Past Medical History:
1. NSCLC s/p pneumonectomy ([**2151**]) and photodynamic therapy
activation and rigid bronchoscopy clean ([**7-11**]) out.
2. SCC diagnosed in [**2161**] at [**Location **], s/p
chemotherapy.
3. Chronic obstructive pulmonary disease, on 2L home O2
4. Hyperlipidemia.
Social History:
Lives w/ wife. Retired post-office worker.
Significant smoking history of >80 pack years, quit [**2150**].
Has prior history of asbestos exposure while working in shipyard
for the Navy.
Family History:
Father with emphysema and lung cancer. Mother with cancer
metastatic to bone. One sister with lung cancer, another sister
with lung and breast cancer. Children healthy.
Physical Exam:
Vitals - T 97.2 HR 126, BP 105/65, SaO2 95% on 5L
General - Chronically ill, thin male laying in bed, in NAD
although occasionally coughing up blood-tingled sputum. Speaking
in full sentences without any distress.
HEENT - NC/AT. MMM, no JVD.
Cardiovascular - Tachycardic, RR, no M/G/R appreciated,
hyperdynamic precordium.
Pulmonary - Absent lung sounds over left lung field, no egophony
or tactile fremitus noted over right field. Decreased BS at
right base.
Abdomen - soft, NT, ND, +BS
Extremities - warm, well perfused, no clubbing/cyanosis/edema.
Neurology - alert, oriented, no focal deficits.
Psych - pleasant, appropriate
Pertinent Results:
PFTs ([**2163-9-29**]):
Marked obstructive ventilatory defect. The reduced FVC is likely
due to gas trapping but a coexisting restrictive defect cannot
be excluded. Suggest lung volume measurements if clinically
indicated. The reduced DLCO suggests a perfusion limitation.
There are no prior studies available for comparison.
FVC 41% predicted
FEV1 27% predicted
FEV1/FVC 67% predicted
DSB 23% predicted
.
CT CHEST ([**2163-9-29**]):
1. Cavitary lesion continuous with an ulcerated bronchus
intermedius has non-aggressive appearing thickened wall with
smooth margins, but a small focus of soft tissue surrounding the
right middle lobe bronchus could be tumor. CT FDG PET-CT might
be able to localize tumor, but discrimination from the
inflammation of the large pocket may be problem[**Name (NI) 115**].
2. Focal fibrosis and traction bronchiectasis in the posterior
segment of the right upper lobe may be sequelae to radiation
therapy.
3. Status post left pneumonectomy with unremarkable left main
bronchus stump.
4. Severe apical predominant emphysema.
.
CXR ([**2163-10-8**]):
The patient is status post left pneumonectomy, with stable
opacification of the left hemithorax and shift of the
mediastinum. The left lung is relatively well aerated. There is
persistent left perihilar opacity, which may correspond to a
cavitated lesion, seen on the recent CT. There is no pleural
effusion and no pneumothorax. There is increase in interstitial
markings above the minor fissure, which may represent early or
atypical pneumonia or asymmetric edema. Interstitial septal
thickening due to lymphangitic tumor spread is also in the
differential diagnosis.
.
EKG: Sinus tachycardia @ rate of 128, some TWI in V5, V6, new as
compared to [**2162-2-3**] EKG. Early R wave progression (V1-V2)
unchanged.
.
[**2163-10-8**] 11:15PM GLUCOSE-82 UREA N-8 CREAT-0.5 SODIUM-138
POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-33* ANION GAP-14
[**2163-10-8**] 11:15PM CALCIUM-8.7 PHOSPHATE-3.4 MAGNESIUM-1.8
[**2163-10-8**] 11:15PM WBC-11.7* RBC-3.54* HGB-10.9* HCT-32.5*
MCV-92 MCH-30.8 MCHC-33.6 RDW-15.5
[**2163-10-8**] 11:15PM PLT COUNT-337
[**2163-10-8**] 01:33PM GLUCOSE-92 UREA N-6 CREAT-0.5 SODIUM-137
POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-35* ANION GAP-13
[**2163-10-8**] 01:33PM estGFR-Using this
[**2163-10-8**] 01:33PM WBC-10.4 RBC-3.83* HGB-11.7* HCT-35.6* MCV-93
MCH-30.4 MCHC-32.7 RDW-15.2
[**2163-10-8**] 01:33PM NEUTS-88.2* BANDS-0 LYMPHS-8.0* MONOS-3.4
EOS-0.2 BASOS-0.2
[**2163-10-8**] 01:33PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2163-10-8**] 01:33PM PLT SMR-NORMAL PLT COUNT-337#
[**2163-10-8**] 01:33PM PT-11.9 PTT-29.1 INR(PT)-1.0
Brief Hospital Course:
Patient was a 62 year-old man with a history of NSCLC s/p
pneumonectomy who presented with hemoptysis.
.
# Hemoptysis: Patient presented at outside hospital coughing up
bright red blood. In setting of his NSCLC and SCC, it was
concerning for several pathologies, including malignancy,
malignant erosion into a bronchial blood vessel, infection,
AVM/fistula, irritation, or trauma.
.
On night of admission, interventional pulmonology, thoracic
surgery, and interventional radiology all were involved in
evaluation of the patient. Thoracic surgery determined that
there was no appropriate surgical intervention. Embolization was
considered, but not immediately pursued due because the patient
only had one functional lung and obviously would have little
reserve capacity if embolization were to be completed. At the
time of initial evaluation, the patient was stable and
demonstrated no further evidence of bleeding. His hematocrit was
monitored overnight and stable.
He was started on broad antibiotic therapy (Vancomycin,
Levofloxacin, and Zosyn) to cover for any possible infectious
component to his symptoms. He was also given Codeine to suppress
his cough.
.
On the morning after admission, the intensive care team
evaluated the patient on morning rounds, who reported he was
doing well. As the team was leaving, patient began to cough up
copious amounts of bright red blood. The patient quickly
progressed to PEA arrest. The full medical intensive care team,
along with the assistance of the full surgical intensive care
team, coded the patient for approximately 30 minutes. During
this time he underwent intubation, central line placement, and
fiberoptic bronchoscopy. With every chest compression, he had a
large amount of blood coming up from the right mainstem. Due to
the absence of left lung and location of the tumor
erosion/cavity, it was not possible to obtain control of the
bleeding. At the end of the code, he had 2 - 3 liters of blood
outside the body as a result of hemoptysis. The most likely
explanation was that the tumor eroded into the main pulmonary
artery. He at no time regained a spontaneous pulse during the
code. Interventional pulmonology and interventional radiology
were also involved. He had been confirmed as a full code status
the night before. After the patient failed to respond to any
interventions, he was pronounced dead. His family was notified
and at the bedside shortly after he expired.
Medications on Admission:
Spiriva 18 mcg cap inhaled daily
- Advair 250/50, puff daily
- Preventil 90 mcg 1 puff 2x daily
- Albuterol 0.5% neb 3-4x daily
- Flunisolide Nasal Soln 25 mcg spray, 2 puffs each nasal 2x
day.
- Simvastatin 40 mg daily
- Codeine/Guafanesin PRN cough
- Prednisone 20 mg (tapering down from prior PNA/COPD
exacerbation)
Discharge Medications:
None, expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
[**Known firstname **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
|
[
"51881",
"2724"
] |
Admission Date: [**2159-3-26**] Discharge Date: [**2159-3-30**]
Date of Birth: [**2117-12-22**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 41-year-old gentleman
who is completely asymptomatic with a known history of a
heart murmur at the age of 18 with echocardiogram and known
mitral regurgitation. On his next evaluation, echo after
diagnosis showed aortic insufficiency and mild MR. [**Name13 (STitle) **] was
referred for serial echo's which he has had done over the
past several years. He has a known bicuspid aortic valve with
a dilated aorta. His exercise tolerance test was negative. He
underwent cardiac catheterization on [**2159-2-22**] which
an ejection fraction of 59%, normal coronaries, moderate AI,
and mild mitral regurgitation, and dilated ascending aorta.
MRI performed in [**2157-6-19**] showed moderate MR and an
ascending aorta of 4.7 cm, with a normal LV ejection
fraction.
PAST MEDICAL HISTORY:
1. L5-S1 sciatica.
2. Mild lactose intolerance.
3. Remote bilateral arm fractures and left fibular fracture.
PAST SURGICAL HISTORY: Includes right inguinal herniorrhaphy
and varicocelectomy.
MEDICATIONS ON ADMISSION: Claritin 10 mg p.o. daily and
p.r.n. antibiotics for dental work.
ALLERGIES: He had no known allergies.
PREOPERATIVE LABORATORY DATA: White count of 5.9, hematocrit
of 44.2, PT of 13.4, PTT of 25.4, INR of 1.1, platelet count
of 213,000. Urinalysis was negative. Glucose of 81, BUN of
19, creatinine of 0.9, sodium of 143, K of 3.8, chloride of
103, bicarbonate of 32, anion gap of 12. ALT of 20, AST of
18, alkaline phosphatase of 43, total bilirubin of 0.7, total
protein of 7.8, albumin of 4.9, globulin of 2.9, HBA1C of
5.5%.
RADIOLOGIC STUDIES: Preoperative chest x-ray showed no
abnormalities and was a normal chest x-ray.
Preoperative EKG showed a sinus rhythm at 77 with a normal
EKG [**Location (un) 1131**].
PREOPERATIVE PHYSICAL EXAMINATION: The patient was referred
to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] to address aortic valve replacement
and possible repair of his ascending aorta. The patient came
in to preadmission testing on [**2159-3-20**] prior to
admission, and on exam had a heart rate of 92 and regular.
Blood pressure on the right was 132/78. Blood pressure on the
left was135/84, 6 feet 6 inches tall, 225 pounds. An active
young man in no apparent distress. Skin was unremarkable. His
pupils were equally round and reactive to light and
accommodation. His EOMs were intact. His eyes were anicteric
and noninjected. He had no JVD. His neck was supple. His
lungs were clear bilaterally. His heart was regular in rate
and rhythm with S1 and S2 and faint diastolic and systolic
[**1-25**] murmurs. His abdomen was soft, nontender, and
nondistended with positive bowel sounds. He had no
hepatosplenomegaly or CVA tenderness. His extremities were
warm and well perfused with no cyanosis, clubbing, or edema.
No varicosities were noted. He was grossly neurologically
intact with a nonfocal exam. He was moving all extremities
with 5/5 strength. Alert and oriented x 3. He had 2+
bilateral femoral, DP, PT, and radial pulses.
HOSPITAL COURSE: The patient came in to the hospital on
[**2159-3-26**] and underwent aortic valve replacement by Dr.
[**First Name (STitle) **] [**Last Name (Prefixes) **] with a 29-mm pericardial CE tissue valve
and replacement of his ascending aorta with a 28-mm Gelweave
graft. He was transferred to the cardiothoracic ICU in stable
condition on a titrated propofol drip and a Neo-Synephrine
drip at 0.2 mcg/kg/min.
On postoperative day 1, the patient had been extubated
overnight. He remained on a Neo-Synephrine drip at 0.5
mcg/kg/min and on an insulin drip at 3 units per hour for
control of his blood sugars. Postoperatively, his white count
was 14.4, hematocrit was 26.8, and platelet count was
158,000. BUN was 17. Creatinine was 1.1. His INR was 1.3. He
began Lasix diuresis. His chest tubes remained in place for a
little bit of additional drainage, and weaning of Neo-
Synephrine began.
The patient was transferred out to the floor on the afternoon
on postoperative day 1. He had 1 episode of tachycardia in
the 90s to 100s, elevating to the 120s when he was out of the
bed to the bathroom. He was given additional Lopressor, and
this brought his blood pressure down to 80/40 and his heart
rate into the 90s. He was asymptomatic with this, and his
blood pressures slowly rose back into the normal range over
the evening. The patient was able to void after the Foley was
discontinued. He was seen on the floor and evaluated by
physical therapy. He began to work on ambulation with the
nurses. He was also evaluated by case management to arrange
for visiting nurse services when he went home.
On postoperative day 2, the patient was restarted on aspirin
therapy. He was taking Percocet for oral pain management. He
was continued with Lasix diuresis. He was doing very well. He
was encouraged to ambulate and to use his incentive
spirometry. Chest tubes remained in place for continuing
drainage. His Lopressor was increased to 25 mg p.o. b.i.d.
The patient was very comfortable and continued to work on
increasing his ambulation and his activity level.
On postoperative day 3, the patient was already doing level
IV activity and was started on his iron and vitamin C therapy
also. His chest tubes were removed. His pacing wires were
removed. His Lopressor was increased to 50 mg p.o. b.i.d. His
heart rate was 68, in sinus rhythm, with a blood pressure of
112/50, and discharge planning was begun.
On postoperative day 4, the patient was doing extremely well
without signs or symptoms of anemia. His hematocrit was 24.0.
He was saturating 97% on room air. In sinus rhythm at 90 with
a blood pressure of 134/80, respiratory rate of 18. He was
100.3 kilograms. He was alert and oriented with a nonfocal
neurologic exam. His lungs were clear bilaterally. His heart
was regular in rate and rhythm. He had no sternal drainage or
erythema. His extremities were warm with trace peripheral
edema. His right groin incision was also clean and dry.
DISCHARGE STATUS: The patient was discharged to home in
stable condition with VNA services with the following
instructions.
DISCHARGE INSTRUCTIONS:
1. To follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **], the primary care
physician, [**Last Name (NamePattern4) **] 1 to 2 weeks.
2. To follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5874**], his
cardiologist, in 1 to 2 weeks post discharge.
3. To follow up with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] in the office for
his postoperative surgical visit in 3 to 4 weeks post
discharge.
MEDICATIONS ON DISCHARGE:
1. Lasix 20 mg p.o. daily (for 5 days).
2. Potassium chloride 20 mEq p.o. daily (for 5 days).
3. Colace 100 mg p.o. twice a day.
4. Enteric coated aspirin 81 mg p.o. daily.
5. Percocet 5/325 1 to 2 tablets p.o. q.4h. p.r.n. (for
pain).
6. Ferrous gluconate 300 mg p.o. daily.
7. Vitamin C 500 mg p.o. twice a day.
8. Metoprolol 50 mg p.o. twice a day.
9. A single multivitamin p.o. daily.
DISCHARGE DIAGNOSES:
1. Status post aortic valve replacement and ascending aortic
repair.
2. L5-S1 sciatica.
3. Mild lactose intolerance.
4. Remote bilateral arm fractures and left fibular fracture.
CONDITION ON DISCHARGE: The patient was discharged to home
in stable condition with VNA services on [**2159-3-30**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2159-5-3**] 17:09:36
T: [**2159-5-3**] 19:11:49
Job#: [**Job Number 38158**]
|
[
"4241"
] |
Admission Date: [**2114-10-24**] Discharge Date: [**2114-11-3**]
Date of Birth: [**2050-7-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Left sided weakness, Left facial droop and headache
Major Surgical or Invasive Procedure:
[**2114-10-25**]: Right craniotomy for IPH evacuation
History of Present Illness:
64 year old right-handed man who was in his usual state of
health until [**2114-5-11**]. At that time, he was admitted to [**Hospital1 18**]
for a left parietal intraparenchymal hemorrhage with
intraventricular spread; he underwent EVD placement and a
ventriculocisternostomy for clot retrieval and was placed on
keppra. Etiology of the bleed was thought to be hypertensive.
The patient was eventually discharged in good condition. His
companion on the day of this admission, informs us that the
patient was ??????completely back to normal except for some mild
cognitive changes.??????
In [**Month (only) 216**], Mr. [**Known lastname 40029**] developed nausea and vomiting.
Noncontrast head CT revealed right frontal new hypodense area
with rim of hyperdensity in the area of prior flair
hyperintensity ([**7-19**]) which was concerning for evolving
hemorrhage versus abcess. The left parietal intraparenchymal
hemorrhage showed good resolution. The patient was admitted to
the [**Month/Year (2) 878**] service and had a
thorough work-up for a CNS cause of his nausea and vomiting.
MRI suggested that the R frontal lesion represented scar tissue
from prior premature removal of EVD by the patient. The overall
conclusion by the [**Month/Year (2) 878**] team was that the patient had an
unrelated (likely GI viral) cause of his nausea and vomiting.
The patient??????s symptoms resolved spontaneously.
On [**10-24**], the patient was speaking with his business partner
when he suddenly became ??????confused?????? and had weakness of the left
face, arm, and leg ?????? as per the business partner. EMS was
called and transported the patient to [**Hospital1 18**] ED. Code Stroke was
called.
Past Medical History:
-Hypertension
-diabetes
-hypercholesterolemia
-left parietal hemorrhage status post EVD and stereotactic
ventriculocisternostomy for clot retrieval
-BPH
-Depression
Social History:
He lives alone and is fairly independent. No EtOH. Remote
tobacco
Family History:
Father had ischemic stroke.
Physical Exam:
Exam Upon Discharge:
Alert, oriented to person, place and date. Intermittant
confusion, however easily redirected. PERRL, left facial droop,
left tongue deviation. Right upper and lower extremity full
strength and sensation.Left upper extremity is 2/5 strength
distally with 0/5 strength proximally. LLE is 4/5 strength in
all groups. Sensation is intact bilaterally. Wound is clean,
dry and intact, without erythema, or exudate.
Pertinent Results:
CT Head [**2114-10-24**]:
1)Right frontal parenchymal hemorrhage with surrounding edema,
mass effect
and approximately 6 mm leftward shift of normally midline
structures.
2)Evolving left parieto-occipital hematoma, containing 2 cm area
of
increased density, increased since the prior exam.
CT Head [**2114-10-25**]:
This is a post-op scan showing evacuation of the IPH,
pneumocephalus, and stable midline shift.
CT Head [**2114-10-26**]:
There is significant improvement. There is less pneumocephalus
and decreased midline shift.
Pathology: preliminary pathology report showing clot is
consistant with metastatic melanoma.
CT Torso: Revealed a RML pulmonary nodule and right apical
pleural bleb.
Brief Hospital Course:
The patient was admitted to the neurosurgery service with a new
IPH after being found confused with left facial weakness and
left arm and leg weakness. His neurologic exam worsened and he
was emergently taken to the OR for evacuation of the hemmorrhage
on [**2114-10-25**]. The patient remained intubated overnight. His
post-operative head CT showed pneumocephalus and evacuation of
the IPH.
On [**2114-10-26**] his repeat CT was much improved with decreased
midline shift and mass effect. The patient was following
commands when he was off sedation. He was extubated later that
day. A Dexamethasone wean began. He was evaluated by
speech/swallow that afternoon but he was too tired to really
participate. His NGT remained in place. He was transferred to
the neuro step down unit on [**10-27**]. The patient pulled out his
NGT overnight on [**10-28**].
On [**10-29**] he was re-evaluated by speech/swallow and was much
improved. He was started on a modified diet and did not require
replacement of the NGT. Preliminary pathology from the IPH
removed in the OR showed malignant neoplasm. Therefore although
his steroids were being tapered to off, he was restarted at 2 mg
[**Hospital1 **] on [**10-30**]. The patient worked with PT and OT and was OOB. The
recommended rehab. He was kept in the hospital until pathology
came back revealing metastatic melanoma. In the absence of
unknown primary source; consults to dermatology, heme/oncology,
opthomology, ENT and radiation/neuro oncology were obtain. Thus
far, primary lesion has not been identified. In this setting, he
was sent to undergo a PET scan to attempt to further identify a
lesion. Neuroradiation Oncologist recommended whole brain
radiation in the setting of this new diagnosis. He was
discharged to rehab facility with this follow up plan on [**11-3**].
Medications on Admission:
Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Amlodipine 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. Labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for Pain or T>101.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Right intraparenchymal hemorrhage, pathology consistant with
metastatic melanoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
- You have been prescribed Levetiracetam (Keppra) for
anti-seizure medication. This medication does not require blood
work for monitoring, however do not abruptly discontinue.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
You have sutures and staples in place. This need to be removed
10-14 days after your surgery. This may be done at the rehab
facility, or you may call [**Telephone/Fax (1) 2731**] to schedule an
appointment with the nurse practitioner for this to be done.
You have an appointment scheduled in the brain tumor clinic;
located on the [**Hospital Ward Name **] on the [**Location (un) **] for [**2114-12-3**] at 4pm.
Please call [**Telephone/Fax (1) 82424**] if you need to resechedule your
appointment. You will not require a MRI of the head, as this was
done during your acute hospitalization
Follow-up with Dr. [**Last Name (STitle) **] in [**4-16**] weeks with a non-contrast head
CT. Call [**Telephone/Fax (1) 2731**] to schedule this appointment.
Completed by:[**2114-11-3**]
|
[
"25000",
"4019",
"2720"
] |
Admission Date: [**2120-11-11**] Discharge Date: [**2120-12-5**]
Date of Birth: [**2092-11-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Milk
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
transfer from OSH with tamponade
Major Surgical or Invasive Procedure:
[**11-11**] right heart cath with pericardiocentesis
[**11-13**] pericardial window
[**11-20**] pericardiectomy
History of Present Illness:
28F with PMH of sarcoidosis s/p recent transbronchial lung
biopsy 2-3 weeks ago in [**State 2690**], who presented to [**Hospital3 **]
Sunday [**11-10**] with chest pain. Per her family, she was well for
approximately 1 week following the lung biopsy. Subsequently,
however, she began to complain of persistent CP, as well as
subjective fevers and night sweats. Her pain was sharp and
substernal, and lasted on the order of minutes. It was
positional, and was worse [**Doctor First Name **] trying to lie flat. Because of
this she began sleeping with 4 pillows to stay upright at night.
No SOB/PND at that time. Additionally, she complained of nausea
and vomited on several occasions. She was weak and complaining
of fatigue and malaise. She present to her Air Force Base in [**Location (un) 75174**] this past Friday evening with persistent CP and fevers.
An echo was reportedly performed at that time which showed a
pericardial effusion, and she was given the diagnosis of
pericarditis. Given her recent fevers, it was presumed to be
post-viral in etiology, and she was prescribed NSAIDS and
Percocet for pain control. She then flew to [**Location (un) 86**] with her
husband for vacation.
.
On Sunday morning she called her mother complaining of severe
chest pain, this time associated with shortness of breath, a new
complaint for her. She went to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. On presentation to
[**Hospital1 **], she was noted to have evidence of pericarditis on EKG
and labs (ESR elevation), and was begun on prednisone and
indomethacin. Troponins were 0.02, 0.05, 0.05. At 7AM this
morning [**11-11**] she was complaining of nausea and CP, then became
lethargic and unresponsive, and was not following commands.
Although not hypotensive, her extremities were cool and clammy.
Her urine output was noted to be zero overnight.
.
She had a stat CT head which was negative. She was urgently
intubated. Stat EKG showed diffuse 1-2mm ST elevations, and
bedside echo showed concentric LVH, large pericardial effusion
with early signs of tamponade with diastolic collapse of RA,
also ?mass outside pericardium. Stat labs showed K 6.5
(treated), Creatinine 4.0 from 0.9, ALT 6600, WBC 28 (12.2 day
prior). HCT 37 (33). Got 100mg solumedrol, given levoquin 500mg
x 1 and was urgently transferred to [**Hospital1 18**].
.
Upon arrival at [**Hospital1 18**] a stat bedside echo confirmed a large
pericardial effusion with L atrial diastolic collapse and
extrinic R ventricular compression. She was immediately taken to
the interventional suites for a R heart cath and
pericardiocentesis to be performed. The pericardial pressure and
RA pressure were noted to be identical at 33mmHg. Approximately
300cc of green purulent fluid was drained from the pericardial
space and sent from gram stain and culture. There was subsequent
separation of the pericardial and RA pressures.
.
Cardiac review of systems is notable for chest pain and 4-pillow
orthopnea to prevent CP. No paroxysmal nocturnal dyspnea, ankle
edema, palpitations, syncope or presyncope.
.
Past Medical History:
Sarcoidosis s/p recent lung biopsy in [**State 2690**]
"Borderline" diabetes diagnosed 1.5 years ago, diet controlled
Remote asthma history, has not used inhaler in >2 years
.
Cardiac Risk Factors:
"borderline" diabetes
.
Cardiac History:
no history of CABG, PCI, MI, or ICD
.
Social History:
Social history is significant for the absence of current or
former tobacco use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T , BP , pulsus measured at 14mmHg, HR , RR , O2 % on
Gen: intubated and sedated young AAF
HEENT: NC/AT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKG demonstrated diffuse 2mm ST elevations
.
2D-ECHOCARDIOGRAM performed on [**11-11**] demonstrated: Moderate
circumferential pericardial effusion with small right
ventricular cavity size and evidence of increased pericardial
pressure. Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function.
.
R HEART CATH performed on [**11-11**] demonstrated:
1. Right heart catheterization revealed equalization of
pressures
between RA, RVEDP and PAD. Mean RA as well as the pericardial
pressure were 30 mmHg. Initial PA saturation was 43%.
2. Close to 400 ccs of purulent yellow-green fluid was withdrawn
from
the pericardial space with separation of the mean RA and the
pericardial pressure. At the end of the case mean RA was 20
mmHg, mean PCWP was 26 mmHg, PA saturation improved to 64%,
pericardial pressure was 4 mmHg.
FINAL DIAGNOSIS:
1. Cardiac tamponade.
2. Successful pericardiocenthesis.
.
HEMODYNAMICS:
HEMODYNAMICS RESULTS BODY SURFACE AREA: 2.18 m2
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 34/33/33
RIGHT VENTRICLE {s/ed} 47/33
PULMONARY ARTERY {s/d/m} 47/34/40
PULMONARY WEDGE {a/v/m} 33/34/32
PERICARDIUM {m} 33
**CARDIAC OUTPUT
HEART RATE {beats/min} 105
RHYTHM SINUS
**% SATURATION DATA (NL)
PA MAIN 43
.
[**11-11**] Pericardial aspirate(Blood cult bottles) 4+ polys,
Prevotella, veillonella, peptostreptococcus, strep milleri
[**11-11**] Pericardial aspirate as above
[**11-12**] Urine Yeast
[**11-13**] Pleural fluid negative
[**11-13**] Pericardial tissue Strep milleri, veillonella
[**11-14**] Pleural fluid negative
[**11-15**] Sputum negative
10/5 Blood cult negative
[**11-15**] Urien yeast
[**2120-12-4**] 10:25AM BLOOD WBC-9.3 RBC-3.29* Hgb-9.9* Hct-28.9*
MCV-88 MCH-29.9 MCHC-34.1 RDW-14.9 Plt Ct-694*
[**2120-12-4**] 10:25AM BLOOD Plt Ct-694*
[**2120-12-4**] 10:25AM BLOOD Glucose-108* UreaN-33* Creat-3.4*# Na-142
K-4.2 Cl-105 HCO3-26 AnGap-15
[**2120-12-2**] 06:00AM BLOOD ALT-23 AST-20 LD(LDH)-265* AlkPhos-79
Amylase-82 TotBili-1.2
[**2120-11-12**] 03:36AM BLOOD %HbA1c-5.9
[**2120-11-25**] 09:10AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2120-12-3**] 06:10AM BLOOD Vanco-16.6
[**2120-11-25**] 09:10AM BLOOD HCV Ab-NEGATIVE
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 75175**] (Complete)
Done [**2120-11-18**] at 12:22:19 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Cardiac Services
[**Location (un) 830**], [**Hospital Ward Name 23**] 7
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2092-11-10**]
Age (years): 28 F Hgt (in): 68
BP (mm Hg): 161/80 Wgt (lb): 220
HR (bpm): 85 BSA (m2): 2.13 m2
Indication: Endocarditis. Pericardial effusion.
ICD-9 Codes: 424.90
Test Information
Date/Time: [**2120-11-18**] at 12:22 Interpret MD: [**First Name8 (NamePattern2) **] [**Name8 (MD) **],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2007W00-0:0 Machine: Vivid i-4
Echocardiographic Measurements
Results Measurements Normal Range
Pericardium - Effusion Size: 0.5 cm
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A prominent Chiari network is
present (normal variant). Normal interatrial septum. No ASD by
2D or color Doppler. Prominent Eustachian valve (normal
variant).
LEFT VENTRICLE: Overall normal LVEF (>55%).
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. [**Name13 (STitle) **]
mass or vegetation on mitral valve.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
mass or vegetation on tricuspid valve. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PERICARDIUM: Small pericardial effusion. Effusion
circumferential. Effusion echo dense, c/w blood, inflammation or
other cellular elements.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was sedated for the TEE.
Medications and dosages are listed above (see Test Information
section). No TEE related complications.
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. There is
no aortic valve stenosis. Trace aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The tricuspid valve leaflets are mildly thickened. There
is a small (0.5 cm) circumferential echo-dense pericardial
effusion. The aorta is free of plaque 5 cm above the aortic
valve and distal to 25 cm. The aorch and proximal descending
aorta were poorly visualized due to poor esophageal contact.
There is a prominent Eustachian valve vs. Chiari network (normal
variant).
IMPRESSION: No echocardiographic evidence of endocarditis. Small
circumferential pericardial effusion.
Electronically signed by [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD, Interpreting
physician
?????? [**2116**]
Brief Hospital Course:
The patient was admitted [**11-11**] with an infective pericarditis
with tamponade physiology, Cr 3.9 and oliguria, and Acute
Hepatitis with coagulopathy, likely "shock liver". Renal
ultrasound was negative for obstruction. She received an
emergent pericardiocentesis on [**2120-11-11**] with removal of 400cc
purulent green fluid and the tamponade physiology subsequently
resolved. She was started on empiric antibiotic treatment with
vanc/zosyn. She had a left VATS pericardial window on [**2120-11-13**]
for persistent purulent drainage. On [**11-14**], started CVVH due to
volume overload. She also had a bronchoscopy and transbronchial
biopsy for further evaluation of her mediastinal
lymphadenopathy. She continued to have a WBC to ~40s and her
antibiotic coverage was broadened to include flagyl for empiric
anaerobic coverage and fluconazole for yeast in urine cx. On
[**11-18**] she had a TEE which revealed a persistent pericardial
effusion. Due to persistent WBC and low grade fevers and
evidence of persistent pericardial effusion with purulent
drainage, she underwent a pericardiectomy and lymph node biopsy
on [**11-20**]. She underwent therapeutic bronchoscopy and BAL on
[**11-21**]. She remained intubated and was started on tube feeds. She
was switched from CVVHD to HD. She was extubated on POD #6. She
was transferred to the floor on POD #8. Creatinine and urine
output improved and dialysis was discontinued. Her antibiotics
for pericarditis were completed. She was cdiff positive and
continued treatment with flagyl. She was cleared for discharge
on [**12-5**] to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 86**] hotel where she will be for 2 weeks
completing oral vanco therapy, and then will return home to
[**State 2690**]. Pt is to follow up with her primary care as soon as she
returns to [**State 2690**], and have a nephrology consult immediately upon
her return.
Medications on Admission:
indomethacin
solumedrol
levoquin 500mg x 1 dose
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 caps* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3
TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
6. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): through [**12-17**].
Disp:*52 Capsule(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
tamponade, acute renal failure, shock liver, purulent
pericarditis
sarcoidosis s/p transbronch lung bx (TX), DM, mild asthma
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.
No lifting more than 10 pounds for 10 wweks.
No driving for one month until follow up with surgeon or while
taking narcotic pain medicine
Shower, no baths, and pat incisions dry.
Followup Instructions:
Dr. [**Last Name (STitle) 10543**] 2 weeks
Dr. [**Last Name (STitle) 914**] 4 weeks [**Telephone/Fax (1) 170**]
See Primary Care as soon as you return to [**State 2690**]
Make an appt. with a nephrologist as soon as possible after
return to [**State 2690**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2120-12-10**] 8:30
Completed by:[**2120-12-5**]
|
[
"5849",
"2762"
] |
Admission Date: [**2151-6-5**] Discharge Date: [**2151-6-9**]
Date of Birth: Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 3314**] is an 89-year-old
male with a past medical history significant for diabetes
mellitus and hypertension who presents with a two day history
of reflux like chest discomfort and shortness of breath who
was in his usual state of health until two days prior to
admission when he began to notice epigastric pain that was
relieved with Zantac. He had no epigastric pain the
following day, however two days prior to admission he had
increased shortness of breath with increased fatigue and
increased pallor noticed by his family. His dyspnea became
especially marked over the last 24 hours prior to admission
with severe dyspnea with walking up one flight of stairs on
the day of admission.
Mr. [**Known lastname 40282**] cardiac risk factors include a positive
tobacco history. He quit cigar smoking 12 years ago.
History of hypertension, history of diabetes mellitus, prior
congestive heart failure symptoms at baseline. The patient
has variable lower extremity edema and has been treated with
variable doses of Maxzide titrated to his level of edema. He
is very functional at baseline, able to walk one half block
before becoming dyspneic. He has no orthopnea and has no
paroxysmal nocturnal dyspnea.
On presentation to the Emergency Department, the patient had
a blood pressure of 80/40 with a heart rate of 75 and an exam
with bibasilar crackles. His electrocardiogram showed ST
segments, elevations in leads 2, 3 and AVF, as well as in
leads V5 and V6. He was given aspirin and started on a
heparin drip for suspicion of acute coronary syndrome leading
to hypotension. Due to his hypotension in the setting of
electrocardiogram changes, he was taken emergently to the
cardiac catheterization lab. His catheter showed a diffuse
tubular 80% mid LAD stenosis as well as an 80% D1 stenosis.
It showed a total occlusion of the OM2 of a non dominant left
circumflex. This lesion was stented. His OM1 was also
totally occluded with left to left collaterals established.
The RCA system demonstrated a total occlusion of a PDA with
left to right septal collaterals. Right heart
catheterization showed a right atrial pressure of 18, a
pulmonary artery pressure of 50/21 and a capillary wedge
pressure of 24.
ADMISSION PHYSICAL EXAM:
VITAL SIGNS: Heart rate 68, blood pressure 118/42,
temperature 96.8??????, respirations 11, O2 saturation 100% on 4
liters nasal cannula.
GENERAL: Well appearing, comfortable, giving appropriate
answers in no acute distress.
SKIN: Mucous membranes moist. Skin pale.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils are equal, round
and reactive to light and accommodation. Extraocular muscles
are intact. Sclerae white.
NECK: Jugular venous distention to the earlobe at head of
bed at 10??????. Carotids with normal upstrokes, no bruits.
CARDIOVASCULAR: Regular rate and rhythm, 3/6 systolic murmur
at the left lower sternal border, no rubs or gallops, normal
S1, S2.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Large umbilical hernia easily reducible and
nontender. Abdomen nontender, nondistended, positive bowel
sounds.
EXTREMITIES: 2+ edema bilaterally at the ankles, dorsal
pedis pulses bilaterally palpable.
RECTAL: Guaiac negative in the Emergency Department.
ADMISSION LABORATORY DATA: White count 9.6, hematocrit 23.0,
platelets 278. Differential 76 neutrophils, 0 bands, 9
lymphocytes. INR 1.2, sodium 135, potassium 4.8, chloride
100, bicarbonate 14, BUN 56, creatinine 2.1, glucose 401,
anion gap of 21, CK of 776, troponin greater than 50.
Lactate level was 10.6. Initial arterial blood gases was 729
pH, 32 PCo2, 136 PO2.
IMAGING: Chest x-ray showed increased vaginal markings
consistent with congestive heart failure.
PAST MEDICAL HISTORY:
1. Hypertension
2. Type II diabetes diagnosed in [**2122**], on oral agents for
the last 10 years.
3. History of prostate cancer diagnosed in [**2139**], status post
XRT and Lupron therapy.
4. Anemia with a baseline hematocrit of around 30 with a
recent negative colonoscopy.
ALLERGIES: No known drug allergies.
ADMISSION MEDICATIONS:
1. Verapamil 240 mg q day
2. Avandia 4 mg q day
3. DiaBeta 2.5 mg q day
4. Maxzide 37.5 to 75 mg po q day
5. Zoloft 50 mg po q day
6. Ambien 2.5 mg po q hs
SOCIAL HISTORY: Mr. [**Known lastname 3314**] lives with his son. [**Name (NI) **] has a
positive tobacco history, quit cigar smoking 12 years ago.
No alcohol history.
FAMILY HISTORY: Noncontributory.
INITIAL IMPRESSION: An 89-year-old male presented with chest
discomfort and shortness of breath with presentation
apparently due to recent myocardial infarction. Patient with
evidence of end organ dysfunction with elevated creatinine in
the setting of hypotension with his event now status post
stent to the left circumflex system at the OM2.
HOSPITAL COURSE:
1. CARDIOVASCULAR: Mr. [**Known lastname 3314**] did quite well status post
his cardiac catheterization. He was started on dopamine for
pressure support prior to arrival in the cardiac
catheterization lab. The stent of his left circumflex system
went without complication and he was transferred to the CCU
where he was quickly weaned off of dopamine. He was started
on aspirin and Plavix. He was then started on a beta blocker
and ACE inhibitor and these were titrated as tolerated by his
blood pressure. His lipid panel was excellent with an HDL of
71, an LDL of 58 and triglycerides of 40 so lipid lowering
drug which was initially started was discontinued prior to
discharge. A transthoracic echocardiogram was done on the
third hospital day which showed an ejection fraction of 30%
to 35% with mild left atrial enlargement. It showed 1+
mitral regurgitation as well as akinesis of the apex with
diffuse hypokinesis through the left ventricle. The patient
was maintained on telemetry throughout his hospital stay and
had minimal events on telemetry with only one episode of
nonsustained ventricular tachycardia of 5 beats on the day
after his intervention. He was otherwise in sinus rhythm
throughout his hospital stay.
2. HEME: Mr. [**Known lastname 3314**] was transfused 2 units of blood
during this cardiac catheterization and in the immediate post
catheterization. Due to an initial hematocrit of 23,
hematocrit improved to 24.5 with these transfusions. Despite
the small increase in hematocrit with 2 units of blood, it
was not thought that he was losing blood through his
gastrointestinal tract due to his negative stool guaiac test.
One additional unit of packed red blood cells was transferred
during his stay on the floor after transfer from the CCU.
His hematocrit remained around 25 at the time of discharge.
Epogen may be helpful for Mr. [**Known lastname 3314**] in the future, but
iron studies and Epogen level prior to initiation of therapy
would help guide therapy given his recent transfusions doing
these studies in approximately one month would be most
beneficial.
3. RENAL: The patient's creatinine on admission was 2.1,
however with improvement in his blood pressures and presumed
cardiac function after his intervention, his creatinine
improved back to baseline with a nadir of 1.0. He maintained
good urine output throughout his hospital stay.
4. GASTROINTESTINAL: The patient's liver enzymes on the
second hospital day were consistent with a shock liver
pattern. His AST was 1488. His ALT was 1310 with a normal
alkaline phosphatase of 74 and normal total bilirubin of 0.4.
His transaminases continued to trend down steadily throughout
his hospital stay with an ALT of 597 and an AST of 169 on one
day prior to discharge. He was also started on proton pump
inhibitor during this hospital stay for gastrointestinal
protection.
5. ENDOCRINE: The patient is normally on Avandia and
DiaBeta for his glucose control. His glucose was well
controlled with sliding scale insulin through his hospital
stay. On the day of discharge, his DiaBeta was restarted.
His Avandia should be held for several days after discharge
due to his elevated liver enzymes and should be restarted
when his liver function tests return to normal.
6. DISPOSITION: The patient was discharged from the
hospital with a plan for him to return to his home in [**State 16269**]. He should follow up with his primary care physician
within the week and have a repeat CBC, chem-7 and liver
function tests drawn at that time.
DISCHARGE CONDITION: The patient was discharged to home in
improved and stable condition.
DISCHARGE MEDICATIONS:
1. Atenolol 25 mg po qd
2. Lisinopril 5 mg po qd
3. Aspirin 325 mg po qd
4. Plavix 75 mg po qd x30 days
5. Pantoprazole 40 mg po qd
6. Ambien 2.5 mg po q hs
7. Zoloft 50 mg po qd
DISCHARGE DIAGNOSES:
1. Acute myocardial infarction
2. Status post stent to the OM2
3. Shock liver now improving
4. Acute renal failure now resolved
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Name8 (MD) 2061**]
MEDQUIST36
D: [**2151-6-9**] 08:04
T: [**2151-6-9**] 08:22
JOB#: [**Job Number **]
|
[
"4280",
"41401",
"5849",
"2859",
"25000",
"4019"
] |
Admission Date: [**2142-11-30**] Discharge Date: [**2142-12-15**]
Date of Birth: [**2113-3-3**] Sex: F
Service: CARDIOTHORACIC
Allergies:
vancomycin / Magnevist / IV Dye, Iodine Containing Contrast
Media
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2142-12-10**]
1. Mitral valve replacement with size #27-mm [**Company 1543**]
tissue valve.
2. Tricuspid valve exploration for possible vegetation.
History of Present Illness:
29 year old female that presented to
OSH with mild nausea, chest pain, abdominal pain, headache and
generalized weakness. Three days prior to presentation [**11-18**]
she
had left rehab AMA and left with PICC line and no antibiotics.
From [**Date range (1) 4359**] she admits to use of heroin but denied putting
anything in PICC, and was brought to the OSH emergency by
police.
She was admitted and continued to be treated for MRSA
endocarditis and now transferred for surgical evaluation
She had previously been discharged from OSH [**10-30**] to rehab for
ongoing antibiotic treatment for MRSA endocarditis with septic
emboli to her spine, lungs, spleen and was complicated by
anemia,
ATN, and skin infection
Discharged on Ceftazidime to complete [**11-5**]
and Linezolid to complete [**11-24**]
Concern for ATN - had presented with creatinine 1.13 [**11-22**] that
increased to 1.8 on [**11-26**] - of note had been receiving NSAID and
dehydrated per outside records.
[**11-26**] received blood transfusion with concern for reaction after
receiving 100 ml blood, tachycardia, chest pain and severe
itching - she was medicated with benadryl and symptoms resolved.
The next day she was premedicated, transfused with two units
with
no reaction.
She was started on MS contin with dilaudid for breakthrough to
prevent opiod withdrawal at the OSH
ID consult OSH - MRSA bacteremia with discitis, splenic infarct,
septic emboli, and mitral valve vegetation - on linezolid due to
renal failure that they felt was from vancomycin
Cardiology consult OSH - MRSA endocarditis involving mitral and
tricuspid valves
Past Medical History:
MRSA endocarditis
Acute tubular necrosis
Anemia
Genital herpes
Hepatitis C
MRSA abscesses
Intravenous drug use
VRE
MRSA bacteremia
Cellulitis
Septic emboli
Depression and anxiety with previous admissions
Asthma on inhalers at home
Transfer Diagnosis: Opoid dependence, anemia, hepatitis C,
gential HSV,
Past Surgical History
C section 18 months ago
Social History:
Lives with: friends (OSH records state homeless)
Contact: [**Name (NI) **] [**Known lastname 634**] Phone # [**Telephone/Fax (1) 90651**]
Occupation: does not work
Cigarettes: Smoked no [] yes [x] last cigarette -last week Hx: 1
ppd since age 12
ETOH: denies any use
Illicit drug last use: marjuana 2 years ago, cocaine 7 weeks
ago,
crack 1 year ago, heroin last week
Family History:
none
Physical Exam:
Pulse: 117 Resp: 22 O2 sat: 98% RA
B/P 109/79
General: Sitting in bed
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs diminished throughout no airation bilateral bases
Heart: RRR [x] Murmur [x] grade 4/6 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] hepatomegaly
Extremities: Warm [x], well-perfused [x] Edema trace
left calf with rubar area no drainage ? septic emboli
Varicosities: multiple varicosities
Neuro: sm droop right lip, alert, oriented x3, 5/5 strength,
steady gait but decreased tolerance due to shortness of breath
Pulses:
Femoral Right: +2 Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +2 Left: +2
Carotid Bruit MURMUR
Pertinent Results:
[**2142-11-30**] UE u/s
IMPRESSION: Partially occlusive thrombus within one of the right
brachial
veins. Findings were discussed with Dr. [**First Name8 (NamePattern2) 66255**] [**Last Name (NamePattern1) 90652**] at 9:14
p.m. on [**11-30**], [**2142**] via telephone.
.
[**12-2**]/ MR head
IMPRESSION:
1. Abnormal FLAIR signal in right frontal sulci raises the
possibility of
leptomeningitis. Correlation with CSF study is recommended.
2. Multiple foci of abnormal susceptibility in bilateral frontal
and right
parietal lobes may represent hemorrhagic foci/calcifications. CT
of the head
is requested to rule out calcifications.
.
[**2142-12-3**] CT head
IMPRESSION:
1. No right frontal subarachnoid hemorrhage. The signal
abnormality on the
prior MRI is likely related to leptomeningeal infection, given
the history of
endocarditis, or other leptomeningeal infiltration.
2. No calcifications corresponding to the abnormal
susceptibility foci in the
right frontal, left frontal, and right parietal lobes,
indicating that the
abnormal susceptibility is related to non-acute blood products.
Since the
left frontal and the right parietal foci are associated with
abnormal contrast
enhancement and subtle high signal on precontrast T1 weighted
images, these
could be secondary to subacute septic emboli.
.
[**2142-12-6**] MR spine
IMPRESSION: Limited MRI study as patient could not continue with
the
examination. Only sagittal T2-weighted sequences through the
cervical and
thoracic spine were obtained. There is reduced intervertebral
disc height
along with signal abnormalities in the adjoining endplates at
T4-T5 as
described above, which may be degenerative. However, possibility
of
underlying infection (discitis/osteomyelitis) cannot be
excluded. A repeat
MRI study with gadolinium is requested.
.
[**2142-12-8**] CT spine
IMPRESSION: No evidence of paraspinal abscess in the thoracic or
lumbar
region. No evidence of high-grade thecal sac compression seen
and no obvious
evidence of epidural abscess seen, although CT is not as
sensitive as MR [**First Name (Titles) **] [**Last Name (Titles) 16671**]n of intraspinal abscess. Mild irregularity of the
endplates at T3-4
level seen. Bilateral pleural effusions are identified. Defect
is seen in
the partially visualized spleen, which could be due to an
infarct. Clinical
correlation recommended. A torso CT can help for further
assessment.
.
[**2142-12-10**] prelim Intra-op TEE
Conclusions
PRE-BYPASS: No spontaneous echo contrast is seen in the body of
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses 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%). The
right ventricular cavity is mildly dilated with normal free wall
contractility. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. No
aortic regurgitation is seen. There is a moderate-sized
vegetation on the mitral valve. Severe (4+) mitral regurgitation
is seen. There is a mobile mass on the tricuspid valve. There is
mild-to-moderate ([**1-28**]+) tricuspid regurgitation with an
eccentric jet. There is a small to moderate sized pericardial
effusion. Dr. [**Last Name (STitle) **] was notified in person of the
results at time of surgery.
POST-BYPASS: The patient is AV paced. The patient is on no
inotropes. Left ventricular function is mildly depressed (LVEF =
50%). There is mild hypokinesis of the interventricular septum.
Right ventricular function is moderately depressed. There is a
well-seated bioprosthetic valve in the mitral position. No
mitral regurgitation is seen. There is a mean gradient of 7 mmHg
across the prosthetic mitral valve at a blood pressure of
101/63. Moderate (2+) tricuspid regurgitation is seen. The aorta
is intact post-decannulation.
.
Brief Hospital Course:
The patient was admitted for further evaluation and pre-op
workup. ID consulted and helped direct antibiotic course of
Daptomycin. Psychiatry made recommendations in light of her
history of bipolar disorder. She was started on Seroquel. She
was started on heparin for right upper extremity non-occlusive
thrombus seen on ultrasound. Vascular surgery was consulted.
Anti-coagulation was stopped and ultrasound will be repeatedin
4-6 weeks. Cipro was started for UTI. Nutrition consult
recommended Ensure supplements. Dental clearance was obtained.
Social work consult was obtained, along with addiction
counseling. CT of the spine did not reveal evidence of osteo.
The patient was brought to the operating room on [**2142-12-10**] where
the patient underwent Mitral Valve Replacement (25mm [**Company 1543**]
Mosaic Porcine) and tricuspid exploration with Dr. [**First Name (STitle) **].
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Pain was initially managed with Dilaudid
PCA. The patient was transitioned to PO MS Contin with
immediate release Morphine for breakthrough pain as well as
Flexeril for pain related to spasm.
Beta blocker was initiated and the patient was gently diuresed
toward the preoperative weight. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. The
patient was evaluated by the physical therapy service for
assistance with strength and mobility.
OR cultures were negative, antibiotics were discontinued, and
PICC line removed.
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 her
grandmother in good condition with appropriate follow up
instructions.
SR morphine x 4 doses was prescribed, as well as short-acting to
help with pain mgmt until her wound check appt.
Medications on Admission:
Albuterol 2 puffs [**Hospital1 **]
Flovent 2 puffs [**Hospital1 **]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
5. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*3 MDI* Refills:*1*
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours).
Disp:*3 MDI* Refills:*1*
7. quetiapine 50 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
Disp:*90 Tablet(s)* Refills:*1*
8. quetiapine 50 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*1*
9. morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours) for 4 doses.
Disp:*4 Tablet Extended Release(s)* Refills:*0*
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
12. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for back spasm .
Disp:*50 Tablet(s)* Refills:*0*
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
14. potassium chloride 10 mEq Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day for 5 days.
Disp:*5 Capsule, Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
MRSA, endocarditis s/p MVR
Acute tubular necrosis, Anemia, Genital herpes, Hepatitis C,
MRSA abscesses, Intravenous drug use, VRE MRSA bacteremia,
Cellulitis Septic emboli, Depression and anxiety with previous
admissions, Asthma on inhalers at home
Past Surgical History: C section 18 months ago
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 trace to 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2143-1-15**] 1:30
Cardiologist: Dr. [**Last Name (STitle) 4922**] on [**1-10**] at 2:30pm
Wound check [**Hospital Ward Name **] [**Hospital Unit Name **] on [**12-27**] at 10:45am
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) 13469**] in [**5-1**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2142-12-15**]
|
[
"5990",
"49390"
] |
Admission Date: [**2171-11-21**] Discharge Date: [**2172-1-28**]
Date of Birth: [**2093-7-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Bilateral pulmonary embolus
Major Surgical or Invasive Procedure:
Inferior vena cava filter
Midline intravenous catheter
Cystoscopy
History of Present Illness:
other than kidney stones, presents with R side pain and SOB. He
reports that 4 days of worsening shortness of breath. He was
only able to walk 4 steps at a time. Prior to this, he was able
to accomplish all of his activities of daily living and had not
shortness of breath. He denies cough, chest pain, hemoptysis,
fever, chills, nausea, vomiting, abdominal pain or back pain. He
initially presened to [**Hospital1 **] found to have large bilateral
saddle PE. There are no records available from [**Location (un) 620**], although
the pt was started on heparin gtt and transferred to [**Hospital1 18**]
because there were no ICU beds at [**Location (un) 620**]. Of note, his
creatinine was 2.0. On arrival to ED here T 97.1 p90 165/71 20
94 on 3L. LE US was perfomed revealing Nonocclusive thrombus in
the left common femoral vein. He was admitted to [**Hospital Unit Name 153**] for
further mgmt, then to CCU, and finally transferred to medicine
for further care.
Past Medical History:
Nephrolithiasis
Social History:
Widower, patient lives alone. No smoking, Etoh use daily 1.5
glasses of wine. He drives.
Family History:
Mother died of cancer.
Physical Exam:
VS: 97.0 axillary / 134/72 / 68 / 18 / 95% 2.5L nc
GEN: Pleasant, alert, normal affect, in no acute distress
HEENT: MMM, OP clear, no LAD, PERRL, EOMI
Chest: CTA bilaterally, 8cm JVD
Heart: Irregularly irregular, no m/r/g, no ventricular heave
Abd: Soft, +BS, ND, NT
Ext: No c/c, no peripheral edema, 2+ DP pulses bilaterally, no
calf tenderness bilaterally
GU: large right scrotal hernia
Pertinent Results:
Hematology:
[**2171-11-21**] 10:00PM BLOOD WBC-10.1 RBC-3.97* Hgb-14.5 Hct-41.0
MCV-103* MCH-36.4* MCHC-35.2* RDW-14.4 Plt Ct-222
[**2171-12-24**] 05:15AM BLOOD WBC-4.9 RBC-3.40* Hgb-12.0* Hct-33.4*
MCV-98 MCH-35.2* MCHC-35.8* RDW-13.7 Plt Ct-106*
[**2172-1-17**] 06:35AM BLOOD WBC-3.2* RBC-3.25* Hgb-10.9* Hct-31.7*
MCV-98 MCH-33.6* MCHC-34.5 RDW-13.7 Plt Ct-150
[**2172-1-22**] 06:10AM BLOOD WBC-3.9* Plt Ct-138*
[**2171-11-21**] 10:00PM BLOOD Neuts-88.0* Lymphs-6.6* Monos-5.2 Eos-0.1
Baso-0
[**2172-1-16**] 06:35AM BLOOD Neuts-53.8 Lymphs-35.2 Monos-7.6 Eos-3.1
Baso-0.3
[**2171-11-21**] 10:00PM BLOOD PT-16.2* PTT-131.4* INR(PT)-1.5*
[**2172-1-3**] 05:05AM BLOOD PT-13.2* PTT-44.7* INR(PT)-1.2*
.
Chemistry:
[**2171-11-21**] 10:00PM BLOOD Glucose-122* UreaN-46* Creat-1.7* Na-136
K-6.3* Cl-103 HCO3-20* AnGap-19
[**2172-1-16**] 06:35AM BLOOD Glucose-85 UreaN-14 Creat-0.9 Na-140
K-3.5 Cl-106 HCO3-29 AnGap-9
[**2171-11-22**] 05:26AM BLOOD ALT-26 AST-39 LD(LDH)-190 CK(CPK)-36*
AlkPhos-76 Amylase-23 TotBili-0.6
[**2172-1-4**] 07:50AM BLOOD LD(LDH)-153 TotBili-0.5
[**2171-11-22**] 05:26AM BLOOD Lipase-18
[**2171-11-21**] 10:00PM BLOOD cTropnT-0.11* proBNP-[**Numeric Identifier **]*
[**2171-11-24**] 01:01AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2171-11-24**] 07:35AM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2171-11-24**] 07:35AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.9 Iron-24*
Cholest-103
[**2171-11-26**] 10:15AM BLOOD Albumin-2.8* Calcium-8.1* Phos-2.6*
Mg-2.2
[**2171-11-24**] 07:35AM BLOOD calTIBC-150* VitB12-357 Folate-6.6
Ferritn-420* TRF-115*
[**2171-11-24**] 07:35AM BLOOD Triglyc-61 HDL-33 CHOL/HD-3.1 LDLcalc-58
[**2171-11-25**] 05:20AM BLOOD TSH-2.3
[**2171-12-11**] 11:46PM BLOOD TSH-2.4
[**2171-11-26**] 10:15AM BLOOD CEA-1.7 PSA-3.5
[**2171-11-23**] 10:27AM BLOOD PEP-NO SPECIFI
[**2171-11-28**] RPR non-reactive
.
Urine:
Creatinine, Urine 147 mg/dL
Total Protein, Urine 249 mg/dL
Protein/Creatinine Ratio 1.7* Ratio 0 - .2
.
Prot. Electrophoresis, Urine +/- MULTIPLE PROTEIN BANDS SEEN,
WITH ALBUMIN PREDOMINATING' Immunofixation, Urine - NO
MONOCLONAL IMMUNOGLOBULIN SEEN, NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN
.
URINE CULTURE (Final [**2172-1-22**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| STAPH AUREUS COAG +
| |
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R <=0.5 S
IMIPENEM-------------- =>16 R
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- =>16 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ =>16 R
VANCOMYCIN------------ <=1 S
.
ECG ([**11-20**]): Sinus rhythm with frequent atrial premature beats.
Left axis deviation with left anterior fascicular block.
Prominent early R wave progression with ST-T wave abnormalities
in the anterior leads. Consider myocardial ischemia versus right
ventricular overload. Clinical correlation is suggested. No
previous tracing available for comparison.
.
BILATERAL LOWER EXTREMITY ULTRASOUND ([**11-20**]): [**Doctor Last Name **]-scale,
color, and spectral Doppler analysis of the right and left
common femoral, superficial femoral, and popliteal veins was
performed. There is no evidence of right lower extremity DVT.
There is nonocclusive thrombus extending from the left common
femoral vein to the proximal portion of the left superficial
femoral vein. The mid and distal superficial femoral veins on
the left showed no evidence of thrombus.
IMPRESSION: Nonocclusive thrombus extending from the left
common femoral vein to the proximal portion of the left
superficial femoral vein. No evidence of right lower extremity
DVT.
.
TTE ([**11-21**]):
1. The left atrium is mildly dilated. No atrial septal defect or
patent
foramen ovale is seen by 2D, color Doppler or saline contrast
with maneuvers.
A small pulmonary AV shunt is probably present.
2. The left ventricular cavity size is normal. There is severe
global left ventricular hypokinesis. Overall left ventricular
systolic function is severely depressed.
3. The right ventricular cavity is dilated. There is severe
global right
ventricular free wall hypokinesis.
4. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
5. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
6. There is mild pulmonary artery systolic hypertension.
7. There is a small, loculated (apical) pericardial effusion
with fibrin
deposits on the surface of the heart..
.
CT abdomen/pelvis with contrast ([**11-21**]):
1. Very large bowel-containing right inguinal/scrotal hernia
without evidence of obstruction or ischemia.
2. Thickening of the bladder wall with possible intraluminal
blood clots.
3. Small bilateral pleural effusions and pericardial effusion.
4. No intraabdominal mass or lymphadenopathy.
.
BLADDER ULTRASOUND STUDY ([**11-24**]): Numerous images of the bladder
demonstrate a diffusely abnormal wall with irregular thickness
and contour, predominantly on the anterior aspect. Some areas of
the irregularly thickened anterior wall demonstrate increased
vascularity. There is echogenic fluid in the bladder with debris
seen in the dependent portion, some of which is mobile.
IMPRESSION: Irregularly thickened bladder wall, most pronounced
anteriorly with small areas of increased vascularity. Given the
appearance of the wall, a cystoscopy is recommended to exclude
malignancy.
.
CT head without contrast ([**11-26**]):
FINDINGS: There is no intracranial hemorrhage. There is no
midline shift, mass effect, or hydrocephalus. There are areas
of low attenuation within the periventricular white matter, most
consistent with chronic microvascular ischemic change. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. There are no
fractures.
IMPRESSION: No intracranial hemorrhage. No mass effect.
.
TTE ([**12-26**]):
The left atrium is moderately dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal (LVEF
60-70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion. Compared with the
findings of the prior study (images reviewed) of [**2171-11-22**], contractile function of the right ventricle is now normal.
The left ventricle was poorly visualized on the prior study, but
was probably normal.
.
Urine cytology ([**1-12**]): NEGATIVE FOR MALIGNANT CELLS. No
urothelial cells seen. Predominantly neutrophils. Red blood
cells.
.
Cystoscopy ([**1-24**]): (per Dr.[**Initials (NamePattern4) 825**] [**Last Name (NamePattern4) **] note) 3+
trabeculated bladder. Bladder stone. No evidence malignancy.
Brief Hospital Course:
78M with no known past medical history originally p/w CP & SOB,
found to have saddle PEs, ARF, and urinary retention. Patient
arrived to the [**Hospital1 18**] ED from [**Location (un) 620**] with known bilateral saddle
pulmonary emboli. He was continued on heparin, started on IV
fluids, and transferred to the CCU given evidence of heart
failure on echo (EF 25%, RV dysfunction). An US of his lower
extremities showed a clot in his left common femoral vein. He
was anticoagulated. On day 2 of his hospital course, a removable
IVC Filter was placed successfully without complications. The
patient developed agitation and delerium, threatened to leave
AMA, but was deemed not competent to make medical decisions.
Guardianship was pursued and evenutally decided on [**1-17**]. His
course was also complicated by UTI for which he received
antibiotics. See below for further details.
Course on the floor as follows:
#) Bilateral saddle PEs: Presented with CP and SOB, found to
have bilateral PEs and DVT with evidence of heart failure and RV
dysfunction. Anticoagulated with heparin and then coumadin
briefly but then d/c'd coumadin in favor of lovenox as planned
for inpaitent cystoscopy for malignancy workup (see below). s/p
IVC filter on [**2171-11-22**] given DVT present and concern for further
embolization. He was continued on lovenox for anticoagulation
until cystoscopy performed [**2172-1-24**] and then started on coumadin.
He will continue lovenox until reaches goal INR [**1-25**] at which
time coumadin can be discontinued. Following resolution of the
acute issues, he has remained hemodynamically stable with no
respiratory complaints. Discussed removal of IVC filter with IR
but they believe high likelihood of failure and procedural risks
so deferred. Further hypercoagulability evaluation deferred to
outpatient. Followup with PCP. [**Name10 (NameIs) **] patient will need daily INR
checks until therapeutic on coumadin at which time lovenox can
be discontinued.
.
#) Dementia, agitation, altered mental status: Patient was very
agitated, confused early in hospital stay. Likely etiology was
toxic-metabolic [**1-24**] acute illness and urinary infection in the
setting of chronic dementia. Improved somewhat with resolution
of acute medical problems but not completely. He repeatedly
attempted to leave AMA and required code purple intermittently
with physical restraints. Psychiatry was consulted and the
patient was started on standing haldol [**Hospital1 **] with improvement and
resolution of his agitation. There was concern regarding his
ability to understand his illness, comply with treatment, and
care for self. He required a 1:1 sitter due to flight risk and
occasional agitation. Guardianship was established (see below).
At discharge the patient was calm, cooperative, and conversant.
.
#) Urology: UTI, urinary retention, acute renal failure,
abnormal bladder ultrasound. On hospital day 4 the patient
developed a UTI. He was initially treated with ceftriaxone,
which was then switched to ciprofloxacin. His Foley catheter was
removed, but patient developed urinary retention with drainage
of 1.4L from his bladder. Renal failure was likely post-renal
due to obstruction and resolved with drainage of bladder.
Urology was consulted for very difficult foley placement and he
was started on flomax. PSA was normal. The foley was initially
left in place due to the difficulty of placement and the fact
that he was asymptomatic; he was continued on ciprofloxacin, but
he developed symptoms of bladder irritation on [**1-20**]. Repeat
urine culture grew pseudomonas resistant to quinolones and MRSA.
Ciprofloxacin was discontinued and ceftazadime and vancomycin
were started to complete a 2 week course (started on [**1-20**] and
[**1-22**], respectively). A midline catheter was placed [**1-22**] and
should be removed on [**2172-2-4**] after completing his course of IV
antibiotics. He failed two voiding trials the week prior to
discharge and therefore an indwelling foley was left in place
with urology followup for urodynamics studies and consideration
of TURP. Also found to have bladder U/S with irregular wall
thickening. Concern was for malignancy, however urine cytology
was negative and the patient underwent cystoscopy on [**2172-1-24**]
which revealed no evidence of malignancy. Plan for outpatient
urology followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] on [**2172-2-6**].
.
#) Malignancy screening: Given hypercoagulability, initiated
cancer screening as possible etiology. Abdominal/pelvic CT was
notable for a thickened bladder wall and further followed up
with a bladder US that confirmed the finding. Urine cytology and
cystoscopy was negative. Chest CT at presentation showed
bibasilar nodular densities in the setting of bilat PEs, and
repeat study revealed that these had completely resolved.
However, an indicental finding of hypoattenuating liver lesion
was noted that should be followed up with MRI per radiology as
an outpatient. He was also scheduled for screening colonoscopy
with Dr. [**First Name (STitle) 2643**]; instructions for the bowel preparation are
attached with the discharge information. Followup with urology
per above.
.
#) Thrombocytopenia: Platelets 222 on arrival, and noted slow
downward progression during initial hospital course with nadir
in low 100s. Possibly [**1-24**] consumption for underlying blood
clots, but not clear. Hematology was consulted. Did not appear
to meet trends for either Type I or II HIT; HIT antibody was
sent and was negative. No other signs of DIC, TTP. Initially on
heparin, then coumadin, and finally lovenox. Discontinued
protonix secondary to small likelihood that PPI/H2 blockers
cause thrombocytopenia. Platelets slowly increased and
normalized around 150. Would continue to monitor weekly as
outpatient.
.
#) Cardiac: No known CAD and on no cardiac meds at home. Upon
arrival, echocardiogram initially with EF 25% and RV dysfunction
likely [**1-24**] PE, so ACEi and BB were initiated for presumed
cardiomyopathy. Repeat echo was performed after acute events
resolved and showed preserved EF with normal wall motion. ACEi
and BB were then discontinued. He remained in sinus rhythm,
normotensive. Euvolemic on exam. Ambulating wihtout difficulty.
No further issues.
.
#) Scrotal hernia: Large scrotal hernia noted on exam, althogh
patient asymptomatic. Abdomen/pelvis CT scan with large amount
of bowel in hernia sac. No evidence of incarceration, volvulus.
Patient declining eval for herniorraphy and given no symptoms
unlikely need at this time. Monitor as outpatient with surgery
referral as indicated.
.
#) Disposition: On [**2171-12-1**], the patient appeared to be
medically clear discharge, however it was clear that patient was
not safe to go home given limited mobility, anticoagulation,
lack of social supports, and extremely limited understanding of
his condition. He was deemed to lack capacity to understand
risks/benefits of refusing care and inability to care for self
at home safely. In addition, it was discovered that his home was
condemned by public health department. As a result, guardianship
was pursued with family and his attorney. Official guardianship
appointed [**2172-1-17**] between [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], JD and [**Name (NI) **] [**Name (NI) 32153**]
(cousin; [**Telephone/Fax (1) 69985**]).
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever or pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Hexavitamin Tablet Sig: One (1) Cap PO QAM (once a day
(in the morning)).
Disp:*30 Cap(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID prn as needed
for constipation.
Disp:*60 Tablet(s)* Refills:*0*
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID
prn.
Disp:*60 Capsule(s)* Refills:*2*
7. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
8. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) gram Intravenous Q8H (every 8 hours) for 5 days.
10. Heparin Flush Midline (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.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
12. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 7 days.
13. Enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg
Subcutaneous twice a day: discontinue when INR >2.
14. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO at bedtime.
15. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime). Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] - [**Location (un) 2498**]
Discharge Diagnosis:
Primary:
1) Bilateral Saddle Pulmonary Emboli
2) Delirium
3) Alcohol Withdrawal
4) Dementia
5) Urinary retention
6) Complicated urinary tract infection
7) Thrombocytopenia NOS
.
Secondary:
1) Macrocytic anemia
2) History of alcoholism
3) Hypertension
4) Lung nodules NOS
Discharge Condition:
Good
Discharge Instructions:
Please take all medications as prescribed.
.
Call your doctor or return to the ED immediately if you
experience worsening chest pain, shortness of breath, nausea,
vomiting, sweating, fevers, chills, bleeding, or other
concerning symptoms.
Followup Instructions:
You are scheduled for the following appointments. Please contact
the [**Name2 (NI) 11686**] provider with any questions or if you need to
reschedule.
.
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11302**]. [**Hospital1 18**], [**Street Address(2) **], [**Location (un) 620**], MA. ([**Telephone/Fax (1) 69986**]. [**2172-2-3**] at 1:30pm. You were found to have a possible
abnormality in your liver. It was suggested that you have an MRI
of your liver for further evaluation. You will need to be
accompanied by an attendant or your guardian.
.
Urology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD. [**Hospital1 18**]. Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2172-2-6**] 3:10. Followup for urodynamics studies and
consideration of possible TURP procedure.
.
Colonoscopy: GI WEST,ROOM ONE GI ROOMS Date/Time:[**2172-3-6**] 10:30
Gastroenterology: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2172-3-6**] 10:30. Colonoscopy. You must arrive by
9:30am. You will need to complete a bowel prep starting the day
before this appointment. Please see the sheet given to you at
discharge for instructions on how to perform the preparation.
|
[
"5849",
"4280",
"5990",
"2875"
] |
Admission Date: [**2152-1-13**] Discharge Date: [**2152-1-18**]
Date of Birth: [**2113-1-9**] Sex: F
Service: MEDICINE
Allergies:
Ultram
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
Tylenol Overdose
Major Surgical or Invasive Procedure:
None
History of Present Illness:
39 year-old female with hepatitis B (diagnosed [**5-28**]) and alcohol
abuse presented to OSH with nausea, hematemesis; found to have
transaminitis and acetaminophen toxicity (54 at OSH);
transferred to [**Hospital1 18**] for further management. Underwent multiple
teeth extraction over past two weeks; during this time was
taking Vicodin and Tylenol ES - several tablets several times
per day. Approximately 5 days ago began feeling nauseous with
vomiting; had 1 episode of hematemesis, about 1 cup.
Subsequently had 6-9 episodes per day without blood or
coffee-grounds. Vomiting, inability to tolerate POs continued.
Also with RUQ abdominal pain, diarrhea. Did not have
lightheadedness, BRBPR, melena.
.
On [**2152-1-12**] she presented to PCPs office with above complaints;
instructed to proceed to ED, declined.
.
On [**2152-1-13**] she presented to [**Hospital3 **] with nausea and
vomiting. AST 4445, ALT 1208, tbili 9.4. QRS 78, QTc 501.
Received Zofran, Protonix 80 IV bolus, initiated on NAC
(150mg/kg over 1 hour, initiated 50mg/kg over 4 hour), and sent
to [**Hospital1 18**] for further management.
.
In ED, vitals were 97.8 93 103/53 16 100%. Physical examination
notable for scleral icterus, jaundice. NG lavage negative.
Laboratory data significant for creatinine 0.8, WBC 9.2 with
left shift, transaminitis (ALT 1862, AST 7201), tbili 9.3, INR
4.3, and serum acetaminophen 38, lactate 3.9. EKG with QTc 440
without concerning changes. Seen by toxicology - recommended
continued NAC at 50mg/kg over 4 hours, immediately followed by
100mg/kg over 16 hours; psychiatry consult; and no role for
decontamination. Hepatology was consulted - recommended ABG,
Q1-2 hour neuro checks given potential compensation. Received
continued NAC, Ativan (for anxiety), Zofran, morphine. On
transfer to MICU, 86, 128/70, 15, 100% RA.
.
On arrival to MICU, she reports feeling well but with fatigue,
sore throat, persistent RUQ discomfort. She denies feelings of
confusion.
.
REVIEW OF SYSTEMS:
(+) Per HPI. Headache earlier today, now resolved.
(-) Denies fever, chills, night sweats, recent weight changes.
Denies cough, shortness of breath, chest pain, palpitations.
Denies dysuria
Past Medical History:
- Hepatitis B: Admitted with acute hepatitis B [**Date range (1) 78771**].
Peak AST 1483, ALT 910, tbili 14.3. HIV, HCV negative.
- Hypothyroidism
- Prior narcotic abuse
- Alcohol abuse
Social History:
One pint vodka per day, mainly on weekends. 0.75PPD x28 years,
since age 11 years. Prior illicit drug use, none in past several
years. Two children. Lives with her father. Currently disabled.
Family History:
Non- contributory
Physical Exam:
97.9 124/71 68 18 98%RA
GENERAL - NAD and tearful, agitated and anxious
HEENT - mildly icteric sclera; adentulous; MMM
NECK - Supple
HEART - RRR, nl S1/S2, no murmurs appreciated
LUNGS - CTAB, rales, or rhonchi
ABDOMEN - Soft, not distended; tenderness to palpation at RUQ;
no rebound or guarding, +BS
EXTREMITIES - DP pulses 2+ and symmetric
SKIN - mildly jaundiced
NEURO - A&Ox3, CNII-XII grossly intact, moving all extremities
Pertinent Results:
Admission:
[**2152-1-13**] 03:32PM BLOOD WBC-9.2# RBC-3.78* Hgb-12.8 Hct-38.2
MCV-101* MCH-33.9*# MCHC-33.5 RDW-16.1* Plt Ct-179
[**2152-1-13**] 03:32PM BLOOD Neuts-95.8* Lymphs-3.5* Monos-0.4*
Eos-0.2 Baso-0
[**2152-1-13**] 05:58PM BLOOD PT-41.2* INR(PT)-4.3*
[**2152-1-13**] 03:32PM BLOOD Glucose-91 UreaN-19 Creat-0.8 Na-140
K-3.8 Cl-99 HCO3-26 AnGap-19
[**2152-1-13**] 10:00PM BLOOD ALT-2360* AST-8900* LD(LDH)-4620*
AlkPhos-128* TotBili-8.7*
[**2152-1-13**] 10:00PM BLOOD Calcium-7.9* Phos-2.2* Mg-1.5*
[**2152-1-13**] 03:32PM BLOOD Albumin-3.5
[**2152-1-16**] 08:30AM BLOOD Ferritn-667*
[**2152-1-16**] 08:30AM BLOOD Triglyc-80
[**2152-1-14**] 12:30PM BLOOD TSH-0.31
[**2152-1-14**] 01:56AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-POSITIVE HAV Ab-NEGATIVE IgM HAV-NEGATIVE
[**2152-1-13**] 03:32PM BLOOD HCG-<5
[**2152-1-17**] 03:25PM BLOOD HIV Ab-NEGATIVE
[**2152-1-13**] 03:32PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-38*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2152-1-14**] 01:56AM BLOOD HCV Ab-NEGATIVE
[**2152-1-14**] 01:56AM BLOOD HEPATITIS Be ANTIGEN-Test
[**2152-1-14**] 01:56AM BLOOD HEPATITIS DELTA ANTIBODY-PND
Discharge:
[**2152-1-18**] 06:20AM BLOOD WBC-2.8* RBC-3.15* Hgb-10.5* Hct-32.9*
MCV-104* MCH-33.3* MCHC-31.9 RDW-17.5* Plt Ct-77*
[**2152-1-18**] 06:20AM BLOOD Neuts-42* Bands-0 Lymphs-44* Monos-10
Eos-3 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2152-1-18**] 06:20AM BLOOD PT-14.2* PTT-31.2 INR(PT)-1.2*
[**2152-1-18**] 06:20AM BLOOD Glucose-86 UreaN-7 Creat-0.6 Na-140 K-3.7
Cl-103 HCO3-29 AnGap-12
[**2152-1-18**] 06:20AM BLOOD ALT-536* AST-134* LD(LDH)-160
AlkPhos-133* TotBili-3.9*
[**2152-1-18**] 06:20AM BLOOD Calcium-9.0 Phos-4.3 Mg-1.8
[**2152-1-15**] 01:10PM BLOOD Acetmnp-NEG
Micro:
HBV Viral Load (Final [**2152-1-18**]):
1,760 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test.
Linear range of quantification: 40 IU/mL - 110million
IU/mL.
Limit of detection: 10 IU/mL.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2152-1-17**]): POSITIVE BY
EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2152-1-17**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2152-1-17**]):
NEGATIVE <1:10 BY IFA.
CMV Viral Load (Final [**2152-1-18**]):
CMV DNA not detected.
Blood Cultures: NGTD
Radiology:
RUQ U/S
IMPRESSION:
1. Normal liver echotexture without focal liver lesion.
2. No evidence for ascites.
CXR:
IMPRESSION: Unchanged chest radiograph without evidence for
focal
consolidation.
ECG:
Sinus rhythm. Early R wave transition. Compared to the previous
tracing
of [**2152-1-13**] baseline artifact is no longer appreciated in the
limb leads.
Brief Hospital Course:
39 year-old female with hepatitis B and alcohol abuse admitted
with hepatitis, coagulopathy, and recent hematemesis following
subacute ingestion of vicodin/Tylenol in setting of multiple
teeth extraction.
#. Acetaminophen Toxicity:
She was admitted to MICU [**2152-1-13**], and transferred to medical
service [**2152-1-15**]. In the MICU, acute hepatitis was suspected due
to acetaminophen toxicity with increased susceptbility due to
know hepatitis B and ongoing alcohol use. She reported taking
vicodin following her dental procedure. She denied suicide
attmept. At presentation, she appeared well - awake, alert, and
mentating appropriately; by laboratory data, evidence of
toxicity more apparent - transaminitis, hyperbiliribunemia,
coagulopathy: ALT:2360, AST:8900, TBili: 8.7. Her initial
tylenol level was 38. RUQ ultrasound was without evidence of
cirrhosis or portal vein thromobosis. Infectious hepatitis
serologies were sent and returned negative except for positve
HepB core and Hep VL (1,760 IU/mL). She was continued on NAC
and closely monitored for neurologic decline. Hepatology and
transplant surgery were actively involved in patient's care.
She was deemed not a transplant candidate given her active
alcohol abuse. Within 24 hours of admission, lactic acidosis
resolved, INR was downtrending, and she remained alert and
oriented. She was transferred to medical service [**2152-1-15**] for
further management. She was continued on NAC infusion until
[**1-16**] and was stopped once her ALT & ALT <1000 and INR was < 1.5.
She improved and was scheduled for follow-up with Liver Clinic
and her PCP. [**Name10 (NameIs) 2772**], the patient left AMA before she could be
given her discharge paperwork with her follow-up appointments.
Her mother, who was listed as her emergency contact, was called
and informed of her upcoming appointments and asked to have the
patient call to confirm her follow-up.
#. EtOH Abuse: The patient reports 1 pint of vodka per day. She
was monitored on a CIWA scale for withdrawl. She did not score
high on the CIWA, but given her anxiety she was given ativan.
The patient was seen by SW and Psych and did not meet inpatient
psych criteria. She was given information regarding outpatient
psych appointments and EtOH abuse resources. The patient was
non-commital and lacked insight into her disease. The patient
left AMA.
.
#. Pancytopenia: The patient was noted to have pancytopenia that
remained stable. It is likely secondary to her EtOH abuse.
Viral etiologies for CMV, EBV and HIV were checked and negative.
Her blod counts remained stable.
Medications on Admission:
Tylenol
Vicodin
Discharge Medications:
Left AMA
Discharge Disposition:
Home
Discharge Diagnosis:
Acetaminophen Overdose
Pancytopenia
EtOH Abuse
Hepatitis B
Discharge Condition:
left AMA
Discharge Instructions:
Left AMA
Followup Instructions:
*** Please call for outpatinet psychiatry intake appointment at
1-800-981-HELP. You will need to call yourself to make the
appointment.
Department: [**Hospital3 249**]
When: MONDAY [**2152-1-24**] at 11:00 AM
With: [**Last Name (LF) **], [**Name8 (MD) **] MD. [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
* This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Department: LIVER CENTER
When: WEDNESDAY [**2152-1-26**] at 11:40 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2152-1-18**]
|
[
"2449",
"3051"
] |
Admission Date: [**2137-9-23**] Discharge Date: [**2137-9-28**]
Date of Birth: [**2116-10-30**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Stab wound right back
Major Surgical or Invasive Procedure:
Thoracostomy tube placement [**2137-9-23**]
Pigtail catheter placement [**2137-9-26**]
History of Present Illness:
20M who stabbed in the right back by an unknown male. He was
brought the ED at [**Hospital1 18**] where a right thoracostomy tube was
placed for a right hemopneumothorax.
Past Medical History:
Psychiatric history
Social History:
He denies tobacco and ETOH use.
Family History:
Noncontributory
Physical Exam:
On Discharge:
VS: 99.7, 90, 120/80, 18, 100% on 2L NC
Gen: no distress, alert and oriented x 3
HEENT: NC/AT, PERLA, EOMi, mucus membranes moist
Neck: supple, no LAD
Chest: RRR, lungs clear bilaterally, pigtail and thoracostomy
tube sites with dressings that are clean/dry/intact
Abd: soft, nontender, nondistended
Ext: palplable pulses, no edema
Pertinent Results:
Admission labs:
[**2137-9-23**] 04:30PM BLOOD WBC-5.0 RBC-4.80 Hgb-12.9* Hct-39.7*
MCV-83 MCH-26.8* MCHC-32.4 RDW-14.4 Plt Ct-191
[**2137-9-23**] 07:10PM BLOOD Neuts-70.3* Lymphs-23.4 Monos-4.8 Eos-1.4
Baso-0.1
[**2137-9-23**] 04:30PM BLOOD PT-15.0* PTT-25.7 INR(PT)-1.3*
[**2137-9-23**] 11:16PM BLOOD Glucose-98 UreaN-7 Creat-1.0 Na-136 K-4.3
Cl-104 HCO3-22 AnGap-14
Discharge labs:
[**2137-9-25**] 07:51AM BLOOD WBC-6.0 RBC-4.27* Hgb-11.5* Hct-34.8*
MCV-82 MCH-27.1 MCHC-33.1 RDW-13.9 Plt Ct-145*
[**2137-9-25**] 07:51AM BLOOD Glucose-94 UreaN-3* Creat-1.0 Na-137
K-3.4 Cl-100 HCO3-26 AnGap-14
[**2137-9-25**] 07:51AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.9
Imaging:
[**9-23**] CXR: Hemopneumothorax (pre chest tube placement)
[**9-23**] CT Torso: Right chest tube in place. residual blood,
multicomponent PTX including anterior, inferior, and medial
components. Bibasilar effusion, some collapse of RUL and RLL. No
subdiaphragmatic injury.
[**9-26**] CXR: Unchanged PTX s/p right pigtail. R chest tube
unchanged
[**9-28**] CXR: no PTX after pigtail removal
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2137-9-23**] after he received a stab
wound to his right back by an unknown male. A right
thoracostomy tube was place in the ED for a right
hydropneumothorax. Serial chest x-rays were performed to ensure
adequate drainage of the hemothorax with re-expansion of the
right lung. He developed a persistent effusion in the right
chest so a pigtail [**Last Name (un) **] was placed into the right chest on HD4
and the right thoracostomy tube was removed. The pneumothorax
resolved and the effusion was drained adequately. The pigtail
catheter was removed on HD6 and a post-pull CXR showed no
pneumothorax. He was tolerating a regular diet and had adequate
pain control and PO medications. He did not have respiratory
complaints or chest pain after pigtail catheter removal. He was
discharged in good condition with appropriate follow up.
Medications on Admission:
Depakote, Prilosec, Haldol
Discharge Medications:
All home medications plus:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Stab wound to right chest
Right hemopneumothorax
Discharge Condition:
Good
Discharge Instructions:
Return to the Emergency Department if you experience:
- fever >101.5 or chills
- increasing pain not relieved by your medication
- inability to eat or drink
- persistent nausea or vomiting
- drainage from your chest incisions
- increasing redness around your incisions
- increasing shortness of breath or chest pain
- any other concerns that you may have
Continue taking all of your home medications.
You will be give a prescription for pain medication. Do not
drive while taking this medication as it may make you drowsy.
Do not take a tub bath. You may shower. You may remove the
dressings on Monday.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2359**] Call to schedule
appointment or if you have any questions.
|
[
"5119"
] |
Admission Date: [**2190-10-11**] Discharge Date: [**2190-11-4**]
Date of Birth: [**2113-8-6**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 77-year-old white female
was prepped preoperatively for a knee replacement, and on her
preoperative work-up, she had a positive stress test on
[**2190-9-22**]. She had shortness of breath and mild
anteroseptal and apical ischemia with an ejection fraction of
62 percent. She denied chest pain but does have a history of
congestive heart failure.
A cardiac catheterization revealed an ejection fraction of 55
percent, 100 percent mid left anterior descending coronary
artery lesion, a 95 percent diagonal lesion, and 80 percent
obtuse marginal one lesion, and a subtotal mid right coronary
artery lesion. She was admitted for elective coronary artery
bypass graft.
PAST MEDICAL HISTORY: History of atrial fibrillation,
history of congestive heart failure, history of hypertension,
history of hypothyroidism, history of noninsulin dependent
diabetes mellitus, history of osteoarthritis. She is status
post permanent pacemaker ten years ago. She is status post
right lumpectomy. Status post appendectomy. Status post
cataract removal. Status post bilateral vein stripping 40
years ago.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Coumadin 3 mg p.o. daily,
Glucotrol 2.5 mg p.o. daily, Digoxin 0.125 mg p.o. daily,
Neurontin 300 mg p.o. b.i.d., Levoxyl 0.1 mg p.o. daily,
Diltiazem 240 mg p.o. daily, Captopril 37.5 mg p.o. t.i.d.,
Lasix 120 mg p.o. daily.
SOCIAL HISTORY: She lives alone. Her husband passed away in
[**Name (NI) 216**]. She has children who are very involved. She does
not smoke cigarettes. She drinks 3-4 glasses of wine per
day.
FAMILY HISTORY: Coronary artery disease.
REVIEW OF SYMPTOMS: General: The patient is a well-
developed, thin, elderly white female in no apparent
distress. Vital signs stable. Afebrile. HEENT:
Normocephalic, atraumatic. Extraocular movements intact.
Oropharynx benign. Neck supple. Full range of motion. No
lymphadenopathy or thyromegaly. Carotids 2 plus and equal
bilaterally without bruits. Lungs: Clear to auscultation
and percussion. Cardiovascular: Irregular, rate, and
rhythm, with a 3/6 systolic ejection murmur. Abdomen: Soft
and nontender with positive bowel sounds. No masses or
hepatosplenomegaly. Extremities: Without clubbing,
cyanosis, or edema. She had bilateral lower extremity venous
changes in her skin. Pulses: Femorals to 1 plus and equal
bilaterally, radials, dorsalis pedis, posterior tibial were 2
plus and equal bilaterally throughout.
HOSPITAL COURSE: She was admitted, and on [**10-12**], she
underwent a coronary artery bypass graft times four with left
internal mammary artery to the left anterior descending
coronary artery, reversed saphenous vein graft to obtuse
marginal, diagonal, and right coronary artery.
She was transferred to the CSRU in stable condition on no
drugs but was put on Nipride for agitation while she was
weaning. She was attempted to be weaned that night but was
very agitated when her propofol was turned down, and she was
started on Precedex. She also had some bleeding
postoperatively and was transfused platelets, FFP, cryo, and
packed red cells. This eventually subsided.
On postoperative day 1, she remained on the Precedex. Her
blood pressure was labile with a borderline cardiac index.
She was in Nipride and Nitroglycerin. She was weaned and was
extubated on postoperative day 1. She required aggressive
pulmonary therapy and inhalers. She did go into atrial
fibrillation and was started back on Lopressor.
She was intermittently agitated and ended up required Ativan
drip on postoperative day 3, she was going through alcohol
withdrawal. She also was very confused. She had a feeding
tube placed on postoperative day 4 for fear of aspiration.
On postoperative day 5, she required reintubation and had to
back on propofol. Her Ativan was discontinued at that point.
She also at that point then became very lethargic. Her
propofol was discontinued. She was seen by Neurology. She
had a head CT at that point which was read as unremarkable.
She became more alert on postoperative day 7 and started to
be weaned again from the vent. She was also placed back on
Precedex but became unresponsive again, and this was turned
off.
She was placed on CPAP on postoperative day 8. She was then
also placed on heparin through this time. She was extubated
on postoperative day 9. She remained confused. She also
developed a rash which was followed by Dermatology which was
felt to be a drug rash from Bactrim, and this was
discontinued.
She had a bedside swallowing evaluation where it was
determined that she could eat all things, including thin
liquids; however, she would need supervision.
She continued to require aggressive respiratory therapy and
eventually was also started back on her Lisinopril. She
slowly progressed and was transferred to the floor on
postoperative day 13.
She continued to be disoriented and required a sitter but was
becoming slightly less agitated. She then had a fall on
postoperative day 14 trying to get out of bed. She had no
evidence of any injury. She received a head CT at that point
which was negative for bleed. We were avoiding all
psychoactive medications, and she was having physical
therapy.
She was then seen by Psychiatry who felt they wanted to have
Neurology see her. They then saw her on postoperative day
16, and they reviewed the head CT and noted two areas of
hypodensity bilaterally in the parietal exoccipital area.
They found on their examination that she had infarct which
was giving her [**Doctor First Name **] syndrome which was corticale blindness
with cognosia. She was reflecting her left side. She had
superimposed confabulation, disconjugate gaze, and decreased
attention which could have been also from Wernicke's
encephalopathy.
She had been on Thiamin, but she was started back on that
again intravenous, and she could not get an MRI because of
her pacer. This was discussed with the family by Dr. [**Last Name (STitle) **]
and the team. She was eventually weaned from her sitter and
did become more coherent and eventually knew who she was and
where she lived, and said she was in the hospital, which she
knew most of the time.
She was screened for rehabilitation. On postoperative day
23, she was discharged to rehabilitation in stable condition.
DISCHARGE LABORATORY DATA: Sodium 141, potassium 4.8,
chloride 108, CO2 26, BUN 18, creatinine 0.9; blood sugar 95;
INR 2; hematocrit 31.8, white count 9.6.
DISCHARGE DIAGNOSIS: Coronary artery disease.
Noninsulin dependent diabetes mellitus.
Congestive heart failure.
Atrial fibrillation.
Cerebrovascular accident.
Osteoarthritis.
Hypothyroidism.
Status post permanent pacemaker.
DISCHARGE MEDICATIONS: Tylenol [**1-15**] p.o. q.[**4-20**] p.r.n. pain,
Levoxyl 100 mcg p.o. daily, Miconazole Nitrate powder
topically q.i.d., Triamcinolone cream topically t.i.d.,
Lisinopril 20 mg p.o. daily, Glipizide 2.5 mg p.o. b.i.d.,
Lopressor 50 mg p.o. b.i.d., Thiamin 100 mg p.o. daily.
FOLLOW UP: She will be seen by Dr. [**Last Name (STitle) 56945**] in [**1-15**] weeks
following discharge from rehabilitation and by Dr. [**Last Name (STitle) **] in
four weeks.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2190-11-3**] 18:43:49
T: [**2190-11-3**] 19:26:01
Job#: [**Job Number 56946**]
|
[
"41401",
"9971",
"42731",
"4280",
"25000",
"2449"
] |
Admission Date: [**2123-1-6**] [**Month/Day/Year **] Date: [**2123-1-14**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 52022**]
Chief Complaint:
Left knee osteoarthritis
Major Surgical or Invasive Procedure:
Left total knee replacement [**1-6**]
History of Present Illness:
Ms. [**Known lastname **] has had considerable pain in her left knee for several
months. Pain in the knee limits her walking, and the pain is
severe when she turns in bed. She has tried Tylenol which offers
no relief. She has walked with a rolling walker for the past 6
months. She would like to proceed with left total knee
arthroplasty.
Past Medical History:
chronic low back pain
high cholesterol
s/p right nephrectomy
atrial fibrillation diagnosed on preop assessment
Social History:
denies tobacco, EtOH, or other drug use
Physical Exam:
slightly overweight
walks with rolling walker, rises from chair slowly [**3-4**] pain in
knees
stands and walks w/ slight flexion and left tilt of lower spine
& slight flexion of both hips and both knees
left knee:
-no effusion
-flexion contracture of 10 degrees
-ROM 10-105, pain at extremes of range
-patella with restricted passive mobility and painful
crepitations
-significant tenderness to palpation at medial and lateral joint
lines
Pertinent Results:
[**2123-1-6**] 05:10PM WBC-6.5 RBC-2.90* HGB-8.5* HCT-25.8* MCV-89
MCH-29.5 MCHC-33.1 RDW-14.1
[**2123-1-6**] 05:10PM PLT COUNT-304
[**2123-1-6**] 10:54PM GLUCOSE-158* UREA N-21* CREAT-0.9 SODIUM-140
POTASSIUM-4.4 CHLORIDE-111* TOTAL CO2-22 ANION GAP-11
[**2123-1-6**] 10:54PM CALCIUM-9.2 PHOSPHATE-3.2 MAGNESIUM-1.6
[**1-14**] INR: 1.2
EKG [**1-7**]:
Sinus rhythm
Borderline first degree A-V delay
Left atrial abnormality
Since previous tracing of [**2122-12-30**], atrial fibrillation now
absent
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 214 80 392/412.42 50 -12 8
Echocardiogram [**1-8**]:
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.6 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.2 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.2 cm
Left Ventricle - Fractional Shortening: 0.48 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 60% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.3 m/sec
Mitral Valve - E Wave Deceleration Time: 207 msec
TR Gradient (+ RA = PASP): *36 to 38 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Dilated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
LEFT VENTRICLE: Normal LV cavity size. Overall normal LVEF
(>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS. No
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
to moderate [[**2-1**]+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: The rhythm appears to be atrial fibrillation.
Conclusions:
The left atrium is dilated. The right atrium is moderately
dilated. 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 are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
Electronically signed by [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], MD on [**2123-1-8**] 17:15.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
CXR [**1-8**]:
CHEST (PORTABLE AP)
[**Hospital 93**] MEDICAL CONDITION:
89 year old woman s/p left TKR, post-op currently, with h/o
patchy ground-glass opacities on recent chest CT, being
aggressively volume resuscitated; recent RIJ placement
COMPARISON: [**2123-1-7**].
INDICATION: Aggressive volume resuscitation.
A right internal jugular vascular catheter remains in place,
terminating at the junction of the superior vena cava and right
atrium. The heart is enlarged but stable. There is pulmonary
vascular engorgement and bilateral perihilar haziness. Overall,
this appears slightly worse than on the most recent chest
radiograph but improved compared to the earlier radiograph of
[**1-7**] at 7:29 a.m. Bibasilar atelectatic changes are noted
as well as small pleural effusions.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: FRI [**2123-1-8**] 3:30 PM
Brief Hospital Course:
Pt was admitted through same day admission and taken to the OR
for left total knee arthroplasty with Dr. [**Last Name (STitle) **]. See operative
report for details. She tolerated the procedure well and was
extubated in the OR. She was noted to have atrial fibrillation
at her preoperative assessment visit and again at the start of
the case, however this resolved during the operation. She was
transferred to the PACU and then to the ICU for observation
given her age and the late evening end time of the surgery.
Postoperatively her left foot was noted to be less well-perfused
than her right; this resolved immediately upon loosening of the
outer dressing. She received 2 units PRBCs in the OR+PACU
period, and 2 additional units on postoperative day 1. She had
some hypotension in the first 24 hours post-op, which resolved
with fluid repletion.
On postoperative day 2 she again developed atrial fibrillation,
which was treated with amiodarone. Her coumadin became
supratherapeutic with an INR=5.1 on [**1-9**] (POD#3), likely due to
the interaction with amiodarone. Coumadin was held and her INR
normalized. She developed some ecchymosis over her left knee
which continues to improve at the time of [**Month/Year (2) **].
She was transferred to the orthopaedic floor on [**1-9**] in stable
condition. She was monitored on telemetry and continued in
atrial fibrillation with rate in 80s throughout her stay.
On postoperative day 5 she was transfused another 2 units PRBCs
and 3 units FFP for persistently low hematocrit, possiblyly due
to continued surgical bleeding with supratherapeutic coumadin.
She continued to improve medically and her INR and hematocrit
both stabilized. She should continue to be cautiously
anticoagulated with coumadin to a goal INR of 2.0-2.5, given her
postoperative DVT risk as well as her new diagnosis of atrial
fibrillation. She should follow-up with her primary medical
doctor [**First Name (Titles) **] [**Last Name (Titles) **] of the atrial fibrillation.
Medications on Admission:
lipitor 10'
[**Last Name (Titles) **] Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) for 2 weeks.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Amiodarone 200 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day): should be transitioned [**1-24**] to 300mg QD maintenance dose.
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain for 2 weeks.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: One
(1) Packet PO TID (3 times a day).
8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day for 4
weeks: Goal INR 1.5-2.0
To be followed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 174**] [**Telephone/Fax (1) **] at orthopaedic
clinic.
[**Telephone/Fax (1) **] Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
[**Location (un) **] Diagnosis:
left knee osteoarthritis
[**Location (un) **] Condition:
stable
[**Location (un) **] Instructions:
Take all medications as prescribed. Keep all follow-up
appointments. Keep incision clean and dry, can be covered with
dry sterile dressing changed daily as needed. You may shower but
do not scrub the wound area or immerse the wound area in water.
Call your doctor or return to the ER if you experience:
-chest pain or shortness of breath
-fevers or chills
-increased pain, redness, or drainage from incision site
You are being discharged on coumadin. INR levels need to be
checked frequently with a goal INR of 1.5-2.0
Physical Therapy:
WBAT, ROM as tol Left knee
Treatments Frequency:
Remainder of staples will be removed at first postoperative
visit.
Daily DSD changes to Left knee
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] Phone:[**Telephone/Fax (1) 10657**] Date/Time:[**2123-1-22**]
10:15
Follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Call ([**Telephone/Fax (1) 2007**] to
schedule your appointment.
Follow-up with your primary medical doctor [**First Name (Titles) **] [**Last Name (Titles) **] for
[**Last Name (Titles) **] of recent onset atrial fibrillation.
|
[
"42731",
"2720"
] |
Admission Date: [**2111-9-23**] Discharge Date: [**2111-10-6**]
Date of Birth: [**2069-3-22**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
External ventricular catheter
History of Present Illness:
42 y/o male transferred here from [**Hospital **] hospital with
intraventricular hemorrhage. Pt. had a [**10-3**] headache two days
ago and persistent nausea and vomiting. Pt. was found by his
wife
to be disoriented and ataxic this morning with several falls.
Patient started having difficulty speaking and moving the Left
side of his body per wife's report. EMS was called, and the Pt.
was Taken to [**Hospital **] hospital where a CT of the head showed a
large IVH predominately in the left lateral ventricle extending
to the third and less so to the fourth.
Past Medical History:
Congenital atrophic kidney
Social History:
Married
Smokes cigars socially
No significant history of ETOH
Family History:
Mother with cranial AVM operated on at age 50
Physical Exam:
EXAM ON ADMISSION:
O: T: BP:155 /84 (on caredene gtt) HR: 56 R 18 O2Sats 98%
NC
Gen: Lethargic, responds to loud voice, and requires some
physical stimuli at times.
HEENT: Pupils: [**2-23**] bilaterally EOMs: grossly intact, tracks
examiner
Neck: trauma collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Lethargic but answering questions with a little
prompting.
Orientation: Oriented to self, place, month.
Language: Speech fluent with good comprehension
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,4 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Unable to asses
[**Doctor First Name 81**]: Unable to asses.
XII: UA.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Antigravity with all extremities.
Sensation: Intact to light touch, proprioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Upon discharge:
Patient is Neurologically intact.
Sutures at the site of the ventricular catheter insertion are
clean, dry and intact without evidence of infection.
Pertinent Results:
.
Brief Hospital Course:
Mr. [**Known lastname 18808**] is a 42 year old male who was admitted for an
intraventricular hemorrhage of unknown etiology. He was admitted
to the ICU upon arrival, an extensive workup was undertaken
including a CTA and cerbral angiogram to identify the underlying
cause of his hemorrhage. No vascular anomoly was identified.
His IVH appears to have been hypertensive in etiology.
During the first 48 hours patient's mental status declined and a
CT of the head revealed that the patient had developed
hydrocephalus, he was intubated and a ventricular catheter was
placed.
Mr. [**Known lastname 18808**] was able to be extubated in the ICU in the
following days and aggressive BP manegment was undertaken. A
medical consult was obtained for aid in workup and follow up of
his blood pressure.
Medications on Admission:
None
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
Disp:*60 Tablet(s)* Refills:*0*
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Clonidine 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
5. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*35 Tablet(s)* Refills:*0*
7. Dilantin Extended 100 mg Capsule Sig: One (1) Capsule PO
three times a day: Take one Tid for three days, then one [**Hospital1 **] for
two days, then one QD for two days, then D/C.
Disp:*15 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
IVH
Hypertention
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Please call and make an appointment with Dr. [**Last Name (STitle) 18809**] from
[**Hospital3 **].
You have the following appointment :
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2111-10-13**]
1:45
Completed by:[**2111-10-6**]
|
[
"2761"
] |
Admission Date: [**2120-12-12**] Discharge Date: [**2120-12-17**]
Date of Birth: [**2056-9-4**] Sex: F
Service: MEDICINE
Allergies:
Latex / Vancomycin / Sudafed / IVIG
Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
Left transverse patella fracture
Acute Respiratory Distress likely due to pneumonia and pulmonary
edema
Major Surgical or Invasive Procedure:
[**2120-12-11**]: Open reduction internal fixation with K-wires in
a figure-of-eight cerclage wire construct
History of Present Illness:
64 yo female with history of metastatic breast cancer to bone
and brain, SVC thrombus on lovenox for many years,
hypogammaglobulinemia and recurrent pneumonias with recent CAP
in [**11-11**] treated with levofloxacin who was transferred from St.
[**Doctor First Name **] for left parapatellar fracture. The patient underwent a
left patellar ORIF today in the OR. The procedure was quick and
noninvasive with a superficial incision and minimal blood loss
under general anesthesia. She received 1L of fluid and
cefazolin peri-operatively.
.
Tonight, on the floor, she had the acute onset of dypsnea and
tachypnea, with a sudden desaturation to the 70's and
tachycardia to the 110's. She was placed on 5L but was still in
the low 80's, so she was given a NRB. She had finished eating
[**Country 1073**] for dinner but denies any cough or choking event. She
missed one dose prior to surgery. She describes five days of
cough with sputum production since admission to St. [**Doctor First Name **]. She
also reports associated nausea and some vomiting with her
symptoms.
.
On arrival to the MICU, she is tachypneic and anxious. She
finds her left leg and the immobilization brace to be extremely
uncomfortable.
Past Medical History:
Past Oncologic History:
Metastatic breast cancer:
- [**2106**]: diagnosed at stage IV with mets to lymph nodes and
liver; initially treated with doxorubicin, a bone marrow
transplant,
and a partial mastectomy
- [**2108**]: had recurrence with multiple liver lesions seen in her
liver; treated with trastuzumab and paclitaxel
- remained in remission on trastuzumab and paclitaxel for 5
years, until [**2113**] when she had mets to her left hip and
underwent a partial hip replacement
- [**2114**]: noted to have brain mets, and she underwent surgical
resection and Cyberknife therapy
- [**2116**]: noted to have cancer in her femur and underwent more
surgery; received additional therapy (which she could not
recall) in the meantime, and she has continued to be on
trastuzumab
- [**5-/2118**]: underwent XRT for metastatic disease in her spine
- [**1-/2119**]: had L2 progressive metastases, underwent surgery and
then gamma knife radiation treatment in [**4-/2119**]; developed
thrombocytopenia after radiation
- combination of lapatinib and trastuzumab were tried, but
patient developed significant diarrhea as well as pneumonia;
lapatinib was discontinued
- [**5-/2119**]: started zolendronate again
- [**2119-6-2**]: re-staging showed no new systemic metastases; she has
old cerebellar met, which had been radiated.
- continued on fulvestrant every month and trastuzumab every
three weeks; zolendronate being held due to recent tooth pull
[**2-9**] Revision PSF T9-L4 related to increased pain.
--[**3-12**] PET scan showed two foci in the
left lateral thigh. ? mets vs post-surgical The area from
T11-L4 lights up, ? mets vs post surgical. right acetabulum
unchanged. CEA increasing. Switched to CPT-11 and herceptin
continued.
.
Other Past Medical History:
- HTN
- Dyslipidemia
- GERD
- RLS
- Depression
- Insomnia
- Chronic pain
- Hypercoagulability/SVC thrombus: possible borderline
protein C/S deficiency; on enoxaparin
- Hypogammaglobulinemia: previous reaction to IVIG, now on Doxy
ppx since [**2-9**]
Social History:
She is married. She lives with her husband. [**Name (NI) **] daughter and
grandchildren also live with her. She smoked 1ppd for a few
years, but quit ~30 years ago. She admits to occasional alcohol
use (about 2 dinks per week). She denies any illicit drug use.
Family History:
Her daughter had breast cancer at 29, and had a recurrence. Her
neice also had breast cancer. Her brother had lung cancer. She
denies any other family history of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
.
LLE: Her exam reveals a closed fracture of the patella with some
effusion as expected and no abrasion or skin bridge. No
palpable defect.
.
Vitals: 103.5 103 133/76 93% on 50% FM
General: Alert, oriented, uncomfortable
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL and
8mm bilaterally
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Rhonchi and crackles mid way up on the left side with
crackles and the right base
Abdomen: +BS, soft, non-tender, non-distended, no organomegaly,
multiple bruises from lovenox injections
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, no calf pain, left leg with [**Doctor Last Name **] locked in extention
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
.
DISCHARGE PHYSICAL EXAM:
afebrile, vital signs stable
exam unchanged except crackles are improved
Pertinent Results:
ADMISSION LABS:
[**2120-12-12**] 10:00PM BLOOD WBC-2.0*# RBC-4.46 Hgb-13.4 Hct-40.8
MCV-91 MCH-30.0 MCHC-32.9 RDW-16.7* Plt Ct-49*
[**2120-12-12**] 10:00PM BLOOD Neuts-86* Bands-0 Lymphs-11* Monos-2
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2120-12-13**] 04:24AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-OCCASIONAL Polychr-NORMAL Ovalocy-OCCASIONAL
[**2120-12-12**] 10:00PM BLOOD Glucose-135* UreaN-13 Creat-0.9 Na-138
K-4.3 Cl-101 HCO3-24 AnGap-17
[**2120-12-12**] 10:00PM BLOOD CK(CPK)-223*
[**2120-12-12**] 10:00PM BLOOD CK-MB-8 cTropnT-<0.01
[**2120-12-12**] 10:00PM BLOOD Calcium-8.5 Phos-4.2 Mg-1.4*
[**2120-12-12**] 10:00PM BLOOD IgG-322* IgA-24* IgM-13*
[**2120-12-12**] 09:02PM BLOOD Type-ART pO2-60* pCO2-43 pH-7.43
calTCO2-29 Base XS-3
[**2120-12-12**] 09:02PM BLOOD Glucose-120* Lactate-1.7 Na-137 K-3.9
Cl-98
.
[**12-12**] CXR: IMPRESSION: Bibasilar pneumonia
.
[**12-13**] TTE: The left atrium is mildly dilated. A patent foramen
ovale is present. A right-to-left shunt across the interatrial
septum is seen at rest. The estimated right atrial pressure is
at least 15 mmHg. Left ventricular wall thickness, cavity size
and regional/global systolic function are normal (LVEF 65%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is dilated with borderline normal free wall
function. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion 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.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
The inferior vena cava is massively dilated. The entrance of the
inferior vena cava into the right atrium is narrowed with
extrinsic compression and possibly intraluminal mass/thrombus as
well.
Compared with the findings of the prior study (images reviewed)
of [**2120-6-19**], a right-to-left shunt across a patent foramen
ovale is present. The right ventricle is similarly dilated, with
at least moderate pulmonary hypertension. The findings suggest
acute-on-chronic right ventricular afterload excess consistent
with venous thromboembolic phenomena, pulmonary lymphangitic
spread of breast cancer, pulmonary parenchymal disease,
.
[**12-13**] CTA chest: IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic injury.
2. Bibasilar ground-glass opacification concerning for
aspiration versus
pneumonia.
3. 3-mm calcified nodule in the right upper lung (2, 13), stable
compared to
the prior PET-CT of [**2120-9-20**].
4. Upper lobe bronchus appears to arise directly from the
trachea (2, 13) and
may represent normal variant anatomy.
5. Large hiatal hernia.
6. Fluid-filled esophagus.
7. Extensive coronary calcifications.
8. A 12-mm right hilar lymph node (series 3, 24) is noted.
.
[**12-13**] bilateral lower extremity dopplers: no DVT
.
DISCHARGE LABS:
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the Orthopedic service on [**2120-12-12**] for
a left transverse patella fracture after being evaluated in the
Orthopedic Trauma Clinic. She underwent open reduction internal
fixation of the fracture without complication on [**2120-12-11**]. Please
see operative report for full details. She was extubated
without difficulty and transferred to the recovery room in
stable condition. In the early post-operative course Ms. [**Known lastname **]
did well and was transferred to the floor in stable condition.
She had adequate pain management and worked with physical
therapy while in the hospital.
.
On [**2120-12-13**], the patient had an acute episode of hypoxia and
tachypnea on the floor. Her O2 saturations fell into the 70s,
but came back up with NRB. A CXR was concerning for bibasilar
pneumonia versus pulmonary edema. The patient was started on
broad spectrum Vanc, Cefepime, Cipro for treatment of HCAP. The
patient was also given some diuretics to augment her urine
output. For completeness of this episode, a TTE was ordered that
showed RV strain, slightly worse than a previous study. We were
concerned about possible acute on chronic pulmonary emboli, so a
CTA was performed that was negative for PE. The CT, however, did
find bibasliar opacities, concerning for lymphangetic spread of
her known breast cancer, pneumonia/aspiration, or edema. The
patient's breathing continued to improve and she was weaned off
the oxygen. Her abx were narrowed to levofloxacin after three
days since infection was less likely. It was thought that her
hypoxia and hypotensive episode was most concerning for an
aspiration event. She was discharged to complete a 7-day course
of empiric levofloxacin to be completed [**2120-12-19**].
.
CHRONIC PROBLEMS:
# Leukopenia, thrombocytopenia: Worsened in hospital acutely
but without symptoms. Possibly secondary to stress reaction
from pneumonia infection.
.
# Left parapatellar fracture: See discussion about ORIF above.
Did well with pain control and was discharged with oxycodone SR
and IR as well as standing tylenol. She has a LLE brace and is
non-weight bearing on left extremity. She was continued on her
lovenox for known SVC clot and new immobility.
.
# Metastatic breast cancer: Currently on herceptin as an
outpatient, with plans to restart irinotecan. Continued pain
management.
# Depression: continued sertraline and buproprion
# GERD: continued pantoprazole and ranitidine
# HTN: continued valsartan
# Med rec: continued pramipexole, vitamin D
.
# Communication: Husband [**Name (NI) **]: [**Telephone/Fax (1) 24145**] (c), [**Telephone/Fax (1) 24142**]
(h)
.
TRANSITIONAL ISSUES:
- Patient needs outpsatient video swallow study for chronic
intermittent aspiration and nighttime coughing
- Patient needs outpatient Pulmonary evaluation for chronic
cough and basilar scarring
Medications on Admission:
BONE STIMULATOR - - wear 2 hours daily
BUPROPION HCL [BUDEPRION SR] - 100 mg Tablet Extended Release -
1
Tablet(s) by mouth daily for additional benefit with zoloft
DEXAMETHASONE SODIUM PHOSPHATE - 4 mg/mL Solution - please give
to therapist for iontophoresis twice weekely
DIAZEPAM - (Prescribed by Other Provider: [**Name10 (NameIs) 86**] [**Name11 (NameIs) 24146**]
center) - 5 mg Tablet - 1 Tablet(s) by mouth up to 2 tablets
daily as needed for spasm wean as able.
DOXYCYCLINE HYCLATE - 100 mg Capsule - 1 Capsule(s) by mouth
twice a day
ENOXAPARIN [LOVENOX] - 80 mg/0.8 mL Syringe - Inject 80MG SC
TWICE A DAY
GABAPENTIN - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 300 mg Capsule - 2 Capsule(s) by mouth three times
daily
OXYCODONE - (Prescribed by Other Provider: [**Name10 (NameIs) 86**] [**Name11 (NameIs) 24146**]
[**Name12 (NameIs) **]) - 15 mg Tablet - 1 Tablet(s) by mouth as needed for as
needed up to 5 a day
OXYCODONE [OXYCONTIN] - (Prescribed by Other Provider) - 40 mg
Tablet Extended Release 12 hr - 1 Tablet(s) by mouth twice a day
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth twice a day
PRAMIPEXOLE [MIRAPEX] - 0.25 mg Tablet - [**12-2**] Tablet(s) by mouth
at bedtime
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every 6 hours as needed for nausea
RANITIDINE HCL - 150 mg Tablet - 2 Tablet(s) by mouth at bedtime
SERTRALINE - 100 mg Tablet - 2 Tablet(s) by mouth once a day
take
2 tablets daily for total of 200mg
TRASTUZUMAB [HERCEPTIN] - (Prescribed by Other Provider) -
Dosage uncertain
VALSARTAN [DIOVAN] - 160 mg Tablet - 1 (One) Tablet(s) by mouth
once a day
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 6138**] Home Care Services
Discharge Diagnosis:
Left transverse patella fracture
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:
Wound Care:
- Keep Incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dresssing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be non-weight bearing on your left leg
- You should not lift anything greater than 5 pounds.
- Elevate left leg to reduce swelling and pain.
- Do not remove the brace on your left leg and keep it dry. It
is locked to prevent you from bending your left knee.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at [**Telephone/Fax (1) 1228**] or go
to your local emergency room.
Physical Therapy:
Activity as tolerated
Left lower extremity: Non weight bearing in locked [**Doctor Last Name **]
Brace
Encourage turn, cough and deep breathe q2h when awake. [**Doctor Last Name **]
brace locked in extention at all times
Treatments Frequency:
Wound care:
Site: Incision
Type: Surgical
Dressing: Gauze - dry
Comment: change daily by RN; please overwrap any dressing
bleedthrough with ABDs and ACE
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up
appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks at [**Telephone/Fax (1) 1228**].
Please follow-up with your primary care physician regarding this
admission.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
|
[
"486",
"51881",
"5849",
"4168",
"V1582",
"53081",
"2724",
"311"
] |
Admission Date: [**2133-11-18**] Discharge Date: [**2133-11-26**]
Date of Birth: [**2057-3-21**] Sex: F
Service: GENERAL SURGERY/PURPLE TEAM.
HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old
female with a known gastric ulcer on EGD presenting initially
to the Medical Intensive Care Unit with bleeding per rectum.
The patient was in the usual state of health until the day
prior to admission, when she developed gradual weakness. She
also had several loose stools of unusual collar and poor PO
intake. The daughter reported noticing bright red blood in
the patient's bowel movements and brought the patient to the
emergency room for evaluation. The patient was managed
medically by the MICU team during which time she received
approximately 10 units of blood over a three-day period.
On hospital day #2, the patient was taken for EGD, which
demonstrated old clotted blood in the entire stomach. No
apparent bleeding within the stomach itself. After
excavation and area of active bleeding was sitting in the
pyloric channel, similar to that described on 8/[**2133**].
Hemostasis was achieved with epinephrine injections. After
the procedure, she was discharged back to the Intensive Care
Unit for continued medical management.
On [**2133-11-19**], the Department of General Surgery was
consulted. At that time, recommendations were made. Medical
management was recommended, as well as discontinuing any
nonsteroidals or aspirin products with request for surgery to
be consulted if bleeding continued to be a problem.
On [**2133-11-21**], the patient was noted to become profoundly
hypotensive with blood pressure in the 80s/50s. Surgery was
called. Hematocrit measured at that time was 26, down from a
previous of 30. It was determined at that time that the
patient would require an operation to repair her bleeding
ulcer. Consent was obtained. The patient was taken to the
operating room for a subtotal gastrectomy with Billroth II
anastomosis. Please see operative note from
Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] for details of this operation. The
patient, after the operation, was transferred to the
Intensive Care Unit, where she was given aggressive volume
rehydration. The patient had received two units of packed
red blood cells in the MICU.
On [**2133-11-21**], she received an additional two units in the
operating room. The patient did well within the Intensive
Care Unit. She was gradually weaned from her FIO2 to room
air. She was transferred to the floor.
On postoperative day #3, she was gradually advanced from
clear sips to full clears to general diet. Due to the
patient's poor ambulatory status, rehabilitation was
considered appropriate, intermediate move from the hospital
to home.
At the time of discharge, the patient was tolerating a post-
gastrectomy diet without difficulty. She was quite requiring
any rehydration to maintain adequate fluid. She was voiding
and stooling normally. Stools did demonstrate old clot
within them, consistent with the amount of bleeding that she
had had previously in her upper GI tract. This was not
considered worrisome due to the fact that the hematocrit had
remained stable at or above 30 during this entire period.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The patient was discharged to a
rehabilitation facility.
DISCHARGE DIAGNOSES: Bleeding pyloric ulcer, status post
subtotal gastrectomy and Billroth II anastomosis.
DISCHARGE MEDICATIONS:
1. Percocet one to two tablets PO q.3h.
2. Albuterol p.r.n.
3. Fluticasone 110 mcg, two puffs IH b.i.d.
4. Subcutaneous heparin 5000 units q.8h.
5. Fentanyl patch 75 mcg per hour, TP q.72h.
6. Metoprolol 25 mg PO b.i.d., hold for systolic less than
100, heart rate less than 60.
7. Ativan ?????? mg IV q.8h.
8. Haldol ?????? mg IV p.r.n.
9. Protonix 40 mg PO q.24h.
10. Klonopin ?????? mg PO t.i.d.
11. Mirtazapine 15 mg PO q.h.s.
FOLLOWUP PLAN: The patient will see Dr. [**Last Name (STitle) **] in
approximately two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 1752**]
MEDQUIST36
D: [**2133-11-26**] 09:43
T: [**2133-11-26**] 10:23
JOB#: [**Job Number 19190**]
|
[
"496",
"311"
] |
Admission Date: [**2106-6-18**] Discharge Date: [**2106-8-12**]
Date of Birth: [**2026-6-18**] Sex: M
Service: MEDICINE
Allergies:
Iodine / Crestor / lisinopril
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
New metastatic cancer to spine found on outside MRI
Major Surgical or Invasive Procedure:
Ortho Surgery #1 [**6-21**]:
1. L3 bilateral hemilaminectomy.
2. L4 laminectomy for biopsy of neoplasm.
3. Open treatment lumbar fracture, posterior.
4. Posterolateral fusion L3-L4, L4-L5.
5. Posterior spinal instrumentation L3-L5.
6. Iliac crest bone graft harvest for fusion augmentation.
7. Allograft for fusion augmentation.
8. Deep muscle open biopsy.
9. Open biopsy deep bone.
Ortho Surgery #2 [**7-20**]:
1. L4 corpectomy.
2. L3 partial vertebral body resection for lesion.
3. Application of interbody device L3-L5.
4. L3-L4 anterior fusion.
5. L4-L5 anterior fusion.
6. Allograft for fusion augmentation.
NGT placement x 3
Chest Tube Placement
EGD with balloon dilation of duodenal stricture
PICC placement
Anoscopy
History of Present Illness:
80 yo m with hx MVR bioprosthetic, AF on coumadin, 1 month hx of
left shoulder and side pain, presents after MRI today noted what
looked like mets cancer at T1, T2, and T3. He was called by his
physician who asked him to come to ED at [**Hospital1 18**] for specialty
evaluation. Pt reports being in usoh when he began to have L
upper chest pain with coughing about 4 weeks ago. 2 weeks ago
noticed left shoulder and scapula pain, as well as left
arm/elbow pain. In context of all of this he had recent surgery
in [**11/2105**] for MVR, and had 30 lbs weight loss and early satiety
since. He has undergoing several EGDs which have demonstrated a
short duodenal stricture. This has been dilated x 2 and
biopsied with results c/w peptic stricture; benign w/o
malignancy. EUS performed end of [**2106-4-23**] by Dr. [**Last Name (STitle) 26064**] at
[**Hospital1 112**] showed benign stricture. He also had Abd CT w/o contrast
[**2106-4-1**] which showed narrowing of post-bulbar duodenum
(stricture as above), with cystic lesion at L4. Because of the
latter, he underwent bone scan [**2106-4-1**] which was negative. MRI
cervical spine was reportedly performed today in [**Location (un) 1411**] w/o
gadolinium and showed Thoracic lesions above. However, we do
not have report nor images of this.
Pt denies fevers, abd pain, diarrhea, or night sweats. No
problems with urination. He reports colonoscopy 4 months ago at
[**Hospital1 882**], which was normal. We do not have this report. He
reports yearly prostate exam which has been normal. No other
localizing complaints. He did have a past basal cell carcinoma
which was removed 20 years ago and has not been a problem since.
Past Medical History:
ESOPHAGEAL REFLUX
OBESITY
SLEEP APNEA
ISCHEMIC HEART DISEASE - OTHER CHRONIC
AMNESIA/MEMORY DISORDER [**2102-6-21**]
BACK PAIN
HYPERLIPIDEMIA
PULMONARY NODULE/LESION, SOLITARY [**2104-7-16**]
MACROCYTOSIS WITHOUT ANEMIA [**2105-4-20**]
S/P MITRAL VALVE REPLACEMENT [**2106-2-26**]
ATRIAL FIBRILLATION [**2106-3-30**]
ANTICOAGULANT LONG-TERM USE [**2106-3-30**]
Past Surgical History:
Pilonidal cyst surgery x 2 [Other] [**2048**],[**2050**]
Left shoulder, right elbow,right wrist x2; rig*
TONSILLECTOMY & ADENOIDECTOMY
Lumbar rhizotomy [Other] [**2099**]
right shoulder surgery [Other] [**2078**]
right carpal tunnel surgery [Other] [**2092**]
both thumb surgery [Other] 99 - [**2096**]
VASECTOMY [**2072**]
RT SHOULDR ACRIOMPLASTY [Other] [**2102-11-28**]
right tennnis elbow surgery [Other] [**2073**]
left shoulder surgery [Other] [**2091**]
mitral valve replacement [Other] [**11/2105**]
Dr [**Last Name (STitle) 1537**] - B/W - bovine valve
Social History:
Pt is married with 2 children. Past pipe smoker, but quit in
[**2062**]. Three [**1-24**] glasses of wine per week. No drug use.
Family History:
Father - progressive supranuclear palsy. Mother - CHF. [**Name2 (NI) **]
cancers.
Physical Exam:
Admission Exam:
Vitals: 96.5, 124/72, 93, 18, 99% RA
Gen: Pleasant, NAD.
HEENT: No OP erythema or exudate. No scleral icterus.
Pulm: CTA B.
Heart: RRR. No m/r/g.
Abd: +BS. NTND. No HSM.
Rectal: Prostate without clear mass, although there did seem to
be some slight irregularity of unclear significance.
Ext: No c/c/e.
Discharge Exam:
Vitals: 99.2 122/70 88 22 96%
Gen: fatigued, no acute distress
HEENT: MMM, anicteric, no lymphadenopathy
CV: RRR, 3/6 systolic murmur
Lungs: Clear bilaterally
Abd: soft, non-tender, non-distend, hyperactive bowel sounds,
midline incision well-healing
Ext: no CCE, rash on lower legs c/w tinea
Back: deep tissue injury to left buttock
Pertinent Results:
Admission Labs:
138 103 14 105 AGap=10
---------------
4.1 29 0.7
Ca: 8.9 Mg: 2.0 P: 3.7
6.1 > 38.6 < 238
N:64.3 L:27.3 M:4.3 E:3.1 Bas:0.9
On discharge:
[**2106-8-12**] 05:27AM BLOOD WBC-7.4 RBC-2.73* Hgb-9.1* Hct-27.1*
MCV-99* MCH-33.3* MCHC-33.5 RDW-20.6* Plt Ct-176
[**2106-8-2**] 03:13AM BLOOD PT-15.5* INR(PT)-1.4*
[**2106-8-12**] 05:27AM BLOOD Glucose-101* UreaN-16 Creat-0.6 Na-140
K-3.7 Cl-107 HCO3-28 AnGap-9
[**2106-7-28**] 07:55AM BLOOD ALT-7 AST-42* AlkPhos-134* TotBili-0.5
[**2106-8-11**] 05:31AM BLOOD Calcium-7.1* Phos-3.0 Mg-1.8
[**2106-8-8**] 04:38PM BLOOD freeCa-1.21
Video Swallow Evaluation [**2106-8-10**]:
Mr. [**Known lastname **] presented with a moderate oropharyngeal dysphagia
as
characterized above with penetration of thin liquids,
nectar-thick liquids, and ground solid. Pt also had trace
aspiration of thin and nectar-thick liquids with one episode of
significant aspiration with large consecutive sips of thin
liquids. Pt had a spontaneous throat clear in response to
penetration which was moderately effective for clearing the
airway, more so with nectar-thick liquids than with thin
liquids.
RECOMMENDATIONS:
1. PO diet: nectar-thick liquids, pureed solids.
2. PO meds crushed with applesauce.
3. 1:1 supervision to maintain strict aspiration precautions
4. Small sips, ONE sip at a time.
5. TID oral care.
6. Agree with keeping NG tube in place until pt demonstrates
sufficient PO intake.
7. We will f/u later this week to evaluate for further upgrades.
Brief Hospital Course:
In Summary (please see below for more details):
80 yo m with hx MVR bioprosthetic, AF on coumadin, 1 month hx of
left shoulder and side pain, presents after MRI noted what
looked like mets cancer at T1, T2, and T3. Biopsy of the spine
identified multiple myeloma as the cause of the lytic lesions.
His hospital course has included:
- posterior lumbar fusions on [**2106-6-21**]
- Anterior lumbar fusion [**2106-7-20**]
- ileus and gastric outlet obstruction, requiring dilation
- acalculous cholecystitis and infectious pericholecystic fluid
- C difficile diarrhea
- right sided exudative pleural effusion s/p chest tube and
removal
- health care associate pneumonia (treated with
vanc/cefe/flagyl)
- sacral decubitus ulcer
On discharge, his condition has significantly improved. His
active problem list now includes:
- multiple myeloma: untreated, will likely start chemo soon
- nutrition: tolerating pureed and nectar diet, advance as
tolerated
- duodenal stricture: tolerating diet, GI will followup if
having difficulty with PO
- afib: in NSR during hospitalization, holding warfarin given
comorbidities
- sacral decub: needs wound care
- physical therapy
.
.
Hospital Course:
#) Multiple Myeloma: Pt presented initially with concern for
metastatic disease seen on outside MRI. He was found to have a
pathologic L4 fracture in need of stabilization and his multiple
myeloma was diagnosed via tissue pathology from posterior spine
stabilization on [**2106-6-21**]. Heme/Onc and Rad/Onc were aware of
patient but put further treatment or evaluation for multiple
myeloma on hold until more acute hospital issues are resolved
(see below). From the beginning family expressed desire to
pursue treatment of myeloma once patient able. Given his
improved medical status, he was transferred to rehab with
followup by the oncology there to consider therapy with decadron
and velcade. The family also opted for Dr. [**Last Name (STitle) **] [**Name (STitle) 2405**] as
their oncologist, and he can be reached at [**Telephone/Fax (1) 17667**]. Will
need pamidronate q4wks (1st dose was [**8-8**]).
.
#) Pathologic Spine Fracture:
Pt had lumbar instability due to L4 lytic lesion found
incidentally on initial MRI. Pt had no symptoms at time of this
discovery. Pt underwent L3-L4 bilateral hemilaminectomy with
posterolateral fusion of L3-L5 with iliac crest bone graft
harvest for fursion augmentation. Due to extent of metastatic
destruction, also needed second surgery for anterior spine
stabilization. On [**7-20**] patient went to OR and underwent anterior
fusion of L3-L5. He was transferred to the MICU post-op then
called out to the floor. On the floor he was helped out of bed
to chair without use of the brace.
.
#) Gastric Outlet Obstruction/Ileus:
Post operative ileus was present from date of initial spine
stabilization surgery. Pt also had known benign duodenal
stricture dilated x 4 at OSH ([**Hospital1 882**]/[**Hospital1 112**] - see Atrius records)
in [**Month (only) 547**]/[**Month (only) 116**]. He became acutely obstructed on [**2106-6-25**] with AXR
showing severe dilation of his stomach. An NGT placement yielded
1L bilious fluid. ERCP took to EGD later that day and performed
another balloon dilation of stricture. Afterward pt had some
improvement but over the next 10 days twice become more
distended and had NGTs placed twice with some bilious output
from the NGT and abdominal relief each time. Possible that the
2nd two events were due to total bowel distension and ileus [**2-24**]
to narcotics, Cdiff, immobility, and limited diet as much as a
problem with the duodenal stricture as they were not completely
relieved with NGT placement and abdominal imaging showed
persistently dilated bowel loops. After his anterior fusion,
abdomen remained distended possibly from gastric
obstruction/post-operative ileus/narcotic use. KUB showed no
signs of SBO. On POD4 he had 2BMs and he was started on clears
for diet. On the [**Hospital1 **], he was tolerating clear diet, moving
bowels reguarly. However there was concern for aspiration
pneumonia and patient was transferred to MICU for respiratory
distress. He was started on TPN in the MICU, and then
transitioned to tube feeds. He was transferred back to the floor
and TPN was discontinued. He continued on continuous tube feeds
until his mental status was improved, and then underwent another
video swallow eval. Recommendations from speech/swallow were to
start him on a pureed and nectar diet. He tolerated this well
without further abdominal distention, and the NG tube and tube
feeds were discontinued. He was discharged to rehab on the
pureed diet, which he was tolerating well.
.
#) Cdiff Infection:
Pt started developing leukocytosis with low grade temps on
[**2106-6-29**]. Was having very little stool but it was liquid and Cdiff
toxin sent on [**2106-6-30**] came back positive on [**2106-7-1**]. Pt had
already been started on metronidazole on [**6-30**] (along with CTX)
for emperic coverage of gallbladder. Initially WBC and exam
improved with this therapy but when WBC worsened again PO vanco
was added to metronidazole on [**2106-7-5**]. Bowel distension slowly
improved with this treatment and abdominal pain slowly resolved.
However, continued to have persistently dilated bowel loops as
noted above. Since pt was started on Cefepime/Vanco for HAP
coverage when transfered to the ICU initially and completed a 8
day course of this therapy, decision was made to extend PO
Vanco/IV metronidazole coverage to end [**7-27**]. PO Vanco was
restarted because of the high likelihood of recurrence. He
continued prophylactic PO vanco coverage until [**8-12**].
.
#) Poor respiratory status:
This was not present on hospital admission and CXR on [**2106-6-29**] had
no effusion but PICC confirmation CXR on [**7-2**] showed large
unilateral (right) effusion which had developed in the 3 day
interval. Pt had worsening of breathing status a day or two
before this was observed as well as discomfort in R side which
presumably was due to effusion although initially had been
attributed to either Cdiff or Choleystitis as both were being
evaluated at that time. Pt was doing okay on 2-3L NC but fluid
was not responding well to lasix when on the evening of [**7-5**] he
became acutely tachypnic and was transfered to the ICU where he
was briefly on BIPAP and CT surgery placed a chest tube with >1L
of output. Fluid studies boarderline exudate vs transudate and
cultures pending. Abx were broadened to cefepime and vancomycin
at time of unit transfer. Pt now with stabilized respiratory
status and has largely resolved effusion on f/u CXRs. Chest tube
removed today and pt doing well enough to call out to floor on
[**7-7**]. After arrival to the floor, stayed comfortable on RA-2L NC
with only minimal reaccumulation of R pleural effusion noted on
f/u CXRs. Completed 8 day course of Cefepime/IV Vancomycin as
noted above for presumed hospital acquired pneumonia and WBC
which had spiked up on day of hospital transfer trended down to
the normal range with these treatments. Pt returned to the OR on
[**7-20**] and remained intubated post-op. He was extubated on [**7-22**].
Since transfer to the [**Hospital1 **] on 06/31, he has remained tachypneic,
with RR rising upto 50. He was also tachycardic with HR up to
120. EKG was unchanged from previous, ABG shows alkolosis,
Multiple CXRs and MRI with contrast ([**7-29**]) showed only stable
atelectasis and stable right-sided pleural effusion, with no
evidence of pneumonia or PE. Started therapeutic heparin to
treat presumptive PE on [**7-28**]; He was not fluid overloaded and
did not improve w/ lasix. Given aspiration risk, pleural
effusion and previous HCAP, restarted IV vancomycin and cefipime
on [**7-29**] for 1 week. He was transferred out of the MICU on [**8-6**]
and continued to be tachypnic to high 20s, but respiratory
status was otherwise stable. His respiratory status continued
to improve and he was discharged with a RR ~20 on room air with
a normal oxygen saturation.
.
#) Question of Cholecystitis:
During time when pt initially developed leukocytosis, low grade
temps, and abd distension, concern developed about possible
gallbladder process. Abdominal CT had showed GB enlargement but
picture muddied by fluid around gallbladder from small amount of
ascites due to low albumin. Gallbladder U/S was non-diagnostic
so HIDA scan was obtained. This showed evidence of acute
cholecystitis with caveat that some question if could be falsely
positive in setting of NPO status. Due to concerns for risk of
perc cholecystostomy tube recommended by surgical service,
decision was made to initially treat with IV abx and pt had some
improvement. Development of R pleural effusion raised concern
again for GB process and resulting sympathetic effusion in right
lung. However, pt improved again with drainage of pleural
effusion and empiric treatment for hospital acquired pneumonia
and GI consulting service agreed that less likely pt had
cholecystitis in current setting although pt continued to remain
at very high risk for acalculous cholecystitis due to his
overall level of poor health.
.
#) Delirium:
Pt was intermittently delirious for 4-5 days after initial
ortho/spine surgery. This largely resolved in the following 10
days with pt only requiring a couple of doses of haldol (which
had only limited effect). Pt again started to become somewhat
confused on AM of [**2106-7-13**] which was attributed to multifactorial
delerium in an elderly, very sick patient who had been in the
hospital for almost 4 weeks. Family actually thought patient
looked better than he had the entire hospitalization that day
but the next day delirium seemed further worsened and that night
patient again required ICU transfer due to 2 blood containing
bowel movements and a small Hct drop.
In the MICU patient had visual hallucinations and required
restraints because started pulling at lines. On POD2 after
anterior spinal fusion pt became slightly agitated. On transfer
to the [**Hospital1 **], delirium continued to wax and wane. On discharge,
he is alert and oriented to name, sometimes to date, sometimes
to location.
.
#) GI Bleed:
Although patient had multiple above GI issues, no GI bleeding
had been noted during first 3 weeks of hospitalization. Pt had
history of bleeding hemorrhoids and was on [**Hospital1 **] omeprazole for
GERD/GI prophylaxis considering his level of sickness. On the
afternoon of [**2106-7-13**], pt was reported to have a blood bowel
movement while working with physical therapy. On physician exam
of the stool, it was brown with some blood streaking and patient
had notable hemorrhoid protruding externally on physical exam.
In light of stool appearance with very little total blood,
hemorrhoid, and pt report of past bleeding hemorrhoids, this
bleed was attributed to hemorrhoidal source. However, later that
evening pt had a large maroon bowel movement in the setting of
low grade new tachycardia and mild respiratory distress. Stat
Hct showed drop from 28.7 to 24.5 which was slightly outside the
range of lab error and in the setting of this and other clinic
changes (HR and RR), pt was transferred to the MICU and IV PPI
initiated. Of note, this occurred in setting of patient being
advanced from liquids to regular diet in the last 24hrs. In the
MICU, pt was transfused 1u prbc. Anoscopy performed by GI. No
lesion was visualized. Sigmoidoscopy was performed on [**7-16**] which
suggested bleeding was likely an internal hemmorhoid. Hct were
stable afterwards. There was concern on a subsequent MICU
admission for bleeding given a downtrending H/H. Upper endoscopy
by GI demonstrated a non-bleeding duodenal ulcer. On discharge,
H/H was stable. He was converted to pantoprazole 40 [**Hospital1 **] PO at
discharge.
.
#) Atrial Fibrillation:
Pt had history of atrial fibrillation for which he had been on
warfarin. This was stopped on admission due to need for spinal
surgery and relatively low day to day risk of embolic stroke
compared to high risk of spinal bleeding on therapeutic
anticoagulation. Also has prosthetic mitral valve but it since
it was a tissue valve, it did not need anticoagulation. Pt was
actually sinus most of admission and midly tachycardic when was
febrile/developing infection. On low dose metoprolol as an
outpatient which was held for the concern of GI bleed. Warfarin
was held on discharge given multiple comorbidities and
relatively low embolic risk. This was discussed with the PCP at
discharge. His metoprolol was not re-started during the
hospitalization but should be restarted at rehab and was
included in his medication list.
.
# Nutrition Status:
Mr. [**Known lastname **] was intermittently on TPN, tube feeds, and diets
throughout his hospitalization. Most recently he was
transitioned from TPN to tube feeds. A video swallow eval
recommended nectars and pureed food. He tolerated this diet well
over the last 24 to 48 hours. His tube feeds were stopped and
his NG tube was removed prior to discharge.
.
# Adrenal Insufficiency
There was a question of adrenal insufficiency raised while the
patient was hypotensive in the MICU. He was started on steroids
with relief of his hypotension. He was then tapered down from
the stress dose to a maintenance dose of 10mg AM and 5mg PM of
hydrocortisone. On [**8-11**] he underwent a cortisol stim test, and
his cortisol level at 1hr and 15min was 17.8. It was felt that
this was nearly a normal response and that his steroids could be
tapered. It was likely that the poor adrenal response was
related to his signficantly troubled hospital stay. He received
10mg hydrocortisone in the hospital prior to discharge, and then
will receive 5mg hydrocortisone at rehab and then will stop.
.
Medications on Admission:
Simvastatin 20 qd
Xalatan 0.005% 1 drop each eye daily
Warfarin 5 mg Sun/Mon/Wed/Fri; 2.5 mg Tue/Thurs/Sat
Omeprazole 40 mg [**Hospital1 **]
Metoprolol 25 qd
MVI
Citracal + D.
Tylenol
Oxycodone 5 mg prn
Baclofen 10 prn
Erythromycin eye ointment tid (for 7 days for eye infection).
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
4. clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
5. 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.
6. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
7. hydrocortisone 5 mg Tablet Sig: One (1) Tablet PO once a day
for 1 doses: finishing steroid taper, give one dose friday
morning, then discontinue.
8. Pantoprazole 40 mg IV Q12H
9. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain.
10. Zyprexa 2.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia or agitation.
11. zoledronic acid 4 mg/5 mL Solution Sig: One (1) dose
Intravenous once a month: last dose [**2106-8-8**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital-[**Hospital1 8**]
Discharge Diagnosis:
Multiple myeloma
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:
Mr. [**Known lastname **], you were originally admitted almost two months ago
with back pain, and spinal surgery revealed this was called by
multiple myeloma lesions. Your hospital stay has since been
prolonged by multiple complications including many transfers to
the MICU. You are being transferred to a rehabilitation hospital
for further therapy.
Followup Instructions:
---Follow-up with PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 7842**] ([**Telephone/Fax (1) **] after
rehab.
---Hem/onc at [**Hospital1 **] will follow multiple myeloma. Can
contact Dr. [**Last Name (STitle) **] [**Name (STitle) 2405**] at [**Telephone/Fax (1) 17667**] to coordinate care
---Follow-up with [**Hospital1 18**] GI after rehab regarding duodenal
stricture
|
[
"486",
"2760",
"5849",
"42731",
"V5861",
"53081",
"32723",
"41401",
"2724"
] |
Admission Date: [**2100-11-2**] Discharge Date: [**2100-11-17**]
Date of Birth: [**2044-8-21**] Sex: M
Service: MEDICINE - [**Company 191**] firm
CHIEF COMPLAINT: The patient was found down.
HISTORY OF PRESENT ILLNESS: This is a 56 year old white male
with a past medical history of seizure disorder on Tegretol and
mental retardation among others. The patient was found down at
home today by EMS. Per the patient's brother, the patient lives
alone and the family periodically "checks in with him". No one
has heard from the patient for three days so the EMS broke the
door down. The patient was found down unconscious, covered in
emesis as well as blood (question nosebleed). The patient was
noted to have multiple abrasions over his body.
Little is known about the patient's other history. He was
admitted to [**Hospital1 336**] last week with a change in mental status. His
mental status there was described as awake, alert, but minimally
attentive. His course was complicated by an upper
gastrointestinal bleed. Esophagogastroduodenoscopy showed
severe erosive esophagitis, question of [**Female First Name (un) 564**], and small
gastric polyps. The patient was discharged on Fluconazole,
Tegretol, Prilosec, and Loperamide.
Apparently, the patient's father died on [**Holiday 1451**] one year
ago and the patient was depressed related to this. Many empty
pill bottles were found next to him.
The patient was brought to [**Hospital1 69**]
Emergency Department where his GCS was 6 with oxygen saturation
in the 80s. The patient was intubated. He was hemodynamically
stable with blood pressure in the 120s and heart rate in the 90s.
Left groin line was placed. Chest x-ray showed a right lower
lobe pneumonia and bilateral apical opacities. CT of the head
was negative. CT of the spine was negative for any cervical
spine fractures. The patient was transferred to the Medical
Intensive Care Unit for further evaluation and treatment.
PAST MEDICAL HISTORY:
1. Mental retardation.
2. Hypertension.
3. Seizure disorder secondary to meningitis as a child.
4. Hypercholesterolemia.
5. Fecal incontinence.
6. Recent upper gastrointestinal bleed secondary to erosive
esophagitis.
7. Status post coronary artery bypass graft in [**2094**].
8. Atrial fibrillation.
MEDICATIONS ON ADMISSION:
1. Tegretol.
2. Pravachol.
3. Atenolol.
4. Zantac.
5. Fluconazole
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Non contributory.
SOCIAL HISTORY: The patient denies alcohol or tobacco use. He
lives alone in an apartment in [**Hospital1 8**], [**State 350**] and is
able to care for himself. Once awake, he described how he takes
the subway to see his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 102851**], at [**Hospital 14852**], and described how he gets there. He also
reports that he walks to the grocery store and buys his own
groceries. He keeps in close contact with a social worker, [**Name (NI) **]
[**Name (NI) 12130**], that works in his building. His brother, [**Name (NI) **] [**Name (NI) 13304**],
lives in [**Name (NI) 3844**] and checks in with the patient
periodically.
REVIEW OF SYSTEMS: Unknown.
PHYSICAL EXAMINATION: Vital signs revealed blood pressure of
90/45, temperature maximum 102.4, heart rate 96 to 110,
respiratory rate 16 to 21, oxygen saturation 95 to 98% on
"many" liters of oxygen. General - The patient is not responsive
but moving in athetotic pattern. Skin - multiple abrasions on
bilateral lower extremities (DIP of all toes, lateral malleoli
and dorsum of feet). No petechiae. No jaundice. Head, eyes,
ears, nose and throat examination - The pupils are 2.0
millimeters and reactive bilaterally. Unable to assess
extraocular movements. Bilateral periorbital erythema and edema.
Right eye with subconjunctival hemorrhage superior to pupil. No
Battle sign. Respiratory is clear to auscultation anteriorly.
Examination limited due to the patient's unresponsiveness.
Cardiovascular - regular rate and rhythm, no murmurs, rubs or
gallops. Abdomen is soft, normoactive bowel sounds, nontender,
nondistended, no organomegaly. Extremities - no cyanosis,
clubbing or edema, pulses 2+ bilaterally. Abrasions on lateral
malleoli bilaterally and dorsum of feet. Rectal is guaiac
negative. Neurologically, the patient is moving all four
extremities, withdraws to pain, no posturing, no corneal or gag
reflex (but on Propofol). Toes downgoing.
LABORATORY DATA: White blood cell count 17.6, hematocrit
34.3, platelets 364,000, neutrophils 71%, bands 18%, lymphocytes
6%. Urinalysis is nitrite positive, protein trace, bilirubin
small, pH 5.0, blood negative, red blood cells 0 per high power
field, white blood cells 0-2 per high power field, bacteria rare.
Chem7 revealed sodium 141, potassium 4.4, chloride 105,
bicarbonate 13, blood urea nitrogen 56, creatinine 4.2, glucose
100, anion gap 23. CPK [**Numeric Identifier 40281**], MB 91, index 0.8. Toxicology
screen - Aspirin negative, ETOH negative, Tylenol negative,
benzodiazepines negative, barbiturates negative, TCAs negative.
Carbamazepine 33 ([**3-18**]).
Electrocardiogram revealed normal sinus rhythm, PR interval
204 consistent with first degree AV block, left atrial
enlargement, QRS 140, Q-Tc 450, peaked T waves, 1.0 to 2.[**Street Address(2) 27948**] elevation in V1, V2, but pattern is left bundle
branch block, no T wave inversions, Q wave only in lead III.
IMAGING STUDIES: CT of the head revealed cerebellar atrophy,
mucosal thickening of maxillary and ethmoid sinus. CT spine
revealed normal alignment of vertebra, no fractures, no
subluxation, positive degenerative changes in C4-C5, C5-C6,
C6-C7. Chest x-ray revealed hazy opacities in the bilateral
apices and right lower lobe - ? aspiration.
HOSPITAL COURSE:
1. Toxicology - The patient was noted to have elevated
Carbamazepine levels. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from toxicology
recommended charcoal for absorption of the toxin. Carbamazepine
levels were monitored q3hours. Activated charcoal 30 grams were
given at the time of arrival to the Medical Intensive Care Unit
and three hours afterwards and need for further doses was
evaluated in the a.m. after admission. The patient most likely
had a Carbamazepine overdose (question intentional or confused
or due to interaction with fluconazole, recently begun for
candidiasis). The levels were reduced to therapeutic range with
charcoal treatment and intravenous hydration. They were
monitored for a couple days after that, however, remained in
normal limits for the duration of the hospital course.
2. Cardiology - The patient had a new widening of the QRS on
initial electrocardiogram and this was likely related to sodium
channel blocking activity of Tegretol. One amp of bicarbonate
was pushed and the electrocardiogram was rechecked. QRS
prolongation resolved rapidly after the bicarbonate and
resolution of the patient's acidemia.
3. Pulmonary - Due to the patient's findings on chest x-ray
of right lower lobe and bilateral apical opacities, he was
assumed to have suffered an aspiration event causing aspiration
pneumonia. He was started on Levofloxacin 500 mg intravenously
q.d. and Clindamycin 300 mg t.i.d. intravenously which was
continued for fourteen days. While in the Medical Intensive Care
Unit, he was kept on the ventilator with full support, however,
once he improved, on [**2100-11-8**], he was extubated. No
complications after extubation. The Levofloxacin and Clindamycin
were continued for a fourteen day course and discontinued
starting on [**2100-11-17**]. The patient's lung findings improved
rapidly over the course of the stay and for the last six days he
was clear to auscultation bilaterally with normal oxygen
saturation and no signs or symptoms, i.e., cough.
4. Renal - Initially the patient's creatinine was increased to
4.2. He also had elevated creatinine kinase enzyme levels around
10,000. This was most likely rhabdomyolysis and resolved with
hydration and bicarbonate and eventually the CKs trended
downward. The elevated creatinine normalized within the first
couple of days around [**2100-11-4**], and was postulated to be due to
acute renal failure secondary to severe hydration. His decreased
potassium was also suspected to be secondary to diarrhea,
gastrointestinal losses.
5. Gastrointestinal - His recent gastrointestinal bleed at [**Hospital 14852**] secondary to erosive esophagitis prompted
nasogastric tube lavage on admission in the Emergency Department
which was clear. He was treated with intravenous Protonix for
the duration of his hospital course up until discharge. Multiple
Clostridium difficile toxin assays were sent which were negative.
His abdominal examination continued to appear benign.
6. Neurology - The patient's altered mental status was likely
secondary to the Tegretol overdose. His CT of the head was
negative for any acute process. Cerebrospinal fluid cultures for
HSV and urine toxicology screens were negative, not consistent
with these as possible etiologies of altered mental status. The
patient was also while intubated on Propofol and thus not
allowing assessment of his current mental status. A few days
later, a CT was done of the head again which showed minimal
intraventricular and subarachnoid blood.
Neurology recommendations included electroencephalogram and
magnetic resonance scan to further workup altered mental status.
Two lumbar punctures were also done, one at admission and one
later on. Both were bloody with increased protein, however, CT
of the head initially did not reveal an acute bleed. The repeat
CT on [**2100-11-4**], is stated above. Neurology did not feel that
these were large enough to be treated and thus would resolve on
their own. Follow-up CT will need to be obtained one week after
discharge.
7. Hematology - The patient's hematocrit was 34.3 on admission
and dropped to 26.7 on hospital day number one. He was
transfused with two units after which his hematocrit remained
stable for the duration of the admission.
8. Trauma - He was seen by trauma surgery to be evaluated for
cervical spine instability; they recommended that he be kept in a
cervical collar even though he had no fracture, since ligamentous
injury was not ruled out at the time. Later on in the course of
the hospitalization when he was moved to the floor, flexion and
extension spine films were done and approved by neurosurgery as
clear and thus the collar was removed. He will follow-up with
neurosurgery a week or two after discharge when he will be
reevaluated with flexion and extension films as well as a head CT
to follow his subarachnoid blood and intraventricular blood seen
on CT of the head on [**2100-11-4**].
9. Dermatology - The patient was also seen by dermatology while
in the Medical Intensive Care Unit for his multiple abrasions on
bilateral malleoli and forehead. Initially, it was felt that
these may be trauma induced erosions versus herpetic erosions.
DFA for HSV type I and type II as well as ZBZ were negative
except for an HSV type I DFA which was positive. All other
cultures of the wound were negative and Acyclovir, which was
started empirically when dermatology first saw him for HSV, was
discontinued when these cultures and DFA came back negative.
These abrasions were treated with Bacitracin Ointment and wound
dressing changes b.i.d.
10. Psychiatry - While in the Medical Intensive Care Unit, the
patient was also seen by psychiatry who was unable to fully
evaluate him while he was sedated. They recommended an
electroencephalogram and magnetic resonance scan to evaluate
mental status if this did not improve once he was extubated.
They also were questioning the fact that his Carbamazepine
level of 33 implied overingestion, suggesting possible assault or
possible suicide attempt. The hypothesis that was generated was
that perhaps the patient had a seizure and overdosed with
Tegretol during postictal confusion.
Later on in the hospitalization, they revisited the patient when
he was alert, awake and oriented. The patient disclosed that he
had had a seizure on the day of admission. He did not know
anything about the overingestion of the Tegretol, however, he did
deny assault or suicidal attempts. At the time of discharge, the
patient was not considered to have any psychiatric issues as he
was cheerful and responsive to questions. The psychiatry team
felt that it was reasonable that he was going to be discharged to
a temporary rehabilitation facility prior to returning home to
care for himself.
11. Hospital floor course - The patient was extubated on
[**2100-11-8**], and moved to the floor on [**2100-11-9**]. His respiratory
status was stable and oxygen was in the process of being weaned.
His issues of Tegretol overdose as well as rhabdomyolysis were
resolved and levels of Tegretol as well as CKs were trending
downward towards normal limits.
As aspiration pneumonia continued to be treated with Levofloxacin
and Clindamycin for a fourteen day course. The patient continued
to improve respiratory wise with good oxygen saturation, good
respiratory rate and clear lung examination.
Neurology: he had a repeat head CT done on the day of transfer
from the Medical Intensive Care Unit to the floor which was not
different from the [**2100-11-4**] study and was notable for perhaps a
slightly larger bleed ("subdural fluid collection"). It was
decided that a repeat CT would be done one to two weeks after
discharge when following up with neurosurgery unless there was
significant clinical deterioration. During his continued
hospital course, he had no neurological deficits, no signs of
central nervous system infection. Magnetic resonance scan and
electroencephalogram were postponed as the patient's mental
status continued to improve progressively and once he was awake,
was alert and oriented times three.
Eventually as stated previously, his cervical collar was removed
once he was clinically cleared with extension and flexion
cervical spine films.
He was continued on Lopresor 100 mg b.i.d. for his hypertension
and was switched to Atenolol 100 mg q.d. on discharge.
Nutrition - The patient had a nasogastric tube in since the
Medical Intensive Care Unit stay and due to aspiration pneumonia
history as well as neck instability, tube feeds were started on
this patient two days after he reached the floor in efforts to
give him nutrition. Swallow specialist was consulted. For the
first couple of days, he failed the swallow studies with signs
and symptoms of aspiration upon taking thin liquids. Eventually,
he did better with liquids and was started on soft solids and
thick liquids. This continued to be his diet upon discharge. He
remains on aspiration precautions.
His hematocrit remained stable during his hospital floor course
and his abrasions on his extremities continued to be treated with
Bacitracin Ointment application to the wounds with dressing
changes twice a day.
Of note, the patient's brother visited him once during his
Medical Intensive Care Unit stay at which time he was unable to
talk to the patient. His brother visited one more time while he
was on the floor. He described the patient was slowly returning
to his baseline and at baseline the patient talks and is fully
functional, transports himself around the city, and is very
meticulous about his medication regimen by taking the right
amount at the right time, never over or under.
DISPOSITION: To subacute/acute rehabilitation facility until
function returns to baseline. [**Hospital **] [**Hospital **] Rehab -
[**Telephone/Fax (1) 106748**].
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. [**Last Name (STitle) 102851**] ([**Hospital1 336**]) [**Telephone/Fax (1) 106749**]
CONDITION ON DISCHARGE: Stable.
MEDICATIONS ON DISCHARGE:
1. Tegretol 200 mg p.o. t.i.d.
2. Atenolol 100 mg p.o. q.d.
3. Bacitracin Ointment apply b.i.d. to wounds.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**]
Dictated By:[**Name8 (MD) 106750**]
MEDQUIST36
D: [**2100-11-16**] 16:36
T: [**2100-11-16**] 16:49
JOB#: [**Job Number 40852**]
|
[
"5070",
"4019",
"2720",
"V4581"
] |
Admission Date: [**2184-1-3**] Discharge Date: [**2184-1-16**]
Date of Birth: [**2142-12-11**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Tetanus / Morphine
/ Cefoxitin / Codeine / Lactose
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
fever, cough
Major Surgical or Invasive Procedure:
intubated
History of Present Illness:
41 yo female with childhood ALL, pulmonary fibrosis s/p left
lobe lung transplant, left mainstem bronchomalacia s/p stent
placement, sinus tachycardia, and previous intubation in setting
of aspiration pneumonia) who was transferred from an outside
hospital. She reports 3-4 weeks of cough, and noted fatigue and
insomnia [**2-5**] cough. Family notes recent hospitalizations for PEG
tube change at OSH. No recent travel. She has been around kids
with colds recently. Flu shot given in [**Month (only) 359**]. Also has had
pneumonia vaccine. Flushes every month in pheresis unit. Still
uses nutritional supplement drinks at home. At baseline, she is
tachycardic to as high as 120, respiratory rate 40, Blood
pressure ~100 systolic. EMS noted O2 sat of 83%. She initially
presented to [**Hospital **] Hosp where she had blood cutlures and a
CXR done. She was given 1500cc of NS, ceftriaxone and
azithromycin. She was medflighted to [**Hospital1 18**] on a nonrebreather.
.
In the ED, initial Vitals were HR 150, hypotensive (map mid
50s), and RR 40-60. She was given NS, Tylenol, Vanco, and
zosyn. CXR revealed increased consildation RUL persists with
decreased aeration and more opacifiction; vague patchy opacities
widespread each lung NEW. She was started on neo gtt which was
chosen for hypotension and tachycardia. This was uptitrated to
2.5, but then she was transitioned over to levophed. She was
easily intubated with 6.5 ETT over Bougie, Grade 1 view given
micronathia. Induction with etomidate and succinylcholine,
after pretreatment with push-dose phenylephrine. They placed a
RIJ and pulled back ETT 1 cm. CXR line in place, consolidations
similar, L infrahilar opacity, no ptx. Sedation with fentanyl
and versed. IP requested a CT w/o contrast of chest to looks at
patency of stent in LMSB, which will happen en route to the ICU
as ED feels she is stable enough for CT. Prior to transfer:
37.2 107 91/48 CVP 11-12 100% on 300/16/80/5.
.
On arrival to the MICU, she was able to attempt to open her eyes
but not able to nod yes or no to questions.
Past Medical History:
-ALL - [**2147**], treated with Vincristine, prednisone, Methotrexate,
Adriamycin (total 450 mg/m2), 6MP and L-Asparaginase with
cranial XRT. Bone marrow relapse [**2150**] treated with COAP, stopped
secondary to toxicity. Reinduced with Prednisone, L-Asparaginase
and oral Methotrexate in [**2151**] and underwent allogeneic bone
marrow transplant with whole body radiation.
-Small bowel perforation - [**2167**]
-Pulmonary fibrosis and left lower lobe lung transplant from her
father - [**2170**], complicated by pericardial and pleural effusion
-Staph aureus bronchitis - [**2171**]
-Left mainstem bronchomalacia, s/p stent placement [**2176**]
-Prior intubation for pneumonia in [**12/2182**] c/b trach and PEG
placement
-Chronic sinus tachycardia
-Dyspnea on exertion and with lying supine
-G-tube placement
-Esophageal strictures - s/p multiple dilations
-Moderate MR ([**3-12**])
-Basal Cell Ca (Back - upper chest)
-Edentulous with full dentures due to major dental work
.
PAST SURGICAL HISTORY:
1- Surgical Debridement of thigh abcess from IM pentamidine [**2152**]
2- Appendectomy [**2163**]
3- Laparoscopy to remove ovarian cysts [**2162**]
4- S.P Small bowel perforation complicated with candidal and
bacterial paeritonitis requiring antifungals and antibiotics
5- Cholecystectomy
6- Radiation induced pulmonary fibrosis S/P living related donor
from father [**Name (NI) 25730**] transplant)
7- Post pericardiotomy syndrome [**2170**]
8- Left MS bronchomalacia
9- Bilateral SAH
10- Ilesotomy with enterocutaneous fistula, reversed 10 months
later at [**Hospital1 112**]
11- Closing of enterocutaneous fistula and ostomy [**2174**]
12- S/P port placement for IV access [**9-7**]
13- LMS granuloma debridement and mitomycin
14- Esophageal dilatation, last [**8-14**]
15- Debridement of granulation tissue around stent
[**88**]- Pneumothorax post bronchoscopy with stent granulation tissue
debridement
Social History:
Lives at home by herself. She takes care of two young children
during the day. Performs all of her ADL's independently
including driving.
- Tobacco: denies
- Alcohol: denies
- Illicits: denies
Family History:
Father (66; aortic stenosis); Mother (65 years; smoking,
hyperlipidemia). She has 3 siblings. One brother with history of
testicular cancer.
Physical Exam:
Admission exam
Vitals: afeb 86/57 105 20 100% on 250/20/100/5
General: thin pale female, intubated, attempts to open her eyes,
no acute distress
HEENT: Sclera anicteric, MMM, EOMI, PERRL, edentulous
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, no murmurs, rubs, gallops
Lungs: rhonchi heard throughout, central breath sounds prominent
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, midline abd scar c/d/i, PEG tube in place and
nontender
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema,
bilateral scars on anterior thighs, cool hands
Skin: no rashes
Neuro: opens her eyes on command
Discharge exam
Tcurrent: 36.8 ??????C (98.2 ??????F)
HR: 107 (107 - 142) bpm
BP: 88/56(63) {88/50(61) - 137/77(86)} mmHg
RR: 30 (25 - 44) insp/min
SpO2: 100%
Gen: Alert and oriented, following commands
HEENT: Sclera anicteric, MMM, EOMI, PERRL, edentulous
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, no murmurs, rubs, gallops
Lungs: scattered rhonchi, but improved, no tachypnea or
accessory muscle use, good air movement BL
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, midline abd scar c/d/i, PEG tube in place and
nontender
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema,
bilateral scars on anterior thighs, cool hands
Skin: no rashes
Neuro: alert, responsive, CNIII-XII intact, moving all four
extremities without difficulty, reflexes 2+
Pertinent Results:
Admission labs
[**2184-1-3**] 04:45PM BLOOD WBC-11.8* RBC-3.20* Hgb-9.8* Hct-30.1*
MCV-94 MCH-30.6 MCHC-32.6 RDW-14.2 Plt Ct-250
[**2184-1-3**] 04:45PM BLOOD Neuts-93* Bands-1 Lymphs-5* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2184-1-3**] 04:45PM BLOOD PT-14.0* PTT-28.3 INR(PT)-1.3*
[**2184-1-3**] 04:45PM BLOOD Glucose-93 UreaN-15 Creat-0.3* Na-142
K-3.8 Cl-108 HCO3-26 AnGap-12
[**2184-1-3**] 04:45PM BLOOD ALT-132* AST-149* AlkPhos-179*
TotBili-0.3
[**2184-1-4**] 02:17AM BLOOD Lipase-10
[**2184-1-3**] 04:45PM BLOOD cTropnT-<0.01
[**2184-1-3**] 04:45PM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7
[**2184-1-3**] 04:45PM BLOOD Cortsol-38.0*
[**2184-1-3**] 05:09PM BLOOD Lactate-1.2
Discharge labs
White Blood Cells 10.3 4.0 - 11.0 K/uL
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.63* 4.2 - 5.4 m/uL
PERFORMED AT WEST STAT LAB
Hemoglobin 10.8* 12.0 - 16.0 g/dL
PERFORMED AT WEST STAT LAB
Hematocrit 33.1* 36 - 48 %
Glucose 88 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
PERFORMED AT WEST STAT LAB
Urea Nitrogen 17 6 - 20 mg/dL
PERFORMED AT WEST STAT LAB
Creatinine 0.3* 0.4 - 1.1 mg/dL
PERFORMED AT WEST STAT LAB
Sodium 141 133 - 145 mEq/L
PERFORMED AT WEST STAT LAB
Potassium 4.0 3.3 - 5.1 mEq/L
PERFORMED AT WEST STAT LAB
Chloride 99 96 - 108 mEq/L
PERFORMED AT WEST STAT LAB
Bicarbonate 34* 22 - 32 mEq/L
PERFORMED AT WEST STAT LAB
Anion Gap 12 8 - 20 mEq/L
CHEMISTRY
Calcium, Total 8.8 8.4 - 10.3 mg/dL
PERFORMED AT WEST STAT LAB
Phosphate 4.0 2.7 - 4.5 mg/dL
PERFORMED AT WEST STAT LAB
Magnesium 2.0 1.6 - 2.6 mg/dL
Micro
[**2184-1-3**] 7:50 pm SPUTUM
**FINAL REPORT [**2184-1-8**]**
GRAM STAIN (Final [**2184-1-3**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final [**2184-1-8**]):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
YEAST. SPARSE GROWTH.
PSEUDOMONAS AERUGINOSA. RARE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 0.5 S
OXACILLIN------------- =>4 R
PIPERACILLIN/TAZO----- S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Studies
CXR [**2184-1-3**]
Increasing opacification of the right upper lobe with
substantial
volume loss and air bronchograms, in addition to widespread
patchy opacities including patchy geographic and nodular
opacities in the left lower lung. This appearance could be seen
with an infectious etiology including atypical forms of
pneumonia. Short-term followup radiographs are recommended to
reassess, and particularly of suspicion for discrete nodules
were to persist, then chest CT could be considered.
RUQ U/S [**2184-1-6**]
Status post cholecystectomy without intra- or extra-hepatic
biliary dilatation; trace amount of perihepatic ascites, similar
to prior
exams.
TTE [**2184-1-7**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion. Compared with the prior study dated
[**2182-12-23**] (images reviewed), the degree of mitral regurgitation
appears decreased, although the quality of the current study is
inferior and the amount of regurgitation may be underestimated.
Other findings are similar.
CXR [**2184-1-9**]
As compared to the previous radiograph, there is no relevant
change. The monitoring and support devices are in constant
position. Known right upper lobe atelectasis and extensive left
lung changes. No newly appeared focal parenchymal opacities. The
overall lung volumes remain low.
CXR [**2184-1-13**]
As compared to the previous radiograph, there is no relevant
change. The monitoring and support devices are constant. There
is extensive left basal fibrosis and right upper lobe
atelectasis. In the reasonably well-ventilated lung areas, there
is no newly appeared focal parenchymal
opacity suggesting pneumonia. Normal size of the cardiac
silhouette.
Video Speech and Swallow [**2184-1-15**]
Barium passes freely from the oropharynx into the esophagus
without
evidence of obstruction. There was silent aspiration of thin
liquids with
multiple sips. There was a thin line of penetration noted in the
laryngeal
vestibule with thin liquids during chin tuck. Tongue pumping was
noted with a pureed bolus and moderate residue was present
afterwards in the valleculae. There was mild pharyngeal residue
with cup sips of nectar thick liquids but no penetration or
gross aspiration. For details, please see the speech pathology
note in the OMR. IMPRESSION: Silent aspiration of thin liquids
with persistent penetration on thin liquids with chin tuck.
Moderate vallecular residue with pureed foods.
Brief Hospital Course:
41 yo female with history of childhood ALL, pulmonary fibrosis
s/p left lobe lung transplant, left mainstem bronchus
bronchomalacia s/p stent placement, and sinus tachycardia
presented with fever and cough, found to be tachypneic,
tachycardic, and hypotensive with infiltrates on CXR.
.
Active Issues:
.
# Pneumonia / Hypoxic respiratory failure:
Patient presented with fever and leukocytosis, likely secondary
to alveolar hypoventilation as a result of dense multilobar
infiltrates. Due to her respiratory failure, she was intubated
in the ED and placed on ventilation with low tidal volumes per
ARDSnet protocol. Her left mainstem stent remained patent but
was noted to have migrated distally; this was taken up with
interventional pulmonology but per their recommendation, there
was no indication for intervention at this time. Her pulmonary
compliance was quite low at 10. Given her prior history of MRSA
pneumonia, multiple health care encounters and recent CAP, she
was treated presumptively for HCAP, and was started on
Vancomycin, Cefepime, and Levofloxacin (discontinued on [**1-6**]).
The patient's sputum culture from [**1-3**] grew MRSA, with rare
pseudomonas which was sensitive to cefepime. Subsequent sputum
cultures were negative. An influenza DFA was negative. The
patient's leukocytosis continued to improve throughout her
course and her ventilatory support was gradually weaned until
she was successfully extubated on [**2184-1-13**]. She completed her
antibiotic course on [**2184-1-16**]. At the time of discharge, she was
able to ambulate with assistance, during which time she had an
oxygen saturation of 100% on room air.
.
# Hypotension:
The patient was hypotensive on presentation to the emergency
department, likely as a sequelae of septic shock. A central
line was placed, and she was given aggressive fluid
resuscitation as well as started on norepinephrine and
phenylephrine drips to keep her MAP on target per early
goal-directed therapy protocol. Her phenylephrine was
discontinued late on [**1-3**], and she received several additional
boluses of IV fluid, to which she responded. Her pressures
continued to improve, and her norepinephrine drip was gradually
decreased, until it was finally discontinued on [**2184-1-7**].
.
# Tachycardia:
The patient has a history of sinus tachycardia as high as 120 as
an outpatient. She experienced little change in her resting
heart rate despite resolution of her sepsis. The patient's home
carvedilol was held for the duration of her stay due to her
hypotension, and she was later transitioned to low-dose
metoprolol due to its superior cardioselectivity.
.
# Anemia:
On admission, the patient had a hematocrit of 30, which trended
downward slowly over the course of several days. There was no
evidence of gastrointestinal bleed, no hematuria, acute RP bleed
or bleed into her right fem a-line. Her hematocrit reached a
nadir of 18.2, and she was transfused 2u pRBCs. Subsequently,
her hematocrit stayed between 28.8-33.1 for the remainder of her
hospital course.
.
# Transaminitis:
The patient demonstrated a mild transamonitis early in her
hospital course. However, an right upper quadrant ultrasound
wsa normal with negative [**Doctor First Name **], AMA, and SPEP. Thus, her elevated
enzymes were most likely a result of sepsis, as her
transaminitis improved in tandem with her stable blood
pressures.
.
# Dysphagia: got video speech and swallow after extubation.
There is an excellent note in OMR from [**2184-1-15**] with
recommendations. She should be on nectar thick for 2 weeks, with
repeat speech and swallow in 2 weeks
================
Transitional issues
# Should be on nectar thick for 2 weeks, with repeat speech and
swallow in 2 weeks time
Medications on Admission:
1. Amitriptyline 20mg qhs
2. Carvedilol 6.25mg qAM, 9.375mg qPM
3. estradiol 10 mcg Tablet use as directed three times a week
4. estradiol-levonorgestrel 0.045 mg-0.015 mg/24 hour Patch
Weekly
5. lorazepam 1 mg Tablet by mouth nightly as needed for insomnia
6. artificial tear with lanolin Ointment 2 gtts both eyes as
needed
7. cholecalciferol (vitamin D3) 1,000 unit Tablet, Chewable
daily
8. nut.tx.pulm.disord.reg,lacfree [Nutren Pulmonary] Liquid
31/2-4 cans by mouth once a day
Discharge Medications:
1. amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*60 Tablet(s)* Refills:*2*
2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for Insomnia.
Disp:*30 Tablet(s)* Refills:*0*
3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for eye
irritation.
Disp:*1 month supply* Refills:*2*
4. Nutren Pulmonary Liquid Sig: One (1) can PO 3-4 times per
day.
Disp:*30 cans* Refills:*2*
5. cholecalciferol (vitamin D3) 1,000 unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. estradiol-levonorgestrel 0.045-0.015 mg/24 hr Patch Weekly
Sig: One (1) patch Transdermal once a week.
Disp:*4 patches* Refills:*2*
7. Oxygen
Continuous 1-2L with pulse dose for portability.
8. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
Disp:*1 HFA* Refills:*2*
9. Outpatient Physical Therapy
As per PT recommendations.
10. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO twice a
day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary
Healthcare associated Pneumonia
Secondary
Sepsis with Shock
Pulmonary fibrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for respiratory failure and pneumonia. For this, you were
intubated and given antibiotics.
The following changes were made to your medications
** STOP carvedilol
** START metoprolol 37.5 mg twice a day by G tube. This replaces
the carvedilol and is for heart rate control.
** START Albuterol 1-2 puffs every 6 hrs as needed for wheezing
and shortness of breath.
.
Please follow up with your doctors [**Name5 (PTitle) **] your [**Name5 (PTitle) 4314**] below.
.
Please return to the the hospital if you develop chest pain,
shortness of breath, fever, or any other concerning signs or
symptoms.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2184-1-21**] at 7:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2184-1-21**] at 8:00 AM
With: DR. [**Last Name (STitle) 91**] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: MONDAY [**2184-1-26**] at 1:40 PM
With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor
in follow up.
Speech and Swallow re-evaluation on [**2-3**] at 9:45AM.
Location: Clinical Center [**Location (un) 470**] radiology
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2184-2-3**] at 11:30 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
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2184-3-31**] at 10:00 AM
With: DR. [**Last Name (STitle) 91**] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*The office will be calling you at home with a sooner
appointment. If you have any questions or concerns please call
the office.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"51881",
"78552",
"2762",
"4240",
"99592",
"2859"
] |
Admission Date: [**2131-7-30**] Discharge Date: [**2131-8-2**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **] year old female w hx of severe AS s/p
valvuloplasty [**3-/2131**], subsequent CVA, s/p CABG, hx systolic and
diastolic CHF, hypothyroidism transferred from [**Hospital1 18**] [**Location (un) 620**] ED
for surgical evaluation for possible appendicitis. She presented
with 1 week of worsening belly pain and temp 100.3 taken by VNA.
No n/v/d. Was given cipro, flagyl and 4 L of fluid which
resulted in flash pulmonary edema (hx of MI). She was placed on
Bipap and given lasix unknown dose. CT abdomen notable for
pan-colitis with fluid filled appendix wo stranding - guaiac
neg, nl lactate, well appearing. Surgery eval at [**Last Name (LF) 620**], [**First Name3 (LF) **]
need OR for appy, not clear - would like transfer to [**Location (un) 86**] for
ACS eval due to operative risk. Recieved IV abx. Vitals on
arrival to [**Location (un) 620**]: T 99.5, 101/48, 67, 16, 97/RA.
Her GI history is notable for a colonoscopy that was done in
[**2126**], which showed two polyps, one was removed completely, but
one was flat and behind a fold. Pathology turned out to be an
adenoma. She required 2 blood transfusions on [**5-30**] at [**Hospital1 **] Hospital in [**Location (un) 620**] and has been on iron
supplementation. She was evaluated by Dr. [**First Name (STitle) 679**] from GI and she
declined colonoscopy to w/u malignancy at this time.
ED Course: Surgery consulted. They weaned her O2 from bipap to
NC. Noted to be in afib. She put out 300cc foley to 40mg IV
lasix administered at [**Location (un) **]. Not given add'l lasix.
Discontinued abx given benign imaging findings. UA unremarkable.
EKG: old RBBB, no ST changes - not sent with pt. No labs
obtained - last checked noon at [**Location (un) 620**]. Current access: 18 L x
2 wrist and foley cath for UO. Chest xray showed mild hilar
fullness and pleural effusion on L side.
Exam notable for pulm crackles bibasilar, and abd benign.
Surgery reviewed imaging w radiology: nonspecific edema of
bowel, unclear if colitis, no stranding or specific signs of
infection. Vitals prior to transfer: HR80, BP99/43, 24, 99%3L
NC.
On the floor, she feels well and states that her abd pain has
resolved. Denies chest pain or SOB with position change.
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, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
1. CAD, Severe aortic stenosis with [**Location (un) 109**] of 0.8 cm2, CABG: 3V
CABG
recent catheterization with widening of her aortic valvuloplasty
[**4-4**]
complicated by CVA.
2. Diabetes mellitus type 2.
3. Hypertension
4. Hyperlipidemia.
5. Ischemic and valvular cardiomyopathy with an EF 20-25%
6. History of left breast cancer, grade 3.
7. Right rotator cuff tendinopathy.
8. Right biceps tendinitis.
9. Polymyalgia rheumatica.
10. Osteoporosis.
11. Moderate mitral regurgitation
12. History of squamous cell carcinoma.
13. Moderate MR
14. Severe AS: symptoms started in [**2127**]
15. Atrial fibrillation: coumadin, amiodarone
.
PAST SURGICAL HISTORY:
1. Right mastectomy.
2. Coronary artery bypass graft 22 years ago.
3. Hysterectomy.
4. Excision of left dorsal hand squamous cell carcinoma.
5. Right fourth trigger finger release.
Social History:
Housing: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Hospital3 400**] Facility. Has a daughter
nearby who is her emergency contact.
Occupation: Was a homemaker.
Functional Status: Very active, exercises 3x week, does
treadmill, aerobics and yoga.
Tobacco/EtOH/Illicit Drugs: Denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Physical Exam
Vitals: T: BP:102/66 P:83 R:16 O2:99/3L NC Wt: 47kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar rales and diminished breath sounds at bases, no
wheezes or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, III/VI cres/decresc
murmur at RUSB radiating to carotids, brisk upstroke
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2131-7-30**] 11:04PM BLOOD WBC-16.0*# RBC-3.57* Hgb-10.5* Hct-31.3*
MCV-88 MCH-29.4 MCHC-33.5 RDW-15.1 Plt Ct-226
[**2131-8-2**] 07:20AM BLOOD WBC-8.3 RBC-3.66* Hgb-10.7* Hct-32.1*
MCV-88 MCH-29.3 MCHC-33.4 RDW-15.3 Plt Ct-250
CHEST (PORTABLE AP) Study Date of [**2131-7-31**] 4:05 AM
FINDINGS: In comparison with the study of [**7-30**], there is
continued enlargement
of the cardiac silhouette. The degree of pulmonary congestion
appears to have
improved. Retrocardiac opacification is consistent with volume
loss in the
lower lobe and some blunting of the costophrenic angle suggests
pleural
effusion. Intact midline sternal wires are seen and there are
multiple
surgical clips in the right axillary region in this patient who
has undergone
a previous mastectomy.
CHEST (PA & LAT) Study Date of [**2131-7-30**] 10:21 PM
Minimal pulmonary edema, small bilateral pleural effusions are
present.
Severe cardiomegaly is chronic. No pneumothorax. Sternal wires
reflect
previous sternotomy, and vascular clips previous right axillary
and chest wall surgery, presumably related to breast cancer.
Brief Hospital Course:
Ms. [**Known lastname **] is a [**Age over 90 **] year old woman with hx notable for CABG, AF,
severe AS s/p valvuloplasty in [**3-/2131**], systolic and diastolic
CHF, and [**Hospital **] transferred from OSH for management of 1 week abd
pain and colonic edema, found to have pancolitis on CT, admitted
to MICU for acute on chronic systolic and diastolic CHF
exacerbation.
# Pancolitis
Patient presented initially with significant abdominal pain,
found to have colonic edema and fluid filled appendix with fat
stranding on CT scan at [**Hospital **] transfered to [**Hospital1 18**] for surgical
evaluation for concern for appendicitis because high risk
surgical candidate. Evaluated by surgery at [**Hospital1 18**] who felt that
pt did not have appendicitis and no surgery necessary. CT
findings presumably infectious, so she was started on
cipro and flagyl, and symptoms improved within 24 hrs. Lactate
normal. Differential also included mesenteric ischemia, which
was felt to be unlikely, or translocation with underlying
malignancy. Colonoscopy was felt to be too invasive for her
goals of care at a recent GI appointment with Dr. [**First Name (STitle) 679**]. Cipro
was changed to cefpodoxime prior to transfer to floor to
decrease risk of C diff. Cefpodoxime and Metronidazole should
be continued for 7 more days for total course of 10 days
antibiotics. Pt should follow up with PCP next week and with
gastroenterology as necessary.
# Acute on Chronic Systolic and Diastolic CHF
Pt with hx of severe aortic stenosis s/p valvuloplasty [**3-/2131**],
followed by Dr. [**Last Name (STitle) 911**]. EF improved from 25-30 to 50% s/p
valvuloplasty. On transfer to [**Hospital1 18**], patient was admitted to
MICU for hypoxia, likely secondary to fluid overload in setting
of receiving 4.5L of IVFs at OSH ED. CXR confirmed pulmonary
edema with pleural effusions, improved after bolus IV furosemide
in the MICU. Patient's home dose of furosemide was 40mg daily.
Diuretics were held for two days on transfer to floor in setting
of mild orthostasis. Patient felt no symptoms of orthostasis on
day of discharge. Patient was discharged on furosemide 40mg
every other day, but was asked to check daily weights at home
and call PCP if weights increasing by more than 3 lbs. Followup
appointment set up with primary care office in 6 days. VNA will
draw lytes in 4 days (Monday, [**8-5**]) to be faxed to PCP's office.
Discharge weight 51kg.
# Delirium
Pt with very mild hypoactive delirium noted during
hospitalization, partially improved upon discharge, but there
was concern for mild cognitive dysfunction. Recommend outpatient
cognitive evaluation once recovered completely from acute
illness.
# Diarrhea
Patient with some loose stools during hospitalization, likely in
setting of colitis. Stools seemed to be resolving on discharge,
semi-formed. C diff negative x2.
# Hypertension
Home carvedilol and lisinopril held on admission in setting of
hypotension. Carvedilol was restarted at home dose, but
lisinopril was still held on discharge and should be restarted
by PCP at followup visit as tolerated.
# CAD
Home aspirin and simvastatin continued. Could redose
simvastatin at decreased dose as outpatient of 10mg daily for
interaction with amiodarone. Her home carvedilol and lisinopril
were held initially in setting of relative low BPs. Home
carvedilol was restarted on the floor, but lisinopril should be
restarted at outpatient PCP [**Name Initial (PRE) 4939**].
# DM2
Patient on oral hyperglycemics at home. Fingersticks were
monitored, and she did not require insulin coverage. Her home
metformin was held during hospitalization and restarted on
discharge.
# Hx Paroxysmal Afib
Patient in sinus rhythm during this admission. Continues on
home dose amiodarone. Not requiring warfarin, per cardiologist.
# Decreased Appetite
In setting of hx of decreased appetite, patient was started on
mirtazapine 7.5mg at bedtime. Trazodone was stopped.
# Code: DNR/DNI
Medications on Admission:
AMIODARONE [PACERONE] - 200 mg Tablet - 1 (One) Tablet(s) by
mouth once a day
CARVEDILOL - 6.25 mg Tablet - 1 (One) Tablet(s) by mouth twice a
day
FUROSEMIDE - 40 mg Tablet - 1 (One) Tablet(s) by mouth daily
LEVOTHYROXINE - 50 mcg Tablet - 1 (One) Tablet(s) by mouth once
a
day
LISINOPRIL - 10 mg Tablet - one Tablet(s) by mouth daily
METFORMIN - 850 mg Tablet - one Tablet(s) by mouth once a day
ONDANSETRON HCL - 4 mg Tablet - 1 (One) Tablet(s) by mouth four
times a day as needed for nausea
SIMVASTATIN - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
TRAZODONE - 50 mg Tablet - 1 (One) Tablet(s) by mouth daily
.
Medications - OTC
ACETAMINOPHEN - 500 mg Tablet - 2 (Two) Tablet(s) by mouth three
times a day as needed for pain
ASPIRIN - 81 mg Tablet - one Tablet(s) by mouth daily
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Capsule - 1 (One)
Capsule(s) by mouth once a day
DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth three
times a day
FERROUS SULFATE - 325 mg (65 mg iron) Tablet - 1 (One) Tablet(s)
by mouth three times a day
MULTIVITAMIN WITH MINERALS [MULTIPLE VITAMIN-MINERALS] -
Tablet
- 1 (One) Tablet(s) by mouth once a day
RANITIDINE HCL [ACID CONTROL] - 150 mg Tablet - 1 (One)
Tablet(s)
by mouth once a day
SALIVA STIMULANT AGENTS COMB.2 [BIOTENE ORALBALANCE] - (OTC) -
Liquid - Use twice daily for dry mouth
Discharge Medications:
1. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
2. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day. Tablet(s)
6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
8. metformin 850 mg Tablet Sig: One (1) Tablet PO once a day.
9. Colace 100 mg Capsule Sig: One (1) Capsule PO three times a
day.
10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
11. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day: Do not take with thyroid hormone
(levothyroxine).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO every other
day.
13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
16. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 4-6 hours as needed for nausea.
17. Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for pain.
18. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. Outpatient Lab Work
Please draw electrolytes (Chem 7) on Monday [**8-5**] and fax results
to PCP's office:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] E.
Location: [**Hospital1 **]
DIVISION OF GERONTOLOGY
Address: [**Doctor First Name **], STE 1B, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 719**]
Fax: [**Telephone/Fax (1) 716**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Colitis
Acute on Chronic Systolic and Diastolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs. [**Known lastname **],
You were admitted to the hospital because you were having
significant abdominal pain, found to have inflammation of your
entire colon. You were started on oral antibiotics for your
colitis which significantly improved your abdominal pain.
You had also been given a lot of fluids in the Emergency Room at
the other hospital because it is important to get fluids when
you have a bad infection, so you ended up having some trouble
breathing from your heart failure, which improved quickly. Your
blood pressures were also intermittently low while you were in
the hospital, so we have changed some of your medications as
below.
The following changes were made to your medications:
- Please take LASIX 40 mg every OTHER day (before, you were
taking it every day) until you are seen by your primary care
physician. [**Name10 (NameIs) 357**] make sure to check your weight every day and
let your doctor know if you are gaining weight by more than 3
lbs, and your doctor can adjust your medications as necessary.
- Please STOP taking your TRAZODONE
- Please START MIRTAZAPINE (also called REMERON) 7.5mg at
bedtime in the evenings to help you sleep.
Please continue to take the antibiotics we have prescribed, for
7 more days or through [**8-9**].
-MetRONIDAZOLE (FLagyl) 500 mg every 8 hours x 7 days
-Cefpodoxime Proxetil 200 mg once daily x 7 days
- If you have diarrhea, please do not take COLACE.
- Please start PRIOBIOTICS (you can buy this over the counter)
to help your intestines.
- Please stop your LISINOPRIL for now because of your low blood
pressure. This can be restarted by your primary care doctor or
her nurse practioner at your visit next week.
- You may DECREASE the iron tablets (FERROUS SULFATE)to twice
daily instead of three times daily
Please be sure to weigh yourself every morning and call the
doctor if your weight goes up more than 3 lbs.
Please have the VNA draw your labs on Monday to check your
electrolytes including your kidney function and have it sent to
your primary care doctor who will see you on Wednesday.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] E.
Phone: [**Telephone/Fax (1) 719**]
Fax: [**Telephone/Fax (1) 716**]
Please see [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) 715**],NP next Wednesday for a followup visit,
as below.
Followup Instructions:
Please be sure to keep all of your followup appointments.
Department: GERONTOLOGY
When: WEDNESDAY [**2131-8-8**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RNC [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2131-8-22**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"5849",
"4280",
"V4581",
"4019",
"4240",
"2449",
"25000",
"2724",
"42731",
"V5861"
] |
Admission Date: [**2126-10-24**] [**Month/Day/Year **] Date: [**2126-10-29**]
Date of Birth: [**2058-1-29**] Sex: F
Service: MEDICINE
Allergies:
Cephalosporins / Vancomycin / Codeine
Attending:[**First Name3 (LF) 9157**]
Chief Complaint:
Fevers.
Major Surgical or Invasive Procedure:
- None.
History of Present Illness:
69 yo F with a hx/o cervical cancer s/p radiation with several
radiation-induced sequelae (short gut syndrome requiring
long-term TPN via indwelling central line, resultant central
line infections, and recurrent UTIs in setting of radiation
cystitis & self-catheterization) presents to ED via EMS for
fevers accompanying her most recent TPN infusion. Pt also
reports urinary frequency.
According to the patient, she awoke at 2 AM with shakes & a
fever to 104. She was too tired to go to the ED, but took
tylenol. She continued to intermittently wake up with
fevers/chills through the morning. She relates her symptoms to
starting her TPN cycle just before these episodes. She mentions
several days of urinary urgency, frequency, & cloudy urine. She
has had at least 10 admissions for UTI/urosepsis with cultures
revealing frequent enterococcus & recently a resistant E coli
UTI last winter.
The patient's central line was changed about 4 days ago prior to
admission for frequent leaks. The patient recounts numerous
line infections. She does daily alcohol dwells to prevent
infection.
Upon arrival to the ED, her initial vitals were T103.4, HR 101,
BP 117/100, RR 18, Sat 100RA. She was given 2LNS immediatley.
Urinalysis revealed significant leukouria, and she had a WBC
elevation to 21.0 with 95%PMN. Creatinine was 1.5 from 1.0,
though lactate normal at 1.9. Per ED staff, the central line
site was mildly erythematous but did not appear infected. CXR
unremarkable. She received vancomycin. Her BP was reportedly low
in the 88-90 range following administration of dilaudid for
pain. Prior to transfer to MICU, VS were P 82 BP 88/41 Sat 99RA
RR 14.
Upon arrival to the MICU, her initial VS were: T 102.9 P 101 BP
147/53 P 75 RR 20 Sat 98% RA. She complained of feeling poorly
and endorsed recent generalized aches, malaise, headaches,
fatigue, weakness for the past few days. There is no abdominal
pain or change in ostomy output. She feels dehydrated but has
been trying to keep up with fluid intake. No N/V. No NSAIDs. No
chest pain or shortness of breath.
She has chronic pain from her back, neck, and "entire left
side." On chronic opioids including methadone 5mg & oxycodone
5mg QID. Current pain [**7-28**] when [**6-28**] is at baseline.
Past Medical History:
1. Cervical CA s/p TAH BSO ([**2096**]), XRT with recurrence in [**2097**]
2. Radiation cystitis & urinary Retention
----> Performs straight catheterization ~8x per day
4. R ureteral stricture
----> c/b recurrent infections
----> s/p right nephrectomy ([**2123**])
5. Recurrent UTIs:
----> Klebsiella (amp resistant)
----> Enterococcus (Levo resistant)
6. Radiation enteritis s/p colostomy ([**2109**]) with resultant short
gut syndrome
----> TPN x 15 years via indwelling central line (Hickman)
----> Multiple prior PICC line / Hickman infections
7. Osteoporosis
8. Hypothyroidism
9. Migraine HA
10. Depression
11. Fibromyalgia
12. Chronic abdominal pain syndrome
13. DVT / thrombophlebitis from indwelling central access
14. Lumbar radiculopathy
15. SBO followed by surgery
[**31**]. STEMI [**2-20**] Takotsubo CMP (clean coronaries on cath [**4-27**])
17. Hyponatremia: previously attributed to HCTZ use
19. Suspected [**Month/Year (2) **] [**3-/2126**]
Social History:
- Lives with her husband in an [**Hospital3 4634**] [**Last Name (un) **].
- Tobacco: 80-pack-year smoking history but quit 18 years ago.
- EtOH: Denies
- Illicit drug use: Denies
- Ambulates with a walker but frequently falls
- Independent in ADLS.
Family History:
- Father: EtOH abuse, CAD
- Brother: RCC, CAD
- 3 children, all healthy.
Physical Exam:
ADMISSION EXAM:
Vitals: T103.4 HR 101, BP 117/100, RR 18, Sat 100RA.
General: fatigue, weak appearing, speaking softly, shaking
HEENT: Sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: ostomy bag with liquid stool. soft, non-tender,
non-distended, bowel sounds present, no rebound tenderness or
guarding, GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: right subclavian CVL site is clean, nonerythematous, no
exudates.
[**Last Name (un) 894**] EXAM:
Afebrile.
GEN: Thin woman asleep, rouses easily to voice. NAD.
HEENT: NCAT, MMM
COR: +S1S2, RRR, no m/g/r.
PULM: CTAB no c/w/[**Initials (NamePattern4) **]
[**Last Name (NamePattern4) **]: +NABS in 4Q. Soft, mild TTP in epigastrium with voluntary
guarding. No involuntary guarding or rebound.
EXT: WWP, no c/c/e.
NEURO: Responds appropriately to questions. MAEE.
Pertinent Results:
ADMISSION LABS:
--------------
[**2126-10-24**] 11:09PM TYPE-MIX
[**2126-10-24**] 11:09PM O2 SAT-69
[**2126-10-24**] 09:52PM SODIUM-123* POTASSIUM-4.3 CHLORIDE-96
[**2126-10-24**] 04:40PM URINE HOURS-RANDOM UREA N-329 CREAT-46
SODIUM-20 POTASSIUM-36 CHLORIDE-40
[**2126-10-24**] 04:40PM URINE OSMOLAL-251
[**2126-10-24**] 04:40PM URINE UHOLD-HOLD
[**2126-10-24**] 04:40PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2126-10-24**] 04:40PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2126-10-24**] 04:40PM URINE RBC-1 WBC-86* BACTERIA-NONE YEAST-NONE
EPI-0
[**2126-10-24**] 04:40PM URINE WBCCLUMP-FEW
[**2126-10-24**] 04:26PM LACTATE-1.9
[**2126-10-24**] 04:12PM GLUCOSE-93 UREA N-19 CREAT-1.5* SODIUM-123*
POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-19* ANION GAP-18
[**2126-10-24**] 04:12PM WBC-21.0*# RBC-3.42* HGB-9.6* HCT-28.6*
MCV-84 MCH-28.1 MCHC-33.7 RDW-13.4
[**2126-10-24**] 04:12PM NEUTS-94.8* LYMPHS-3.6* MONOS-1.4* EOS-0
BASOS-0.1
[**2126-10-24**] 04:12PM PLT COUNT-270
[**2126-10-24**] 04:12PM PT-12.6 PTT-28.9 INR(PT)-1.1
10/06/1 URINE CULTURE (Final [**2126-10-25**]):
BETA STREPTOCOCCUS GROUP B. 10,000-100,000 ORGANISMS/ML..
CXR [**2126-10-24**]: Note is made of a dialysis catheter, with the tip
terminating at the upper cavoatrial junction. Cardiac,
mediastinal and hilar contours are normal. There is a calcified
right breast implant. The lungs are clear. There is no pleural
effusion or pneumothorax. A chronic L1 compression fracture is
unchanged.
RENAL ULTRASOUND [**2126-10-25**]:
Normal-appearing left kidney. Collapsed bladder is not well
visualized.
[**Month/Day/Year 894**] LABS:
--------------
[**2126-10-28**] 05:43AM BLOOD WBC-4.0 RBC-2.84* Hgb-8.0* Hct-23.6*
MCV-83 MCH-28.1 MCHC-34.0 RDW-13.6 Plt Ct-247
[**2126-10-29**] 05:59AM BLOOD Glucose-101* UreaN-7 Creat-1.2* Na-135
K-3.9 Cl-101 HCO3-22 AnGap-16
[**2126-10-29**] 05:59AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7
Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION:
Patient is a 68-yo F w recurrent TPN-line infections, recurrent
UTIs due to self-catheterization for radiation cystitis presents
with sepsis.
ACTIVE DIAGNOSES:
# Septic Shock: Patient was initially hemodynamically stable on
admission with fevers to 102-103, leukocytosis, & tachycardia.
Her lactate & CV sat were within normal limits. Her systolic
blood pressure fell to the 70s systolic but remained fluid
responsive; received an additional 5 L normal saline in the MICU
in addition to 2L given in the ED. Pressors were not required
and her BP stabilized by her second hospital day. Suspected
sources included UTI versus line infection. She began IV
vancomycin & meropenem based on a history of resistant
enterococcus & E coli UTI, as well as serratia line infections.
Blood cultures pulled off the line failed to grow bacteria, and
the access site was nonerythematous without pain or [**Month/Day/Year **].
Here line was therefor not changed or removed. Urine culture
eventually showed Group B Strep; meropenem was discontinued. On
the floor the patient's vital signs were stable. Her blood
cultures continued to be negative. As such, her urine was
thought to be the most likely source of sepsis.
# Urinary Track Infection: The patient's urine culture revealed
10-100K Group B Strep. She was continued on vancomycin with a
plan to [**Month/Day/Year **] her with vancomycin 1g Q24H infusions for a
total of two weeks. She will have her vancomycin trough as well
as basic labwork checked twice before her course of antibiotics
is completed. Although group B strep is sensitive to
penicillin, the patient refused medications that required dosing
any more frequently than twice a day.
# Acute Kidney Injury: The patient's creatinine on admission
was elevated to 1.5 from baseline of [**1-19**].2. Given her
hypotension, this was likely due to prerenal [**Last Name (un) **]. Her
creatinine slowly improved with fluid resuscitations; it was 1.2
for several days prior to [**Last Name (un) **].
#. Hyponatremia: Her initial Na low at 123. No mental status
changes apparent on exam. Her sodium improved with fluid
resuscitation suggesting a component of hypovolemia. On
[**Last Name (un) **] her sodium was 122.
CHRONIC DIAGNOSES:
# Hypertension: The patient was noted to have blood pressures as
high as 190s on her last day of admission. She may need to have
her blood pressure medications readjusted as an outpatient.
# Chronic Pain: The patient endorses chronic musculoskeletal &
abdominal pain. On the floor, she was restarted on her home
regimen of methadone 5 mg QID & oxycodone.
# Short Gut Syndrome: The patient will resume TPN on [**Last Name (un) **].
# Hypothyroidism: Levothyroxine was continued.
# Depression: Fluoxetine was continued.
# Fibromyalgia: Pain control as above.
# Radiation Cystitis: Initially a Foley placed. This was
discontinued on the floor; the patient self-catheterizes.
#. Anemia: The patient's HCT was stable in the high twenties
through admission, which is her baseline level.
TRANSITIONAL ISSUES:
# Infusion Set-Up: The patient was reinitiated on her TPN as an
outpatient. Vancomycin infusions were set-up with her infusion
company (course to complete on [**2126-11-7**]). She will need
outpatient labwork for as long as she is on vancomycin.
# Outpatient Labwork: The patient was provided with
prescriptions for a vanco trough & basic metabolic chemistries
on [**11-1**] & [**11-5**] to monitor for possible side effects of her
antibiotics. The patient was instructed to ensure that the
labwork is faxed to her PCP's office.
# Follow-Up: The patient will follow-up with her primary care
doctor [**First Name (Titles) **] [**Last Name (Titles) **].
Medications on Admission:
ALPRAZOLAM - 0.5 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomnia
BETAMETHASONE DIPROPIONATE - 0.05 % Lotion - apply to rash twice
a day
BUTALBITAL-ACETAMINOPHEN-CAFF [FIORICET] - 50 mg-325 mg-40 mg
Tablet - 1 Tablet(s) by mouth every six (6) hours as needed for
headaches
CYANOCOBALAMIN (VITAMIN B-12) - 1,000 mcg/mL Solution - 1000
mcg/ml IM once a month
DARIFENACIN [ENABLEX] - 15 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s)
by mouth daily Mon thru Fri, skip Sat and Sun
ESTRADIOL [VIVELLE-DOT] - 0.0375 mg/24 hour Patch Semiweekly -
apply one patch twice weekly
ETHANOL 70% - - 2 mL ethanol lock, 2 hour dwell time, each
lumen, repeated every 24 hr
FEXOFENADINE [[**Doctor First Name **]] - 60 mg Tablet - 1 Tablet(s) by mouth
once a day
FLUOXETINE [PROZAC] - 20 mg Capsule - 1 Capsule(s) by mouth
three times a day
GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth four times a
day
HYOSCYAMINE SULFATE - (Prescribed by Other Provider) - 0.125 mg
Tablet - 1 Tablet(s) by mouth every eight (8) hours as needed
for bladder spasm
LEVOTHYROXINE - 50 mcg Tablet - 1 Tablet(s) by mouth once a day
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - one patch once a day
LISINOPRIL - 10 mg Tablet - 3 Tablet(s) by mouth once a day
LORAZEPAM - 0.5 mg Tablet - 1 Tablet(s) by mouth once a day as
needed.
MECLIZINE - 25 mg Tablet - 1 Tablet(s) by mouth three times a
day as needed for dizziness
METHADONE - 5 mg Tablet - 1 Tablet(s) by mouth four times a day
for pain
METRONIDAZOLE - 0.75 % Gel - apply to rash twice a day
ONDANSETRON HCL - 4 mg Tablet - 1 Tablet(s) by mouth every eight
(8) hours as needed for nausea
OXYCODONE - 5 mg Tablet - one Tablet(s) by mouth every six (6)
hours as needed for pain
PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
PILOCARPINE HCL [SALAGEN] - 5 mg Tablet - one Tablet(s) by mouth
four times a day
SUMATRIPTAN SUCCINATE - 50 mg Tablet - 1 Tablet(s) by mouth at
onset of headache. [**Month (only) 116**] take additional 1 tablet in 2 hours as
needed.
[**Month (only) **] Medications:
1. vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
every twenty-four(24) hours for 9 days: Please run slowly over 2
hours. To end on [**2126-11-7**].
[**Date Range **]:*9 g* Refills:*0*
2. Outpatient Lab Work
Vanco trough before dose on [**2126-11-1**] and [**2126-11-5**]. Fax results
to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] at [**Telephone/Fax (1) 4004**].
3. Outpatient Lab Work
Please draw basic metabolic panel on [**2126-11-1**] and [**2126-11-5**]. Fax
results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] at [**Telephone/Fax (1) 4004**].
4. Heparin LockFlush(Porcine)(PF) 10 unit/mL Syringe Sig: Five
(5) mL Intravenous as dir: Flush with heparin 5 mL 10 units/mL
after each dose of antibiotic or TPN. SASH.
[**Telephone/Fax (1) **]:*QS 30 day supply* Refills:*0*
5. Saline Flush 0.9 % Syringe Sig: Five (5) mL Injection As
directed: Flush with 5 mL normal saline before & after each
medication & TPN. SASH.
[**Telephone/Fax (1) **]:*QS 30 day supply* Refills:*3*
6. Central Line Dressing
Change dressing & tubing weekly.
7. Ethanol 70%
To be instilled into each central catheter lumen for local dwell
for 2 hours daily at completion of TPN or if no TPN, instilled
into each central catheter lumen for local dwell for 2 hours
daily.
[**Telephone/Fax (1) **]: QS
Refill: 0
8. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
9. betamethasone dipropionate 0.05 % Lotion Sig: One (1)
application Topical twice a day: To rash.
10. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q6H (every 6 hours) as needed for headache.
11. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) injection Injection once a month.
12. darifenacin 15 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
13. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO As directed: [**Telephone/Fax (1) 766**]-Friday (skip Sat & Sun).
14. Vivelle-Dot 0.0375 mg/24 hr Patch Semiweekly Sig: One (1)
patch Transdermal Twice weekly.
15. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO three times
a day.
17. gabapentin 300 mg Capsule Sig: One (1) Capsule PO four times
a day.
18. hyoscyamine sulfate 0.125 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for bladder spasm.
19. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
21. lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
22. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
23. meclizine 25 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for dizziness.
24. methadone 5 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
25. metronidazole 0.75 % Gel Sig: One (1) application Topical
twice a day: to rash.
26. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
27. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
28. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
29. pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
30. sumatriptan succinate 50 mg Tablet Sig: One (1) Tablet PO
once a day as needed for headache: Take at onset of headache.
[**Month (only) 116**] take additional 1 tablet in 2 hours as needed.
[**Month (only) **] Disposition:
Home With Service
Facility:
[**First Name5 (NamePattern1) 189**] [**Last Name (NamePattern1) 269**]
[**Last Name (NamePattern1) **] Diagnosis:
PRIMARY DIAGNOSIS:
- Sepsis
SECONDARY DIAGNOSIS:
- Urinary tract infection
- Indwelling TPN line
[**Last Name (NamePattern1) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
[**Last Name (NamePattern1) **] Instructions:
Ms. [**Known lastname 13275**], it was a pleasure to participate in your care while
you were at [**Hospital1 18**]. You came to the hospital with a serious
infection leading to a condition called "sepsis". Your blood
pressure was low so you went to the ICU. Your blood cultures
were negative and we did not feel that your TPN catheter was
infected. We did find, however, that you may have a urinary
tract infection that could have been the cause of your symptoms.
You were started on antibiotics to treat your infection. These
antibiotics will need to be continued with your home infusion
company for 9 days after your [**Hospital1 **].
MEDICATIONS CHANGED:
- Medications ADDED:
----> Please START taking vancomycin 1g IV every day (Start date
[**2126-10-24**], end date [**2126-11-7**])
- Medications STOPPED: None.
- Medications CHANGED: None.
You will have labwork drawn periodically to monitor your kidney
function, which will be followed up by your primary care doctor.
Followup Instructions:
The following appointments have been scheduled for you:
PCP:
[**Name Initial (NameIs) **]: [**Hospital3 249**]
When: [**Hospital3 **] [**2126-11-4**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*Dr. [**First Name (STitle) 1022**] will be following up on the labs that will be drawn
periodically (first draw on [**2126-11-1**]).
Department: RHEUMATOLOGY
When: WEDNESDAY [**2127-2-5**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: GASTROENTEROLOGY
When: THURSDAY [**2127-3-20**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"0389",
"78552",
"5990",
"5849",
"2761",
"2762",
"2449",
"311",
"412",
"99592",
"4019"
] |
Admission Date: [**2123-1-27**] Discharge Date: [**2123-1-29**]
Date of Birth: [**2047-4-21**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
CC:[**CC Contact Info 6348**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The patient is a 75 year old right handed woman with a
history of atrial fibrillation on Coumadin, hypertension, and
Grave's Disease who presented with headache, vomiting, and
confusion, and was transferred from an OSH with left
temporoparietal IPH with midline shift and left uncal
herniation.
The history is obtained from the patient's husband and daughter.
The patient was in her usual state of health until 8:00-8:30 pm
on the evening prior to admission when she complained of a
headache and wanted to lay down. At approximately 10:00 pm she
called out her husband's name, and said help me. She walked from
the bedroom to the bathroom and vomited. Her husband found her
sitting on the edge of the tub confused, saying "give me a few
minutes". She had difficulty sitting upright and was leaning to
the left per her husband. She was more sleepy than usual. After
10 minutes, her husband called 911. [**Name2 (NI) **] husband denied any head
trauma. Per EMS notes, exam showed pupils pinpoint, EKG showed
sinus bradycardia at 50 bpm.
She initially presented to [**Hospital3 417**] Hospital, where SBP
174/79. Labs showed WBC 12.5, plt 185, INR 2.2, glucose 213, Cr
0.9. Head CT at the OSH showed 6.5 x 3.3 cm acute
intraparenchymal hematoma in the left temporoparietal lobe with
surrounding edema and 1.4 cm midline shift to the right, left
uncal herniation with impending transtentorial herniation. She
was given 2 U FFP and intubated. It is difficult to determine
what other medications she received, but they may include
Decadron 10 mg, Fosphenytoin 1 gm, Labetalol, Succs, Fentanyl,
and Valium. She was transferred to [**Hospital1 18**] for further care.
At the [**Hospital1 18**] ED, INR was 2.0 on admission. Here she was given
Vitamin K 10 mg IV, Profilnine, and Nicardipine gtt.
Past Medical History:
[**Doctor Last Name 933**] Disease
- status post radioactive iodine ablation
Atrial Fibrillation - not on coumadin, occured in setting of
hyperthyroid, resolved since treatment
Hypertension
Glaucoma
Social History:
Patient lives in [**Location 701**], MA with her husband, one daughter
who is ped radiologist at [**Name (NI) 1926**].
Tobacco: None
ETOH: [**12-25**] mixed drinks daily, last drink yesterday
Illicits: None
.
Family History:
Father - MI age 50, died 90s
Mother - Died 92 natural cuases
8 siblings
Physical Exam:
PHYSICAL EXAM:
VS: temp 97.7, bp 155/97, HR 76, RR 18, SaO2 100% (intubated)
Genl: Intubated, eyes open
HEENT: Sclerae anicteric, bilateral conjunctival injection
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally anteriorly, no wheezes, rhonchi, rales
Abd: +BS, soft, NTND abdomen
Neurologic examination:
Mental status: Intubated, eyes open. Does not follow commands to
squeeze hands bilaterally. Does not arouse to name being called
or sternal rub.
Cranial Nerves: Pinpoint pupils nonreactive to light, 1.5 mm on
the left and 1 mm on the right. Minimal corneal reflex
bilaterally, slightly more brisk on the left. No gag reflex. No
obvious facial asymmetry. Eyes turn in the same direction as the
head with Doll's eye maneuver.
Motor/Sensation: No observed myoclonus, asterixis, or tremor.
The
patient withdraws her right>left upper extremity to noxious
stimulus. She occasionally spontaneously moves her right upper
extremiy. There is a flicker of contraction of her bilateral
lower extremities to noxious, but she does not withdraw them.
She
occasionally spontaneously rotates her left lower extremity.
Reflexes: 2+ and symmetric in biceps, brachioradialis, and
knees.
No ankle clonus. Toes equivocal bilaterally.
Pertinent Results:
IMAGING:
CT Head (prelim): large left temporal lobe intraparenchymal
hemorrhage with extensive surrounding edema resulting in 13mm
rightward shift of normally midline structures and entrapment of
the right lateral ventricle. There is associated mild left uncal
herniation
[**2123-1-27**] 01:15AM WBC-13.1*# RBC-4.07* HGB-12.0 HCT-34.1*
MCV-84 MCH-29.4 MCHC-35.1* RDW-13.1
[**2123-1-27**] 01:15AM NEUTS-87.9* LYMPHS-9.6* MONOS-2.1 EOS-0.3
BASOS-0.1
[**2123-1-27**] 01:15AM PLT COUNT-164
[**2123-1-27**] 01:15AM PT-21.2* PTT-27.0 INR(PT)-2.0*
Brief Hospital Course:
The patient is a 75 year old right handed woman with a history
of atrial fibrillation on Coumadin (INR 2.2),hypertension, and
Grave's Disease who presented with a left temporoparietal IPH
with midline shift and left uncal herniation.
Her exam evidences the absence of some brain stem reflexes (gag,
dolls eyes, corneal reflexes) though her exam was not completely
consistent with brain death. Given her poor exam and extensive
size of her hemorrhage she was not a surgical candidate. She was
admitted to the ICU her INR was reversed her SBP was kept less
than 140 and she was started on Dilantin and Mannitol. An MRI
showed Several areas of restricted diffusion within the left
occipital lobe, left thalamus, mid brain, and corpus callosum
most consistent with acute infarction. A few foci of increased
susceptibility within the left thalamus and to a lesser extent
midbrain suggestive of Duret hemorrhage.
On the first morning of her hospital day she had no eye opening
no blink to threat she made a weak attempt to localize on the
right and withdrew her lower extremeties and left arm. Stroke
neurology was consulted and felt that she should not have
surgery due to size of bleed and dominent hemisphere and
recommended medical management.
Extensive discussion were held with the family from
neurosurgery, neurology and critcal care team to discuss the
gravity of the situation.
On her second hospital day the patients exam did not not improve
the family had a meeting with pallative care they planned an
extubation with Morphine and Ativan for comfort. The patient
passed away on [**2123-1-29**].
Medications on Admission:
Medications prior to admission:
Coumadin 5 mg daily
HCTZ 12.5 mg daily
Lisinopril 10 mg qhs
Verapamil 120 mg Sust Release daily
Levothyroxine 88 mcg daily
Lumigan 0.03% drops OU daily
Pilocarpine 2% OU qid
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
cerebral hemorrhage
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2123-4-7**]
|
[
"42731",
"V5861",
"4019"
] |
Admission Date: [**2130-5-22**] Discharge Date: [**2130-5-25**]
Service: CCU
CHIEF COMPLAINT: The patient presented for aortic
valvuloplasty.
HISTORY OF PRESENT ILLNESS: The patient is an 89 year old
female with a history of aortic stenosis, who presented
recently with complaints consistent with congestive heart
failure, which included shortness of breath and increasing
lower extremity edema. Cardiac catheterization revealed an
aortic valve peak gradient of 80 with estimated valve surface
area of 0.5 cm2 and severely elevated filling pressures with
prominent V waves. Cardiac catheterization showed 30% ostial
left circumflex lesion with mild left anterior descending
artery and right coronary artery luminal irregularities.
Left ventriculogram showed a left ventricular ejection
fraction of 60%, 3+ mitral regurgitation and normal wall
motion.
The patient underwent scheduled aortic valvuloplasty on day
one of this admission, which showed a peak gradient of 60 mm
of mercury and a valve area of 0.4 cm2. After valvuloplasty
the gradient was reduced to 30 mm of mercury and the valve
surface area increased to 0.6 cm2. A new left bundle branch
block was noted on a post intervention electrocardiogram with
a heart rate of 75.
The patient was then taken back to the catheterization
laboratory for placement of a temporary ventricular pacing
wire. A repeat electrocardiogram after this procedure showed
atrial fibrillation without left bundle branch block. The
atrial fibrillation is chronic. There were no pacer spikes
on this tracing. The patient's pulmonary artery pressure was
61/22 with a mean of 40. At this point, the patient was
transferred to the Coronary Care Unit for 24 hours of
observation.
PAST MEDICAL HISTORY:
1. Congestive heart failure.
2. Atrial fibrillation.
3. Severe aortic stenosis.
4. Severe mitral regurgitation.
5. Hypertension.
6. Family history of coronary artery disease.
7. Polymyalgia rheumatica.
8. Osteoporosis.
9. Bleeding colonic polyps.
10. Pseudogout.
11. Status post cholecystectomy.
12. Status post cystectomy with stoma.
13. History of gastrointestinal bleed, polyps versus aspirin
induced.
MEDICATIONS ON ADMISSION: Coumadin 1 mg p.o.q.h.s., Lasix 40
mg p.o.q.d., Lopressor 12.5 mg p.o.b.i.d., ferrous sulfate
325 mg p.o.q.d., Os-Cal p.o.q.d., Protonix 40 mg p.o.q.d.,
Prednisone 5 mg p.o.q.d., trazodone 50 mg p.o.q.h.s.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: On physical examination on transfer to
the Coronary Care Unit, the patient had a pulse of 66,
respiratory rate 24, blood pressure 108/49 and oxygen
saturation 100% on two liters nasal cannula. Neurologic
examination: No focal neurological deficits, alert and
oriented times three. Cardiovascular: Irregular heart rate,
IV/VI harsh crescendo-decrescendo systolic murmur, mild
pitting pretibial edema. Pulmonary: Lungs clear to
auscultation bilaterally with bibasilar crackles. Abdomen:
Soft, nontender, nondistended. Extremities: Temporary
pacing wire in right groin.
PERTINENT LABORATORY DATA: Hematocrit 31.4, creatinine 1,
and INR 1.2.
HOSPITAL COURSE: After transfer to the Coronary Care Unit,
the patient did not develop further conduction problems.
Several times she had brief bursts of a rapid atrial
fibrillation, which spontaneously resolved on their own. Her
Coumadin was held for the procedure and it was restarted,
along with subcutaneous heparin 5,000 units twice a day until
the INR is therapeutic. The patient tolerated the procedure
well and there were no complications.
The patient was to be discharged on [**2130-5-24**], but had a
low grade temperature of 100.1 in the morning and stated that
she did not feel well, more specifically that she was a
little bit dizzy. Blood cultures were obtained, a chest
x-ray was obtained and the patient was held for a further 24
hours for observation. On the morning of discharge, her
symptoms of dizziness had resolved. She had no further
temperature spikes, with blood cultures showing no growth at
the time of discharge and a chest x-ray showing mild
congestive heart failure.
DISCHARGE STATUS: The patient is stable for discharge home
with VNA services. She will receive subcutaneous heparin
injections 5,000 units twice a day until her INR is
therapeutic.
FOLLOW-UP: The patient will follow up Monday at the [**Hospital 197**]
Clinic for an INR check and Coumadin adjustment. She will
follow up in two to three weeks with Dr. [**Last Name (STitle) **]. Since she
was having bursts of atrial fibrillation with rapid
ventricular response on her current Lopressor dose, she may
need an increase in the dose of this medication. Because of
problems with bradycardia in the past, she may require a
pacer in order for this to happen.
DISCHARGE DIAGNOSIS:
1. Critical aortic stenosis, status post valvuloplasty.
2. Atrial fibrillation.
DISCHARGE MEDICATIONS:
Heparin 5,000 units s.c.q.12h. until INR therapeutic.
Coumadin 1 mg p.o.q.h.s.
Aspirin 325 mg p.o.q.d.
Lasix 40 mg p.o.q.d.
Ferrous sulfate 325 mg p.o.q.d.
Protonix 40 mg p.o.q.d.
Metoprolol 12.5 mg p.o.b.i.d.
Prednisone 5 mg p.o.q.d.
Trazodone 50 mg p.o.q.h.s.p.r.n.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1544**], M.D. [**MD Number(1) 1545**]
Dictated By:[**Last Name (NamePattern1) 2582**]
MEDQUIST36
D: [**2130-5-25**] 11:59
T: [**2130-5-29**] 19:37
JOB#: [**Job Number 99107**]
|
[
"42731",
"41401",
"4019"
] |
Admission Date: [**2139-6-12**] Discharge Date: [**2139-6-19**]
Service: SURGERY
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Right groin pain
Major Surgical or Invasive Procedure:
[**2139-6-12**]
Open mesh repair of incarcerated right inguinal hernia.
History of Present Illness:
[**Age over 90 **] y/o M with large right inguinal hernia x1 year who presents
with mental status changes for past day. He experiences
intermittent discomfort from the hernia. He denies worsening
pain. One week ago, he was admitted for nausea/vomiting and
diarrhea. His symptoms were thought to be due to gastroenteritis
at that time. Since discharge, he has experienced increased
loss of appetite with continued diarrhea. He has had minimal PO
intake in past few days. No further episodes of emesis. He
presents to ED today when family members were concerned that pt
was becoming increasingly lethargic. No fever.
Past Medical History:
1. Hypertension.
2. Memory loss.
3. Status post stroke [**2134**].
4. History of shortness of breath.
5. Impaired vision. - L retinal detachment
6. History of gout.
7. Urinary frequency.
8. Hearing loss.
9. Left wrist ganglion.
PAST SURGICAL HISTORY:
1. Removal of cataracts, [**2132**].
2. Colon cancer with surgical removal.
3. Left arm skin graft, status post burn when he was young,
working in a laundry.
Social History:
Lives with his daughter [**Name (NI) **] who cooks for him and manages
his medications. He ambulates with walker and toilets
independently. Daughter reports that his memory is pretty good.
Spends his days watching TV or [**Location (un) 1131**]
Family History:
reviewed and noncontributory
Physical Exam:
Temp 88 HR 155/86 R 16 SaO2 96% 3L
Gen: lethargic, follows commands
Heent: no scleral icterus
Lungs: clear
Heart: regular rate and rhythm
Abd: soft, nondistended, nontender, large irreducible right
inguinal hernia
Extrem: 2+ lower extremity edema
Pertinent Results:
[**2139-6-18**] 09:30AM BLOOD WBC-7.2 RBC-3.71* Hgb-11.8* Hct-35.2*
MCV-95 MCH-31.9 MCHC-33.5 RDW-13.6 Plt Ct-276
[**2139-6-17**] 04:38AM BLOOD WBC-8.6 RBC-3.27* Hgb-10.6* Hct-30.6*
MCV-94 MCH-32.5* MCHC-34.7 RDW-13.3 Plt Ct-236
[**2139-6-16**] 05:55AM BLOOD WBC-14.4* RBC-3.49* Hgb-11.1* Hct-33.6*
MCV-97 MCH-32.0 MCHC-33.1 RDW-13.4 Plt Ct-257
[**2139-6-15**] 03:20AM BLOOD WBC-16.5* RBC-3.47* Hgb-11.2* Hct-33.2*
MCV-96 MCH-32.4* MCHC-33.9 RDW-13.5 Plt Ct-257
[**2139-6-12**] 04:30PM BLOOD WBC-9.9 RBC-4.14* Hgb-13.1* Hct-39.6*
MCV-96 MCH-31.5 MCHC-33.0 RDW-13.4 Plt Ct-213
[**2139-6-12**] 05:15PM BLOOD Neuts-73* Bands-2 Lymphs-7* Monos-15*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-2*
[**2139-6-18**] 09:30AM BLOOD Plt Ct-276
[**2139-6-17**] 04:38AM BLOOD Plt Ct-236
[**2139-6-13**] 02:20AM BLOOD PT-13.2 PTT-26.2 INR(PT)-1.1
[**2139-6-12**] 05:15PM BLOOD Plt Smr-NORMAL Plt Ct-229
[**2139-6-19**] 04:50AM BLOOD Glucose-104* UreaN-11 Creat-0.9 Na-136
K-3.4 Cl-97 HCO3-29 AnGap-13
[**2139-6-17**] 04:38AM BLOOD Glucose-127* UreaN-18 Creat-1.0 Na-143
K-3.1* Cl-103 HCO3-31 AnGap-12
[**2139-6-16**] 05:55AM BLOOD Glucose-109* UreaN-22* Creat-1.0 Na-145
K-3.5 Cl-107 HCO3-26 AnGap-16
[**2139-6-12**] 05:45PM BLOOD Glucose-119* UreaN-35* Creat-1.4* Na-136
K-4.6 Cl-101 HCO3-25 AnGap-15
[**2139-6-19**] 04:50AM BLOOD Calcium-8.1* Phos-2.7 Mg-1.8
[**2139-6-12**]: cat scan of abdomen and pelvis:
IMPRESSION:
1. Mechanical small-bowel obstruction. Transition point likely
just proximal to right inguinal hernia. There is normal bowel
wall enhancement. In comparison to [**2139-6-6**] exam, bowel loops
within the right inguinal sacappear more prominent with small
amount of free fluid, raising a possibility of closed loop
obstruction. Early bowel ischemia cannot be excluded.
2. Trace bilateral pleural effusions with adjacent areas of
compressive
atelectasis.
3. Numerous hepatic and renal hypodensities, too small to
characterize, may
represent cysts; however underlying malignant disease cannot be
excluded.
[**2139-6-17**] 04:38AM BLOOD Calcium-7.9* Phos-2.2* Mg-2.0
[**2139-6-12**] 05:51PM BLOOD Lactate-1.3
[**2139-6-12**] 04:31PM BLOOD freeCa-1.03*
[**2139-6-12**]: EKG:
Sinus rhythm. Left axis deviation. Left anterior fascicular
block.
Non-diagnostic repolarization abnormalities. Compared to the
previous tracing of [**2139-6-5**] there is no significant change.
[**2139-6-12**]: chest x-ray:
IMPRESSION:
1. Markedly diminished lung volumes. Bibasilar opacities, most
likely
atelectasis, however, superimposed infection cannot be excluded.
2. Stable appearance of prominent mediastinal silhouette, which
is likely due to tortuous aorta with possible aneurysmal
changes.
[**2139-6-12**]: cat scan of the head:
1. No acute intracranial process.
2. Bilateral extra-axial collections likely chronic subdural
hematomas.
3, Small vessel ischemic disease.
3. Prominent sulci and ventricles, likely age-related
involutional changes
[**2139-6-15**]: Echo:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Physiologic mitral regurgitation is seen
(within normal limits). The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality due to body habitus.
Moderate symmetric left ventricular hypertrophy with a small LV
cavity and hyperdynamic LV systolic function. The RV is not well
seen but is probably normal. Mild aortic regurgitation.
Diastolic function could not be adequately assessed
[**2139-6-15**]: chest x-ray:
There is no change in the cardiomediastinal silhouette. Lungs
are essentially clear, except for bibasal atelectasis and small
bilateral pleuraleffusions.
Minimal vascular engorgement is noted that might reflect changes
in radiograph technique. No pneumothorax is seen.
[**2139-6-15**]: ultrasound of left arm:
IMPRESSION: No DVT in the left upper extremity veins. However,
nonspecific
asymmetry of the subclavian vein waveforms is noted and a more
central
stenosis cannot be entirely excluded.
[**2139-6-18**]: ultrasound of left lower extremity:
IMPRESSION:
No evidence for DVT in the left lower extremity
Brief Hospital Course:
Mr [**Known lastname 84762**] was admitted to the surgical service following repair
of his inguinal hernia on [**2139-6-12**] by Dr [**Last Name (STitle) **]. The
procedure went well without complication. Please see Dr [**Name (NI) 84764**] note for further details. Because of poor oxygenation
and lack of spontaneous deep breaths, he remained intubated
after surgery and was transferred to the ICU intubated/sedated
and off pressors. He was weaned to extubation on POD 1, but
continued to have difficulty with respirations. It became
apparent that he was not mobilizing fluid and had become fluid
overloaded with bibasilar crackles and pitting edema. His IV
fluids were held and he was given IV Lasix. He diuresed well
over the next 24 hours, with measured negative of 1.2 liters. He
was also given regular nebulizers (xopenex and budesonide) given
our suspicion for long-standing undiagnosed COPD. TTE was
performed POD3 revealing normal EF and no significant valvular
disease. He was evaluated by speech and swallow on POD 3 and was
deemed unfit for PO intake. By POD 3, he was saturating well on
2L nasal canula and appeared to have stable mental status, so he
was transferred to the surgical floor, maintaining strict NPO.
Transferred to the surgical floor on POD #3. He was evaluated
by speech and swallow prior to initiating food because of his
history of overt aspirations. He was cleared for pureed solides
with supervision during meals. Nutrition services did speak to
the family about adding supplements to the diet. He dietary
intake has been limited. His foley catheter was discontinued
on POD # 6 and he has been incontinent of urine. He did receive
occasional doses of lasix to help improve mobilzation of his
fluids. He was noted to have swelling of his left upper
extremity and underwent an ultrasound which did not show a DVT,
however, nonspecific asymmetry of the subclavian vein waveforms
was noted and a more central
stenosis could not be entirely excluded.
In preparation for discharge, he was evaluated by physical
therapy and recommendations made for a rehabilitation facility,
his family prefers to provide the necessary care at home with
the assistance of VNA.
His vital signs are stable and he is afebrile. He has resumed
his home medications. His family has been instructed by physical
therapy in assisting him to the commode and into the wheelchair.
VNA will also be available to provide additional assistance. He
will follow-up with the acute care service on [**6-23**] for staple
removal and with your PCP [**Last Name (NamePattern4) **] 2 weeks.
Medications on Admission:
HCTZ 25 mg alternating with 12.5 mg daily, cozaar 25 mg daily
Discharge Medications:
1. budesonide 0.25 mg/2 mL Suspension for Nebulization [**Last Name (NamePattern4) **]: Two
(2) ml Inhalation q6h ().
2. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Last Name (NamePattern4) **]:
One (1) neb Inhalation q6h ().
3. losartan 25 mg Tablet [**Last Name (NamePattern4) **]: One (1) Tablet PO DAILY (Daily).
4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3
times a day).
6. assist device
Wheelchair with removable arms and elevating legs
7. hydrochlorothiazide 12.5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO 3
days per week.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
incarcerated R inguinal hernia
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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-28**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
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.
*Your staples will be removed at your follow-up appointment.
Followup Instructions:
Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2139-6-23**] 3:45
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
in 2 weeks.
Completed by:[**2139-6-19**]
|
[
"496",
"4019",
"412"
] |
Admission Date: [**2129-6-10**] Discharge Date: [**2129-6-24**]
Date of Birth: [**2072-9-6**] Sex: M
Service: MEDICINE
Allergies:
sertraline
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Agitation, combativeness, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 56yo M with alcohol abuse and distant opioid abuse
on methadone maintenance presents following recent discharge
from [**Hospital 8**] Hospital for alcohol detox.
According to his brother, the patient was drinking more than
usual the past several months eventually leading to drinking at
all hours of the day. The patient was admitted to [**Hospital1 8**] for
detox and was discharged two days prior to arrival with several
prescriptions including Haldol. He now presents to the ED with
confusion. Of note, the patient is on a methadone maintenance
program (100mg daily), and the patient continues to ask for
additional methadone.
In the ED, patient was somnolent, AOx2 (knows person and
"hospital"), exam being unremarkable, but he was trying to get
OOB every 5 minutes. Noted to be hypotensive with SBPs in the
70s, improved with IVFs. Additional banana bag also given in the
ED. [**Name6 (MD) **] [**Name8 (MD) **] RN report, he was calm and polite, but forgot what he
was asked as soon as someone left the room. Vitals upon transfer
to the floor: 98, 50, 16, 91/48, 98% ra, [**3-31**] pain.
He was admitted to the ICU because of AMS and combativeness. IN
the ICU, his OSH records were obtained which revealed negative
RPR, normal TSH, and an MRI scan significant for mammallary body
atrophy. Pt was started on high dose thiamine and improved
significantly (speech), suggesting wernickes encephalopathy. He
was receiving standing haldol for several days but his qtc
lengthened with peak of 486. He was then changed to prn haldol
2.5mg.
He was initially on a CIWA scale but was not [**Doctor Last Name **], and this
was d/ced. He was restarted on his home dose of methadone,
which has helped him. Psychiatry has been consulting and
advising on medication management recs. Social work and PT were
also been consulted.
On transfer, vitals were 105/69 HR 79, rr 17, 99% RA. He is aox3
and does not have any complaints.
Past Medical History:
-HTN
-ETOH abuse
-HCV
-h/o Agoraphobia previously treated w/ sertraline, but stopped
for concern of serotonin syndrome
- Methadone maintenance for opioid detox
Social History:
Former waste management truck worker and cement mixer for 22
years.
Last HIV test negative 2.5 years ago.
Last drink was 5-6 weeks algo, Notes state he may have had odor
of etoh at outside clinic appointment and was sent to detox.
Denies ever smoking. Lives with his brother, [**Name (NI) **].
Family History:
DM2 in both parents, PTSD in his father. Brother is also on
methadone maintenance program.
Physical Exam:
ADMISSION EXAM
Tmax: 37.1 ??????C (98.7 ??????F)
Tcurrent: 37.1 ??????C (98.7 ??????F)
HR: 84 (73 - 84) bpm
BP: 107/79(85) {107/72(85) - 130/86(96)} mmHg
RR: 33 (18 - 33) insp/min
SpO2: 98% RA
Heart rhythm: SR (Sinus Rhythm)
General: Patient in 4 point restraints calling out to be let go
HEENT: NorPERRL. Sclera non-icteric. dryMM. OP without
eryrthema, exudate.
CV: RRR. No M/R/G
Lungs: Nml work of breathing with no accessory muscle use. Clear
to auscultation bilaterally, anteriorly.
Abd: BS+. Soft. NT/ND.
Ext: Right knee bandage in place. Trace pitting edema
bilaterally. 2+ DPs bilaterally. No clubbing, cyanosis.
Neuro: Unable to assess CN [**12-23**] patient's mental status. Moving
all 4 extremities spontaneously. Alert. Oriented only to person.
Psych: [**Month/Day (2) 100549**]. flight of ideas. tearful at times. no
hallucinations at present, no suicidal/homicidal ideation.
DISCHARGE EXAM
Vitals: 98.1/98.3 - 100s - 120s/60s-70s - 65(60-80s)- 100 RA
GEN: Alert, oriented to person, place and time, no acute
distress. Exited bathroom when I came in. Ambulating on
own/using bathroom on own. Appropriate affect and communication
skills.
HEENT: Sclera anicteric, MMM, oropharynx clear,
NECK: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no mrg
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
ABD: No ascites, soft, non-tender, non-distended, bowel sounds
present,
EXT: Ambulating on his own as needed, 2+ pulses, no spider
angiomas
NEURO: No asterixis, Non encephalopathic
CNII-XII intact, 5/5 strength upper/lower extremities, grossly
normal sensation. Slight tremor bilateral. F-t-N with slight
tremor.
Pertinent Results:
ADMISSION LABS
[**2129-6-10**] 01:25PM BLOOD WBC-6.9 RBC-3.18* Hgb-10.6* Hct-33.1*
MCV-104* MCH-33.4* MCHC-32.1 RDW-13.1 Plt Ct-308#
[**2129-6-10**] 01:25PM BLOOD Neuts-63.8 Lymphs-25.3 Monos-4.5 Eos-5.5*
Baso-1.0
[**2129-6-10**] 01:25PM BLOOD PT-10.3 PTT-28.0 INR(PT)-0.9
[**2129-6-10**] 01:25PM BLOOD Glucose-96 UreaN-49* Creat-2.4*# Na-141
K-4.2 Cl-105 HCO3-25 AnGap-15
[**2129-6-10**] 01:25PM BLOOD ALT-48* AST-55* LD(LDH)-236 AlkPhos-45
TotBili-0.3
[**2129-6-10**] 01:25PM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.4 Mg-1.9
[**2129-6-10**] 01:25PM BLOOD VitB12-765 Folate-GREATER TH
[**2129-6-10**] 01:25PM BLOOD TSH-1.4
[**2129-6-14**] 04:44AM BLOOD CRP-2.5
[**2129-6-14**] 04:44AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2129-6-10**] 01:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2129-6-10**] 01:35PM BLOOD Lactate-1.1
DISCHARGE LABS
[**2129-6-19**] 08:10AM BLOOD WBC-9.6 RBC-3.55* Hgb-12.0* Hct-36.2*
MCV-102* MCH-33.8* MCHC-33.2 RDW-13.6 Plt Ct-232
[**2129-6-19**] 08:10AM BLOOD Neuts-77.9* Lymphs-11.7* Monos-4.0
Eos-5.8* Baso-0.7
[**2129-6-19**] 08:10AM BLOOD Glucose-95 UreaN-15 Creat-1.0 Na-143
K-4.3 Cl-102 HCO3-34* AnGap-11
[**2129-6-12**] 05:52AM BLOOD ALT-35 AST-45* AlkPhos-33* TotBili-0.5
[**2129-6-19**] 08:10AM BLOOD Calcium-9.7 Phos-3.6 Mg-1.7
URINALYSIS
[**2129-6-10**] 10:43PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2129-6-10**] 10:43PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2129-6-10**] 10:43PM URINE RBC-<1 WBC-8* Bacteri-FEW Yeast-NONE
Epi-0
[**2129-6-10**] 10:43PM URINE CastHy-3*
MICRO DATA
[**2129-6-11**] BLOOD CULTURE - pending
[**2129-6-10**] BLOOD CULTURE - negative
[**2129-6-10**] RAPID PLASMA REAGIN TEST - negative
[**2129-6-10**] BLOOD CULTURE - negative
ECG [**2129-6-10**] 1:19:10 PM
Sinus bradycardia. Baseline artifact. Early anterior R wave
transition.
Lateral R wave regression. Non-specific T wave inversion in lead
aVF. No
previous tracing available for comparison.
ECG [**2129-6-10**] 9:03:58 PM
Baseline artifact. Sinus rhythm. Compared to the previous
tracing of the same date the rate is slightly faster and no
longer bradycardic. T wave inversion has improved in lead aVF.
Anterior R wave progression is more normal out to lead V5,
likely reflecting differences in precordial electrode placement.
CHEST (PORTABLE AP) Study Date of [**2129-6-10**] 1:43 PM
No evidence of acute disease.
.
[**6-15**] MRI brain
IMPRESSION: Significant cortical volume loss for the patient's
age, and few
scattered foci of high signal intensity throughout the
subcortical and
periventricular white matter as well as in the pons, suggesting
sequela of
small vessel disease. The mamillary bodies demonstrate atrophy
with no
evidence of abnormal enhancement to indicate acute Wernicke's
encephalopathy,
however sequelae of this syndrome resulting in mamillary body
atrophy cannot
be completely ruled out.
.
[**6-19**] CT head-IMPRESSION:
1. No evidence of acute intracranial abnormality.
2. Global atrophy, likely related to the given history of
alcohol abuse.
Brief Hospital Course:
56yo caucasian male with chronic alcohol abuse, opioid abuse on
methadone maintenance, recent detox, and hep C, presenting with
hypotension, altered mental status, combativeness, dehydration
induced [**Last Name (un) **], and positive urine benzo tox screen. Responded to
hydration and IV thiamine, also managed with methadone and
haldol. During hospital course patient became acutely confused
and agitated and attempted to elope twice. Two code purples were
called, and he was deemed to lack medical decision making
capacity. The patient improved significantly with nutrition,
vitamin support, and pain control. The patient's brother was
deemed his health care proxy.
.
## Altered mental status: The patient was recently discharged
from detox at [**Hospital 8**] Hospital 2 prior to arrival.
Differential included EtOH withdrawal versus benzo withdrawal
versus Wernicke's encephalopathy/Korsakoff psychosis.
Neuroimaging appeared to be consistent with subacute/chronic
Wernicke Korsakoff syndrome with an element of related
neurocognitive trouble (global atrophy) in the setting
of long standing alcohol use. MRI finding of chronic Mamillary
Body Atrophy consistent with Wernicke-Korsakoff. Pts cognition
improved with Vitamin repletion, hydration, and methadone.
Unlikely to be other metabolic, infectious etiologies - TSH nml,
infectious workup negative (neg CXR, UA w/ WBCs and bacteria but
no symptoms).Patient was placed on CIWA scale, but did not
score, so this was discontinued. On the floor, patient was noted
to be confabulating extensively, responding to internal stimuli
and hallucinating (both auditory and visual). On [**6-17**], he
patient became acutely confused, agitated and attempted to
elope, code purple was called. He was re-directed and returned
to the floor. On [**6-18**], he attempted to elope and was seen
running outside the hospital, where he fell at some point.
Security found him roughly 25 minutes later at [**Hospital1 100550**], and he returned willingly. Head CT was done to rule
out trauma in the setting of recent fall and showed global
atrophy with no acute intracranial bleed. In light of these
events, he was evaluated by the Psychiatry team and was deemed
to lack decision making capacity. Due to this he could not leave
the hospital, including signing out AMA. OT deemed the patient
to have poor ability with medication dosing and financial
capacity.PT deemed the patient to require minimal assistance for
ambulation. Subsequently the patient's brother was determined to
be the [**Hospital 228**] Health Care Proxy. At a family meeting it was
decided that the patient would live with his brother and the
brother decided to help with daily medication dosing, and
financial management. On discharge the patient was connected
with Home VNA upon discharge. On day of discharge, the patient
was tolerating full PO diet without nausea or emesis, ambulating
independently, moving bowels and urine appropriately and
independently, making rational decisions with improved insight.
The patients vital signs were normal and stable. The patient's
lab findings were normal and stable. Recovery could take
weeks/months and may be limited by pt's discovered global brain
atrophy. He was discharged with VNA/PT and his brother acting to
provide some supervision.
.
## h.o opiate abuse/chronic pain- Pt admitted from OSH on 100mg
methadone/day. On day of discharge patient was on 40mg
methadone/day. Patient, his family and Home VNA were given
instructions on weaning the methadone upon discharge. Weaning
methadone should also help with cognitions
.
## Prolonged QT syndrome: Patient received standing haloperidol
in the MICU for several days secondary to agitation and
combativeness, but his QTc began to lengthen with peak of 486.
As a result haloperidol was used sparingly. His electrolytes
were repleted as needed and methadone was down-titrated to 80
then 60 mg QD. QT improved to 418, and haloperidol was only used
with extreme caution. He was followed with serial daily EKGs.
THus buspirone and haldol were discontinued.
.
## Hepatitis C: Untreated. Patient was followed by Hepatology
and in the past has expressed interest in treatment. Reviewe of
OMR notes suggests that the patient has not initiated treatment
yet. LFTs were trended and were within normal limits. Referral
was made for follow-up with [**Hospital 3585**] clinic.
.
## EtOH Abuse: With macrocytic anemia and Mamillary body
atrophy. Recently discharged from rehab. Unclear time of last
drink. Upon admission patient was placed on CIWA scale, but did
not score, and this was discontinued. The patient was given MVI
daily, as well as intravenous thiamine. No withdraw events
during admission. Patient was interested and willing to pursue
rehab and at discharge patient was connected with outpatient
support groups and rehab centers.
.
## Essential tremor: Well controlled with propranolol on the
floor.
Transitional Issues:
- Please be aware that Mr. [**Known lastname **] [**Last Name (Titles) 100549**] and likely lacks
medical decision making capacity. His brother, [**Name (NI) **] is his
health care proxy.
- Needs de-escalation of methadone, discharged at 40mg/day,
please coordinate with [**Hospital 228**] [**Hospital 2514**] clinic.
- Please be aware that patient has history of prolonged QT (in
the setting of treatment with haloperidol and methadone), please
use these medications with extreme caution and follow EKGs if
haloperidol is necessary.
- Patient needs follow-up with [**Hospital 3585**] clinic at [**Hospital1 18**] (with
Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] at [**Hospital1 18**]).
- Patient needs to see his PCP after discharge (Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 807**]).
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
Family/Caregiver.
1. Lisinopril 10 mg PO DAILY
Hold for SBP < 100
2. Propranolol 20 mg PO TID
Hold for SBP < 100, HR < 50
3. BusPIRone 10 mg PO TID
4. Vitamin D 400 UNIT PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Haloperidol 1 mg PO Q6HR : PRN agitation
10. Tamsulosin 0.4 mg PO HS
11. Methadone 100 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Propranolol 20 mg PO BID
Hold for SBP < 100, HR < 50
4. Aspirin 81 mg PO DAILY
5. BusPIRone 10 mg PO TID
6. Thiamine 100 mg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. Methadone 80 mg PO DAILY
Please hold for RR<12, oversedation
9. Lisinopril 10 mg PO DAILY
Hold for SBP < 100
10. Tamsulosin 0.4 mg PO HS
11. Thiamine 100 mg IV DAILY Duration: 4 Days
at [**Hospital **] Hospital.
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Propranolol 20 mg PO BID
Hold for SBP < 100, HR < 50
RX *propranolol 20 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Thiamine 100 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Methadone 40 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
Hold for SBP < 100
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth every night Disp
#*30 Capsule Refills:*0
10. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Delirium
Wernicke-Korsakoff Psychosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
Thank you for choosing your care at the [**Hospital1 827**]. You were admitted to the [**Hospital1 18**] MICU for
confusion, dehydration, and low blood pressure. Later, once your
blood pressure stabilized, and your confusion improved, you were
transferred to the floor. You were treated with intravenous
thiamine, a vitamin which can be at very low levels in people
who drink alcohol. You were also re-started on your methadone,
but your dose was lowered, because the high dose you had been on
seemed to make you confused. While you were here, you became
confused and attempted to leave the hospital twice. The second
time you left, it was decided that for your safety and because
of your hallucinations and confusion, you did not have decision
making capacity and could not leave the hospital, including
signing out AMA. Your health continued to remain stable in the
hospital, and you were discharged in good condition to [**Hospital **]
Hospital.
While you were here, some changes were made to your medications.
You were continued on methadone, but at a lower dose (80 mg per
day). The doctors at your rehab facility ([**Hospital1 **]) will
continue to manage this dosing. Please follow-up with them
regarding how much methadone you should take at home.
Please follow up with your primary care provider after discharge
from the [**Hospital **] hospital/rehabilitation center.
Followup Instructions:
Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 807**], after being
discharged from [**Hospital **] Hospital.
Location: [**Hospital **] MEDICAL PHYSICIANS, P.C.
Address: [**University/College 808**], [**Location (un) **],[**Numeric Identifier 809**]
Phone: [**Telephone/Fax (1) 823**]
Please follow up with Dr. [**Last Name (STitle) **] at the [**Hospital 18**] [**Hospital 3585**] clinic.
Their phone number is [**Telephone/Fax (1) 463**].
Completed by:[**2129-6-26**]
|
[
"5849",
"2760",
"4019"
] |
Admission Date: [**2187-10-30**] Discharge Date: [**2187-11-1**]
Date of Birth: [**2135-1-27**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Augmentin / Lisinopril / Metoprolol
Attending:[**First Name3 (LF) 9002**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
52 y/o woman with severe systemic sarcoid, ESRD on HD (Tu, Th,
Sa), home O2 3.5L for sarcoid and pulmonary hypertension,
presents with shortness of breath. She was in her usual state of
health until 3AM this morning when she awoke from sleep with
painful leg cramp. She sat up in bed and shortly after became
suddenly short of breath. She tried increasing her oxygen to 8L
without relief. Shortness of breath persisted and she presented
to dialysis this morning, where because of respiratory distress
and hypoxia, she was transferred to the ED prior without a
dialysis session completed. She last received dialysis on
Saturday (3 days prior to admission) and today is 55.3kg
(baseline dry weight 51kg). She denies chest pain, palpitations,
cough, or shortness of breath. She had a low grade temperature
of 99F after dialysis on Saturday which resolved spontaneously.
.
In the ED, initial VS were: 98.5 119 126/69 26 100% 10l. CXR
showed right pleural effusion. Labs notable for lactate 4.0, Cr
9.9, BUN 47, K 5.9, Trop 0.15. ABG 7.42/34/54. Nitroglycerin
drip was started @ 1mcq/kg/min and she received Vanco/Zosyn. On
Bipap doing well. Albuterol/ipratropium nebulizers started.
Nephrology was consulted and plans on dialysis upon admission.
Vitals prior to transfer: afebrile, HR 110, BP 121/74, RR 26 and
100% on Bipap FiO2 50%.
.
On arrival to the MICU, she states her SOB has resolved and she
oxygen saturations are 94% on 4L oxygen via nasal canula.
Nitrolgycerin gtt was stopped. Temperature is 101. She endorses
a headache, but no vision changes or neck stiffness. She has
mild nausea, but no vomitting. Denies abdominal pain, diarrhea,
melena/hematochezia. She does not make urine. Her leg cramping
has resolved. She is alert and oriented and able to detail past
medical history and events leading up to admission. She reports
a similary event with SOB happened 1.5 years ago, increased
prednisone and symptoms resolved during hospitalization.
Past Medical History:
- Systemic sarcoidosis (diagnosed in [**2177**]) w/ pancreatic and
liver involvement and pulm HTN (on daily prednisone)
- ESRD [**2-28**] sarcoidosis on hemodialysis T/R/Sa
- Pulmonary Hypertension: Diagnosed via right heart cath;
treated briefly with sildenafil though did not tolerate this
medication
- Heparin-induced thrombocytopenia (HIT)
- Angioectasias of the stomach and colon.
- SVC thrombosis
- Chronic pancreatitis, required common bile duct stenting and
sphincterotomy in [**2179**]
- Hypertension
- Epilepsy, last seizure [**2182**] (bilateral occipital infarct [**2177**])
- Secondary hyperparathyroidism
- Hyperlipidemia (HL)
- Anemia
- h/o small bowel obstruction
- h/o pericardial effusion
- h/o line associated RUE dvt (formerly on coumadin)
- h/o MRSA line infection
- h/o CVA [**2178**] - no residual weakness
Social History:
She lives with her husband and some of her children and
grandchildren. Prior to being medically disabled from
her illness she was a substance abuse counselor.
Denies Tobacco, EtOH and drug use.
Family History:
Father: renal failure at age 70.
Mother: hypertension and breast cancer.
Physical Exam:
General: Alert, oriented, no acute distress
[**Year (4 digits) 4459**]: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: RRR @100bpm, normal S1 + S2, 3/6 SEM at LLSB
Lungs: decreased breath sounds on right [**1-28**] way up, coarse
crackles at left base, no wheezes or rhonchi
Abdomen: soft, NT/ND, no HSM
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, fistula right upper extremity with thrill
Skin: vitiligo on lower extremities bilaterally
Neuro: 5/5 strength bilaterally, no sensory deficits, CN grossly
intact
Pertinent Results:
[**2187-10-31**] PORTABLE CXR:
In comparison with the study of [**10-30**], there are even lower lung
volumes. Extensive opacification is seen on the right in a
patient with continued enlargement of the cardiac silhouette and
pulmonary edema. Findings are consistent with layering pleural
effusion, though the possibility of developing superimposed
consolidation can certainly not be excluded in the appropriate
clinical setting.
.
[**2187-10-31**] ECHO:
The left atrium is normal in size. The estimated right atrial
pressure is at least 15 mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is dilated with moderate global free wall hypokinesis.
There is abnormal systolic septal motion/position consistent
with right ventricular pressure overload. The diameters of aorta
at the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. There is no aortic regurgitation. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. No mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a trivial pericardial effusion.
IMPRESSION: Dilated right ventricle with global hypokinesis.
Moderate to severe tricuspid regurgitation. Severe pulmonary
hypertension. Normal left ventricular regional and global
systolic function.
ADMISSION LABS
[**2187-10-30**] 07:40AM BLOOD WBC-11.1*# RBC-3.17* Hgb-9.3* Hct-31.8*
MCV-100* MCH-29.3 MCHC-29.2* RDW-17.0* Plt Ct-208
[**2187-10-30**] 12:04PM BLOOD PT-14.3* PTT-30.6 INR(PT)-1.2*
[**2187-10-30**] 07:40AM BLOOD Glucose-140* UreaN-47* Creat-9.9*# Na-133
K-9.7* Cl-98 HCO3-17* AnGap-28*
DISCHARGE LABS
[**2187-10-30**] 12:04PM BLOOD Calcium-8.5 Phos-3.4 Mg-2.8*
[**2187-11-1**] 06:45AM BLOOD WBC-4.1 RBC-3.33* Hgb-10.0* Hct-32.0*
MCV-96 MCH-30.0 MCHC-31.2 RDW-16.9* Plt Ct-168
[**2187-11-1**] 06:45AM BLOOD Neuts-61.4 Lymphs-23.9 Monos-7.9 Eos-6.2*
Baso-0.6
[**2187-11-1**] 06:45AM BLOOD Glucose-84 UreaN-41* Creat-8.2*# Na-141
K-4.9 Cl-96 HCO3-31 AnGap-19
[**2187-11-1**] 06:45AM BLOOD Calcium-9.0 Phos-4.8* Mg-3.0*
Brief Hospital Course:
52 yo F with severe systemic sarcoidosis, ESRD on HD, home O2
3.5L for sarcoid and pulmonary hypertension, presents with
shortness of breath.
# ACUTE on CHRONIC RESPIRATORY DISTRESS: Initially admitted with
hypoxia and dyspnea, related to pulmonary edema and pleural
effusions. She also had a 4kg weight gain up from 51kg dry
weight. Unclear what the etiology of the pulmonary edema is,
though it is possible this has been a chronic worsening
condition. She was admitted to the MICU with bipap and a nitro
drip, but nitro was quickly stopped. She underwent hemodialysis
with ultrafiltration and removal of 3+ liters. Her symptoms
resolved significantly and she was called out to the floor. On
the floor, she felt her dyspnea has improved to better than she
had been in weeks. She underwent dialysis again and then was
discharged home.
.
# FEVER: She spiked a fever to 101 in the MICU on admission. No
specific infectious source was identified. She was started on
vanc/ceftaz/azithro for coverage of a possible pneumonia, given
her fluid overloaded xray that could not rule out pna. She
remained afebrile with a normal WBC throughout her admission.
When her fluid had cleared, a repeat CXR showed no consolidation
or pneumonia. IV antibiotics were stopped. She was discharged
home with levaquin to complete a 7 day course. Blood cultures
showed no growth to date but were pending on discharge.
.
# HYPOTENSION: Hypotensive to the 80s while on dialysis. She had
received her anti-hypertensive medication the day prior, so this
was assumed to be in the setting of ultrafiltration with
lingering anti-hypertensives. The blood pressure normalized
without intervention.
.
# HYPOXIA: Overnight in the MICU she desaturated to the mid-80s
while on 4L NC. This was assumed to be due to sleep apnea. She
was started on facemask O2 and her sat improved to 100%.
.
# SYSTEMIC SARCOID: Possibly responsible for worsening of lung
symptoms. Continued prednisone 7.5mg daily. Consulted
pulmonology who recommended continuing steroids.
.
# ESRD on HD: Continued dialysis. Continued sevelamer,
hydroxyzine and nephrocaps. Returned to outpatient Saturday,
Monday, Weds schedule as an outpatient.
.
# SEIZURE DISORDER: Last seizure [**2182**]. Continued lamotrigine
.
# HYPERTENSION: Restarted losartan and nifedipine on discharge.
.
# HIT: History of heparin induced thrombocytopenia. Avoided
heparin products.
Medications on Admission:
EPOETIN ALFA [EPOGEN] - once weekly
FOLIC ACID - 1mg daily
HYDROXYZINE HCL - 25 mg [**Hospital1 **]
LAMOTRIGINE - 150 mg [**Hospital1 **]
LORAZEPAM - 0.5 mg daily PRN cramping
LOSARTAN [COZAAR] - 150 mg [**Hospital1 **]
NIFEDIPINE [NIFEDIAC CC] - 90 mg [**Hospital1 **]
PANTOPRAZOLE - 40 mg daily
PREDNISONE - 7.5 mg daily
SEVELAMER HCL [RENAGEL] - 2400 mg TID-QID
URSODIOL - 300 mg TID
DOCUSATE SODIUM [COLACE] - 100 mg daily
Discharge Medications:
1. epoetin alfa Injection
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. lamotrigine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for cramping.
6. losartan 100 mg Tablet Sig: 1.5 Tablets PO twice a day.
7. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO twice 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 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
11. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
12. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO once a
day.
13. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO after
dialysis sessions for 3 doses.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
PRIMARY
Systemic Sarcoid
SECONDARY
Pulmonary Hypertension
End stage renal disease on Hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
It was a pleasure caring for you at [**Hospital1 827**]. You were admitted with worsening shortness of
breath and found to have a fever and fluid in your lungs. We
removed some fluid with dialysis and gave you antibiotics.
Medication changes:
# START levaquin 500mg after dialysis sessions for three doses
to treat an infection
Followup Instructions:
Department: [**Hospital3 249**]
When: TUESDAY [**2187-11-6**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2187-11-21**] at 9:00 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2187-11-21**] at 9:30 AM
With: DR. [**Last Name (STitle) 91**] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"40391",
"4168"
] |
Admission Date: [**2177-8-21**] Discharge Date: [**2177-8-26**]
Date of Birth: [**2092-10-29**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
CHF exacerbation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84M with CAD s/p CABG/PCI (LIMA to LAD, SVG to OM1-OM2, SVG to
RCA), systolic and diastolic CHF s/p BiV-IVD (EF=40% in [**6-/2177**]),
ischemic CMP, VT s/p ablation, PAF who presents directly from
clinic for CHF exacerbation. Patient was recently admitted to
the CCU in [**6-/2177**] where he underwent successful VT ablation and
was also diuresed approximately 3 liters. His discharge weight
at that admission was 68.5 kg and dry weight according to prior
records is also approximately 68.5-69kg.
On [**2177-8-15**], he was referred for DCCV and had a TEE which was
negative for atrial thrombus. DCCV was unsuccessful at
restoring sinus rhythm after 300J and 360J external shocks as
well as 35J internal shock with brief return to NSR, but he
subsequently reverted back to Afib.
He reports that over the past 1-2 weeks, he has been feeling
more SOB and more tired. He has DOE after ambulating only a few
feet and reports that he has felt this way in the past when he
has had HF exacerbations. He denies any chest pain or
diaphoresis during this time. He states that he has been
compliant with all of his medications and denies any dietary
indescretions. No fevers or chills. His weight has increased a
few pounds from 152lbs at baseline to 155-156 over the past few
days. He has also been feeling dizzy for the past couple of
weeks and had a fall 3 days prior to admission. He struck his
right arm on the ground, denies head strike.
On arrival to the floor, patient reports ongoing fatigue and
some mild SOB at rest but denies any other complaints at this
time.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-Hypertension
-Dyslipidemia
-CABG: [**2157**] (LIMA-LAD, SVG-OM1-OM2, SVG-RCA)
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2165**] (SVG-RCA,
SVG-OM1-OM2), s/p PCI [**2167**] (Ultra stent to SVG-RCA)
-PACING/ICD: s/p BiV-pacer ([**Company 1543**] Concerto, originally
placed [**2167**], last gen change [**2173**])
- CHF (systolic and diastolic, [**12-26**] ischemic cardiomyopathy),
last LVEF 40% in [**6-/2177**]
- MR
- Atrial fibrillation, on coumadin
- slow VT s/p ablation [**6-/2177**]
- stage IV CKD
- Hypothyroidism
- BPH
- chronic anemia, receiving procrit through Dr.[**Name (NI) 109000**] office
- gout
- chronic low back pain
- migraine headaches
- colonic polyps
Social History:
Patient is a retired furniture businessman. He is married and
lives in [**Location 745**] with his wife. Two daughters (one deceased),
four grandchildren. Independent with ADLs, uses a cane at
baseline, minimal exercise tolerance.
# Tobacco: remote cigar use, no cigarettes
# Alcohol: none
# Illicit: none
Family History:
Mother had severe [**Name (NI) 59282**] leading to double amputations. Father
died of a MI at age 62.
Physical Exam:
Physical Exam on Admission:
VS: T=97.7 HR 70 (paced) BP 135/76 RR 14 SpO2 98%/RA
GENERAL: NAD, A&Ox3.
HEENT: NCAT. Sclera anicteric. Moist MM.
NECK: JVP difficult to assess.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. 2/6 systolic murmur heard best at the
LLSB.
LUNGS: Trace crackles at the bases bilaterally, otherwise CTAB
ABDOMEN: Soft, NTND.
EXTREMITIES: 3+ pitting edema to the knee bilaterally
SKIN: Multiple ecchymoses on arms and chest.
PULSES:
Right: DP 1+ PT 1+
Left: DP 1+ PT 1+
Exam at disccharge:
98.6, 126/57, 71, 18, 94% on RA
General: alert, mildly confused per wife but aware of place,
time and reason for hospitalization
HEENT: JVD 4 cm above clavicle
CHEST: CLear bilat
CV: RRR
Abd; obese, NT, BM this am.
Extremeties: no edema, mult ecchymotic areas
Pertinent Results:
Labs on Admission:
[**2177-8-21**] 01:50PM BLOOD WBC-4.3 RBC-2.71* Hgb-9.6* Hct-29.0*
MCV-107* MCH-
35.5* MCHC-33.2 RDW-16.5* Plt Ct-110*
[**2177-8-21**] 01:50PM BLOOD PT-30.1* INR(PT)-2.9*
[**2177-8-21**] 01:50PM BLOOD UreaN-87* Creat-3.6* Na-135 K-4.7 Cl-93*
HCO3-31 AnGap-16
[**2177-8-21**] 01:50PM BLOOD ALT-10 AST-34 CK(CPK)-152 AlkPhos-91
TotBili-0.6
[**2177-8-21**] 08:09PM BLOOD CK(CPK)-38*
[**2177-8-21**] 01:50PM BLOOD CK-MB-4 cTropnT-0.08*
[**2177-8-21**] 08:09PM BLOOD CK-MB-4 cTropnT-0.06*
[**2177-8-21**] 01:50PM BLOOD Albumin-4.4 Calcium-8.8 Phos-4.8* Mg-2.4
[**2177-8-21**] 01:50PM BLOOD Osmolal-310
[**2177-8-21**] 01:50PM BLOOD TSH-1.6
Imaging:
[**2177-8-25**] CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant change in extent of the pre-existing right pleural
effusion. Unchanged are the areas of basal atelectasis on both
the right side and in the retrocardiac lung areas. Unchanged
appearance of the cardiac silhouette and the pacemaker devices.
Unchanged alignment of the sternal wires.
[**2177-8-22**] ECHO
The left ventricular cavity size is normal. Overall left
ventricular systolic function is moderately depressed (LVEF = 35
%) secondary to severe hypokinesis/akinesis of the inferior and
posterior walls. The right ventricular free wall thickness is
normal. The right ventricular cavity is moderately dilated with
severe global free wall hypokinesis. There is moderate-to-severe
aortic valve stenosis (valve area 1.0 cm2) (possibly with
low-flow/low-gradient physiology). The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. [Due to acoustic shadowing, the
severity of tricuspid regurgitation may be significantly
UNDERestimated.] There is no pericardial effusion.
[**2177-8-21**]
IMPRESSION:
1. New right middle lobe collapse.
2. Stable right pleural effusion.
Discharge:
[**2177-8-26**] 06:20AM BLOOD WBC-6.3# RBC-2.86* Hgb-10.0* Hct-31.1*
MCV-109* MCH-35.1* MCHC-32.3 RDW-16.8* Plt Ct-155
[**2177-8-26**] 06:20AM BLOOD PT-14.5* PTT-36.2 INR(PT)-1.4*
[**2177-8-26**] 06:20AM BLOOD Glucose-94 UreaN-79* Creat-3.1* Na-143
K-3.9 Cl-97 HCO3-35* AnGap-15
Brief Hospital Course:
84M with CAD s/p CABG/PCI (LIMA to LAD, SVG to OM1-OM2, SVG to
RCA), systolic and diastolic CHF s/p BiV-IVD (EF=40% in [**6-/2177**]),
ischemic CMP, VT s/p ablation, PAF on warfarin who presents with
fatigue and DOE with evidence of volume overload and acute on
chronic systolic/diastolic heart failure.
Acute Issues:
# Acute on chronic systolic and diastolic heart failure
(EF=40%): Pt presented with dypsnea, especially with movement
was a major complaint. Etiology for CHF exacerbation was
unclear; no evidence of ischemia, non-compliance, dietary
indiscretions or infection. [**Month (only) 116**] be due to the fact that he was
in atrial fibrillation with loss of atrial kick. Recent
cardioversion was unsuccessful. On admission appeared mildly
volume overloaded with peripheral edema > pulmonary edema on
exam. Cardiac enzymes were trended with CK and CKMB flat and
minimal elevation of troponin to 0.08 in setting of acute on
chronic kidney disease. CXR showed new right middle lobe
collapse and stable pleural effusions without frank pulmonary
edema. The patient was 4 lbs above his dry weight. An 80 mg IV
lasix bolous was given and then patient started on 10mg/hr gtt.
Metolazone was also utilized to augment diuresis, and carvedilol
was continued. Patient was not on ACEi/[**Last Name (un) **] [**12-26**] poor renal
function. The patient was placed on 2g sodium diet, 1.5 L fluid
restriction, daily weights, and strict I/Os. Pt did well with
aggressive diuresis while the team closely followed electrolytes
and was weaned down on oxygen. Lasix gtt was discontinued on
[**8-22**] as Cr bumped and chemistries suggestive of contraction
alkalosis. Milrinone drip used temporarily to assess if dyspnea
and Cr would improve with increased contractility. As little
change was noted, milrinone was discontinued.
Given respiratory status improved with diuresis, the stable R
pleural effusion was not pursued. In addition, pt also underwent
incentive spirometry for the atelectasis which could be
visualized on radiographs. Pt was discharged on digoxin,
amiodarone, carvedilol and torsemide at home doses.
# Acute on chronic kidney disease: Recent baseline Cr is ~2.5,
over the past 1-2 weeks has been increasing to 3.0 and is 3.6 at
admission to the CCU. He appears volume overloaded on exam but
likely has decreased ECV with decreased renal perfusion.
Cautious diuresis as above. Home spironolactone was held. Urine
lytes were obtained that showed FeNa >2%, however hard to
analyze in setting of diuretics. FeUrea slightly > 35% and urine
osmos of 330 making ATN possible. Cr was trended and patient was
discharged with a Cr of 3.1.
Chronic Issues:
# CAD s/p CABG and PCI: No chest pain or diaphoresis, although
he does have worsening SOB and DOE which may represent angina
but seems less likely. ASA 81mg daily and carvedilol continued.
# Afib: Currently appears to be in Afib at admission with no
clear P waves on ECG. Also had recent ablation for VT.
Currently he is primarily V-paced with intermittent A-V pacing.
Rate well controlled. Home mexilitine 150mg daily, warfarin for
goal INR [**12-27**], and Coreg were continued. Warfarin as temporarily
held as thoracentesis of R pleural effusion was considered.
Given pt was saturating well on RA, it was decided not to pursue
tapping pleural effusion, and warfarin was restarted [**2177-8-25**],
the day before discharge. INR on discharge was subtherapeutic at
1.4.
# Anemia: Hct at baseline, he is on Procrit as an outpatient.
Procrit was continued. Hct was trended upwards after
administering Procrit and pt was discharged with Hct of 31.
# Hypothyroidism: Continued levothyroxine 100mcg PO daily.
Transitional Issues:
-WEIGHT AT DISCHARGE: 66.8kg (147lbs)
-consider Isordil and hydralazine for afterload reduction
-Pt is to f/u with cardiology
-Pt is to f/u with heme/onc
-Pt is to f/u with PCP after [**Name Initial (PRE) **]/c from ECF
-Pt expected length of rehab stay of < 30 days
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Allopurinol 100 mg PO DAILY
2. Amiodarone 400 mg PO DAILY
3. Calcitriol 0.25 mcg PO 2X/WEEK (WE,SA)
4. Carvedilol 12.5 mg PO BID
hold for SBP<100
5. Digoxin 0.0625 mg PO EVERY OTHER DAY
6. Finasteride 5 mg PO DAILY
7. fluticasone *NF* 220 mcg Inhalation [**Hospital1 **]
8. FoLIC Acid 1 mg PO DAILY
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Metolazone 2.5 mg PO 2X/WEEK (WE,SA)
11. Mexiletine 150 mg PO Q12H
12. Mirtazapine 7.5 mg PO HS
13. Spironolactone 12.5 mg PO DAILY
14. Torsemide 30 mg PO DAILY
15. Warfarin 2 mg PO DAILY16
16. Aspirin 81 mg PO DAILY
17. Caltrate 600+D Plus Minerals *NF* (calcium carbonate-vit
D3-min) 600 mg (1,500 mg)-400 unit Oral daily
18. Cyanocobalamin 1000 mcg PO DAILY
19. Docusate Sodium 100 mg PO BID
20. Fish Oil (Omega 3) 1200 mg PO BID
21. Pyridoxine 100 mg PO DAILY
22. Vitamin E 100 UNIT PO DAILY
Discharge Medications:
1. Allopurinol 100 mg PO DAILY
2. Amiodarone 400 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO 2X/WEEK (WE,SA)
5. Carvedilol 12.5 mg PO BID
hold for SBP<100
6. Cyanocobalamin 1000 mcg PO DAILY
7. Digoxin 0.0625 mg PO EVERY OTHER DAY
8. Docusate Sodium 100 mg PO BID
9. Finasteride 5 mg PO DAILY
10. Fish Oil (Omega 3) 1200 mg PO BID
11. FoLIC Acid 1 mg PO DAILY
12. Levothyroxine Sodium 100 mcg PO DAILY
13. Mirtazapine 7.5 mg PO HS
14. Pyridoxine 100 mg PO DAILY
15. Torsemide 30 mg PO DAILY
16. Vitamin E 100 UNIT PO DAILY
17. Warfarin 2 mg PO DAILY16
18. Caltrate 600+D Plus Minerals *NF* (calcium carbonate-vit
D3-min) 600 mg (1,500 mg)-400 unit Oral daily
19. fluticasone *NF* 220 mcg Inhalation [**Hospital1 **]
20. Atorvastatin 20 mg PO DAILY
21. Epoetin Alfa 3000 UNIT SC QTUTHSA (TU,TH,SA)
please give first dose today, and give qSat, [**Hospital1 **], Thurs
22. Mexiletine 150 mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
stone instutute
Discharge Diagnosis:
Acute on Chronic systolic Congestive heart failure
Acute on Chronic Kidney Injury
Right pleural effusion
Coronary artery disease
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had an acute exacerbation of your congestive heart failure.
It is unclear what the cause of this is. You were admitted to
the CCU and given intravenous diuretics to remove the extra
fluid. Your weight at dicharge is 147 lbs. You also had an
effusion, an accumulation of fluid around your right lung. After
close monitoring, the decision was made to continue to monitor
it over time. Your kidney function worsened but is now almost
back to your normal level.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 1911**] if weight
goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
reschedule Papageourgiou
.
Department: CARDIAC SERVICES
When: THURSDAY [**2177-9-4**] at 1 PM
With: [**Name6 (MD) 1918**] [**Name8 (MD) **], 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: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2177-9-16**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2178-1-13**] at 1:15 PM
With: CHECKIN HEM ONC CC9 [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2177-8-26**]
|
[
"5849",
"5119",
"42731",
"2449",
"2724",
"40390",
"4280",
"V4581",
"V5861",
"2859"
] |
Admission Date: [**2183-12-24**] Discharge Date: [**2183-12-30**]
Date of Birth: [**2118-9-17**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Percocet
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Pericardial effusion and PE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 year old female with chief complaint of "abdominal
discomfort" X1 month. She does not characterize it as pain but
she has this ongoing diffuse discomfort from her breastbone all
the way down to her suprapubis. She describes it as being worse
during the evening when she is lying down. In fact, it was so
bad the night before last, she had to get up several times and
was unable to sleep. She also describes persistent cough
associated with shortness of breath, which is markedly worse
recently. She denies chest pain, arm pain or jaw pain. She notes
that she is quite uncomfortable and fatigued.
.
She presented to [**Company 191**] and was sent via ambulance to the ED for
further evaluation with concern for CHF.
.
ED Course: Initial VS-99.4 HR91 BP 170/93 20 99%RA. CT scan
done, notable for Subsegmental PE and moderate pericardial
effusion. No pulsus documented, ?done, No note by Cards-did not
see pt in ED. Pt was HD stable throughout ED course, in fact
hypertensive w/o any cardiac meds given. Started Hep gtt sent to
MICU for unclear reason as no tamponade physiology.
.
MICU course (< 24 hrs): In the MICU, she was HD stable. She
was continued on heparin gtt and had a TTE which showed a
loculated pericardial effusion but no tamponade physiology. She
was also give IVF and lasix for hypercalcemia.
.
Upon arrival to the floor, she states that her abdominal
discomfort has gotten significantly better. She has no dyspnea
when resting but does have dyspnea when walking (this has been
getting worse over the past month). + "dark stools" X 1 wk.
She states she has had a colonoscopy about 2 yrs ago but no
doccumentation in OMR. She has had a dry cough X 1 month. No
LE swelling. No long trips. Does live a fairly sedentary
lifestyle. She does endorse neck weakness and shoulder and neck
pain (chronic).
Past Medical History:
Past Medical History:
- Poorly-controlled hypertension
- Inclusion body myositis (?)
- Chronic hypercalcemia and hyperparathyroidism that has not
been fully worked up because the patient has not returned to
endocrine
- Osteoporosis.
- Hypercholesterolemia (defered tx until this point)
- Cardiomyopathy with inferior wall hypokinesis by echo in
[**3-/2180**] and possible old myocardial infarction. (Followed by
[**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**]); [**8-/2183**] EF 45%-->slightly larger area of systolic
dysfunction in the area of presumed prior infarction c/w
possible peri-infarct ischemia
- H/o pulmonary edema on CXR
- Dermatofibromas and blanching papules on the face.
- Left femoral artery thrombosis status post bypass surgery
with Dr. [**Last Name (STitle) 1476**] ([**2168**])
- History of seizure x1, unknown etiology.
- Carpal tunnel syndrome (no longer a problem)
- Gastroesophageal reflux
- Moderate to severe restrictive lung disease with possible
neuromuscular origin
- Parathyroid hyperplasia
- Broken ankle (R)
- Glaucoma
.
Past Surgical History:
1. Total abdominal hysterectomy-s/p TAH/BSO due to fibroids
2. Peripheral vascular disease, status post L fem art bypass
Social History:
-Lives alone in [**Location (un) 2268**]. Walks without a walker.
-Denies any TOB or ETOH use ever. No other drug use
Family History:
Mother had [**Name2 (NI) **]. Father died at 99 and did not have any
particular medical problems. She has one son (39 y.o.) who had
lower back pain.
Physical Exam:
VS:96.8 185/100 97 32 100%3LNC
GEN: Pleasant woman, speaking in full sentences w/some SOB,
comfortable
HEENT: PERRL, EOMI, OP clear, no exudates
RESP/chest: CTABL, minimal crackles at R base, no wheezing,
large keloid scar at sternum ~8cm
CV: Displaced PMI, Irregular, Nml S1,S2, no M/R/G, elevated JVP
8cm
ABD: soft ND/NT, +BS, no rebound/guarding
EXT: No C/C/E, warm 2+DP pulses B/L
NEURO: A&Ox3, CNII-XII intact
Pertinent Results:
[**2183-12-24**] 03:15PM PLT COUNT-311
[**2183-12-24**] 03:15PM NEUTS-68.4 LYMPHS-21.9 MONOS-6.0 EOS-1.7
BASOS-2.0
[**2183-12-24**] 03:15PM WBC-8.8 RBC-4.84 HGB-14.7 HCT-44.6 MCV-92
MCH-30.4 MCHC-33.0 RDW-13.6
[**2183-12-24**] 03:15PM CALCIUM-11.0*
[**2183-12-24**] 03:15PM CK-MB-3 cTropnT-<0.01
[**2183-12-24**] 03:15PM LIPASE-25
[**2183-12-24**] 03:15PM ALT(SGPT)-39 AST(SGOT)-50* CK(CPK)-108 ALK
PHOS-81 AMYLASE-68 TOT BILI-0.8
[**2183-12-24**] 03:15PM estGFR-Using this
[**2183-12-24**] 03:15PM GLUCOSE-97 UREA N-13 CREAT-0.8 SODIUM-141
POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-24 ANION GAP-15
[**2183-12-24**] 04:25PM URINE RBC-0 WBC-[**3-16**] BACTERIA-MANY YEAST-NONE
EPI-0
[**2183-12-24**] 04:25PM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2183-12-24**] 04:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2183-12-24**] 04:25PM URINE UHOLD-HOLD
[**2183-12-24**] 04:25PM URINE HOURS-RANDOM
[**2183-12-24**] 08:45PM CK-MB-NotDone
[**2183-12-24**] 08:45PM cTropnT-0.01
[**2183-12-24**] 08:45PM CK(CPK)-51
[**2183-12-24**] 08:52PM K+-3.7
.
EKG: NSR w/PACs and PVCs, borderline LVH, TWI and q-waves in
I,aVL-Old
.
IMAGING:
CTA
IMPRESSION:
1. Cardiomegaly with moderate pericardial effusion and
interstitial edema.
2. At least two small subsegmental pulmonary embolism in the
left lower lobe. No aortic dissection.
3. Diffuse patchy opacities at the lung bases with prominent air
trapping. These findings can be seen inpatient with asthma/small
airway disease. However, the findings are nonspecific. Clinical
correlation is recommended.
4. Left adrenal nodule of indeterminate appearance. MRI can be
performed for further evaluation.
.
PELVIC CT:
The patient returned for imgaing of the pelvis which revealed no
acute abnormality.
.
[**12-25**] ECHO
Conclusions:
The left atrium is elongated. The right atrium is moderately
dilated. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. No masses or thrombi are seen
in the left ventricle. Overall left ventricular systolic
function is moderately-to-severely depressed (ejection fraction
30 percent) secondarty to severe hypokinesis of the inferior
septum, inferior free wall, and posterior wall. The right
ventricular cavity is dilated. Right ventricular systolic
function appears depressed. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a small
to moderate sized pericardial effusion. The effusion appears
loculated. There are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of [**2183-8-19**], the left ventricular ejection fraction is
further reduced.
.
Labs on discharge:
[**2183-12-29**] 09:10AM BLOOD WBC-7.7 RBC-4.46 Hgb-13.6 Hct-40.1 MCV-90
MCH-30.4 MCHC-33.8 RDW-13.8 Plt Ct-328
[**2183-12-29**] 09:10AM BLOOD PT-14.5* PTT-82.9* INR(PT)-1.3*
[**2183-12-29**] 09:10AM BLOOD Glucose-107* UreaN-22* Creat-0.8 Na-142
K-4.2 Cl-106 HCO3-26 AnGap-14
[**2183-12-29**] 09:10AM BLOOD ALT-47* AST-37 AlkPhos-83 TotBili-0.5
[**2183-12-29**] 09:10AM BLOOD Albumin-4.4 Calcium-11.5* Phos-2.9 Mg-2.2
[**2183-12-26**] 05:20AM BLOOD PTH-169*
Brief Hospital Course:
AP: 65 yo F w/MMP admitted for PE. Hospital course on the floor
complicated by:
.
#. PE: Considered to be idiopathic as no cause identified. Has
a history of femoral artery thrombosis but this was likely [**2-13**]
femoral artery stenosis and PE should be from venous thrombosis.
Also concerning for possible underlying malignancy or other
hypercoaguable state. She has no know history of malignancy.
[**2181**] mammogram negative. Per pt. negative colonoscopy 2 years
ago. She had TAH/BSO for fibroids. CT torso not concerning for
a malignancy, except for possible adrenal adenoma but no
abdominal adenopathy. She was maintained on heparing drip but
was transitioned to Fondaparinox - warfarin cross-over and sent
home with a VNA for injections until warfarin is therapeutic.
Dr. [**Last Name (STitle) **] will follow her INR until [**Hospital **] clinic picks her
up. Respiratory status was stable throughout hospital course
and was discharged with ambulatory sats in the 90s off oxygen.
We gave her the number for Dr. [**Last Name (STitle) 3060**] to further evaluate her as
an outpatient re the etiology of this PE.
.
#. Pericardial effusion: On ECHO, effusion initially appeared
locculated but cardiology revieved the ECHO and decided that it
had not increased in size and that that actually it did not
appear loculated and there was no indication for a
pericardiocentesis. No tamponade physiology. Pt [**Name (NI) **] w/negative
CE x3, no ischemic changes on EKG, pulsus 6. EF on
re-evaluation was considered to be 40%.
.
#. CHF: EF was initially thought to have decreased to 30 % on
TTE in MICU but up on re-evaluation, it was throught to be 40%.
[**8-17**] ECHO estimated EF at 45%. Likely systolic and diastolic
dysfunction. Was volume up upon transfer from MICU, after
receiving fluids for hypercalcemia but was euvolemic off lasix
on discharge after only one dose of furosemide 20 mg IV.
.
#. HTN: Pt w/apparent history of poorly controlled HTN, but no
cardiac meds given in ED. Pt hypertensive upon arrival to MICU.
BP well-controlled on the medical floor with metoprolol 25 mg po
tid. We added lisinopril 2.5 mg po daily due to her history of
CAD and decreased her dose of metoprolol XL to 50 mg po daily.
.
#. Hypercalcemia: Pt w/known hyperparathyroidism and
hypercalcemia. Pt non-compliant w/f/u appointments w/Endocrine.
Thyroid U/S showed parathyroid hyperplasia and per endocrine
note will likely need surgery. An appointment was made for her
to follow-up in endocrine clinic as an outpatient. No
indication for pamidronate. She was advised to keep
well-hydrated. PTH was still elevated on repeat value.
.
#. Hyperlipidemia: Pt states she would be willing to start a
medication to lower her cholesterol. I explained that based on
her ECHO and ECG she very likely has had "silent" heart attacks.
She was sent out on atorvastatin but this was switched to
mevacor due to insurance coverage.
.
#. Guiac + stool: Hct stable. Will need a colonoscopy as an
outpatient.
.
#. Left adrenal nodule: Seen on CT abdomen. Should have an MRI
as an outpatient to further evaluate.
.
#. Osteoporosis: Should be on a bisphosphonate. Recommend
starting as an outpatient.
.
#. FEN: Cardiac diet, dietary counselling was given.
.
#. PPX: Hep gtt, PPI (Guiac +, h/o GERD, did not continue as
outpatient as she is averse to taking too many medications.)
.
#. CODE: Full
.
#. DISPO: to home with VNA for injections and close outpatient
f/u to titrate warfarin
.
Medications on Admission:
-ASA 325 mg daily
-Toprol XL 75 mg daily
-MVI
Discharge Medications:
1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
3. Fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
once a day: until INR [**2-14**], overlap with warfarin X 5 days.
[**Month/Day (3) **]:*14 syringes* Refills:*0*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Month/Day (3) **]:*30 Tablet(s)* Refills:*2*
5. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: per
your physician.
[**Name Initial (NameIs) **]:*150 Tablet(s)* Refills:*2*
6. Outpatient Lab Work
INR on [**2184-1-1**].
Please fax to Dr. [**Last Name (STitle) **]. Fax ([**Telephone/Fax (1) 9190**].
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
[**Telephone/Fax (1) **]:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
[**Telephone/Fax (1) **]:*15 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Unprovoked Pulmonary Embolism.
2. Primary Hyperparathyroidism.
3. Asymptomatic Hypercalcemia.
4. Left Heart Failure.
5. Blood Loss Anemia.
6. Occult Blood Positive Stool.
Secondary:
1. Inclusion Body Myositis (dx not definitive).
2. Scleroderma with Raynaud's, telangiectasia, myalgia.
3. CAD Native Vessel - Positive Stress ECHO [**2183**]
4. LVSD EF ~ 30% with WMA: inferior septum, wall, and posterior
wall.
5. PVD s/p Left femoral thrombosis and BPG.
6. Hypertension.
7. Hyperlipidemia.
8. Mild restrictive ventilatory defect.
9. S/P TAH-BSO for benign mass (per patient)
10. Glaucoma.
11. GERD.
12. Osteoporosis.
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
Please take all medications as instructed. There were several
changes made to your current medications regimen.
If you experience any fever, nausea, vomiting, lightheadedness,
chest pain, shortness of breath, or any other concerning
symptoms please seek medical attention immediately.
Followup Instructions:
Please go to the [**Hospital 191**] clinic on Thursday morning to the
laboratory to have your blood checked for INR (bring the
prescription for lab work with you). Dr. [**Last Name (STitle) **] will follow up
this laboratory result and will notify you on how to adjust your
dose of Warfarin.
.
Please make an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3060**] to evaluate
you for a coagulation problem. [**Name (NI) **] ([**Telephone/Fax (1) 74300**].
.
Dr. [**Last Name (STitle) **] will likely tell you to schedule a colonoscopy as you
were found to have blood in your stool as an inpatient.
.
The following appointments have already been made for you:
Provider: (Primary care doctor, filling in for Dr. [**First Name (STitle) **]
[**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2184-1-2**] 9:00
Provider: [**First Name8 (NamePattern2) 6118**] [**Last Name (NamePattern1) 6119**], RN,MS,[**MD Number(3) 1240**]:[**Telephone/Fax (1) 1971**]
Date/Time:[**2184-1-20**] 9:45
Provider: (Cardiology) [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2184-2-16**] 1:00
Provider: (Endocrinology for your enlarged parathyroid glands
and high calcium) Dr. [**Last Name (STitle) **], MD Phone: [**Telephone/Fax (1) 9941**] Date/Time:
[**2184-2-27**] 10:00.
|
[
"4280",
"4019",
"2720",
"53081"
] |
Admission Date: [**2176-2-14**] Discharge Date: [**2176-2-25**]
Date of Birth: [**2114-4-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Levaquin
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Esophageal adenocarcinoma, Left lung NSCLC
Major Surgical or Invasive Procedure:
[**2176-2-14**]: 1. Left thoracotomy and left lower lobectomy plus
lingulectomy.
2. Intercostal muscle flap buttress.
3. Laparotomy and partial esophagectomy with
esophagogastric anastomosis in the left chest.
4. Tube jejunostomy.
History of Present Illness:
Ms. [**Known lastname 16919**] is a 61-year-old woman with 1 year history of
recurrent URI-type symptoms. Most recently in the past [**1-24**]
weeks
she has had cough, occasionally productive of yellow sputum. A
chest x-ray ordered by her PCP demonstrated [**Name Initial (PRE) **] suspicious
spiculated LLL lung nodule, and CT scan revealed a 5.2-cm
juxtahilar superior segment spiculated mass and left hilar lymph
node enlargement, as well as esophageal thickening consistent
with primary esophageal neoplasm.
Subsequently, she underwent PET scan which revealed a dominant
FDG-avid left hilar mass, SUVmax 13.6, centered in the superior
segment of the left lower lobe, compatible with bronchogenic
carcinoma, as well as low-level FDG-avid nodules at the base of
the left upper lobe and in the right lower lobe and FDG avidity
in and around the distal esophagus with a thickened wall.
Biopsy obtained on EUS revealed adenocarcinoma, positive
staining
of the tumor cells with CDX2, variable staining of the tumor
cells with cytokeratin 7 and few scattered tumor cells staining
with cytokeratin 20, with tumor cells nonreactive with TTF-1.
These finding support a gastrointestinal origin.
Biopsy obtained on EBUS revealed NSCLC, positive staining of the
tumor cells with cytokeratin 7 and TTF-1, few scattered cells
show positive staining with p63, with tumor cells non-reactive
with CK20 and CDX2. These findings support a pulmonary origin.
Past Medical History:
1) hx bilateral breast CA
- s/p L mastectomy and chemo (CMF) [**2153**] for stage II breast
CA, ER/PR positive
- s/p R mastectomy [**2157**] for stage I breast CA, no adj rx
- s/p bilateral breast reconstruction
2) Squamous cell skin CA excised R thigh [**8-28**], invasive,
well-differentiated, at least 3 mm deep, extended to peripheral
and deep specimen margins. Re-excised [**2174-11-28**] - no residual
squamous cell CA.
3) ?? asthmatic bronchitis, allergic rhinitis
4) Hyperlipidemia:
5) Bilateral [**Hospital1 15309**] neuroma
6) Colonoscopy [**3-26**] - diverticulosis
Social History:
Lives with husband
40 pack-year smoker, quit 2 weeks ago upon
learning diagnosis, using chantix. 2 glasses wine / week.
Family History:
Mother - no cancer or heart disease
Father - MI at 88
Physical Exam:
VS: T: 97.3 HR: 90's SR BP: 118/64 Sats: 97% RA
General: 61 year-old female no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR
Resp: diminished breath sounds on left otherwise clear
GI: bowel sounds positive.
Extr: warm no edema
Incision: Left thoracotomy clean, dry, intact, abdominal clean,
dry intact
J-tube site clean. no discharge
Neuro: non-focal
Pertinent Results:
[**2176-2-22**] WBC-9.9 RBC-3.14* Hgb-9.7* Hct-29.1* Plt Ct-348
[**2176-2-20**] WBC-8.1 RBC-3.09* Hgb-9.6* Hct-28.6* Plt Ct-304
[**2176-2-17**] WBC-13.6* RBC-3.21* Hgb-10.0* Hct-29.7* Plt Ct-301
[**2176-2-16**] WBC-12.1*# RBC-3.36* Hgb-10.5* Hct-31.1* Plt Ct-269
[**2176-2-14**] WBC-8.5 RBC-3.21*# Hgb-10.5*# Hct-29.7*# Plt Ct-260
[**2176-2-23**] Glucose-121* UreaN-17 Creat-0.7 Na-141 K-4.2 Cl-107
HCO3-25
[**2176-2-22**] Glucose-126* UreaN-18 Creat-0.7 Na-138 K-4.2 Cl-104
HCO3-24
[**2176-2-20**] Glucose-107* UreaN-16 Creat-0.6 Na-144 K-3.6 Cl-109*
HCO3-28
[**2176-2-19**] Glucose-139* UreaN-16 Creat-0.6 Na-148* K-4.2 Cl-114*
HCO3-28
[**2176-2-15**] Glucose-148* UreaN-19 Creat-0.8 Na-139 K-4.9 Cl-111*
HCO3-23 [**2176-2-14**] Glucose-174* UreaN-17 Creat-0.8 Na-138 K-4.7
Cl-110* HCO3-23
[**2176-2-20**] CK(CPK)-285*
[**2176-2-23**] Calcium-8.7 Phos-3.7 Mg-2.2
CXR:
[**2176-2-23**] FINDINGS: In comparison with the study of [**2-19**], the
chest tubes have been removed and there is no evidence of
pneumothorax. The opacification at the left base is somewhat
less prominent than on the previous images. The right lung is
essentially clear.
[**2176-2-19**] There is residual left upper lobe atelectasis and
interval improvement in the right basilar atelectasis.
[**2176-2-18**] Elevation of the left hemidiaphragm reflecting left
lung resection is stable since [**2-15**]. Leftward mediastinal
shift has improved. There is a combination of atelectasis at the
base of the post-operative left lung and the gastric pull-up
which probably is responsible for most of the opacification at
the medial aspect of the left lower lung. Mild atelectasis in
the right lung is new. Upper lungs are clear. No pneumothorax.
Cardiomediastinal silhouette, normal post-operative appearance.
Left jugular line in standard placement. A drainage tube pull up
above the diaphragm. Left pleural tubes still present at the
base and upper midline left hemithorax.
Esophagus: [**2176-2-21**] Status post esophagectomy with gastric
pull-through, without evidence of a leak.
Echo: TEE [**2176-2-14**] Surgeons performed egd prior to TEE to ensure
saftey of probe placement. No atrial septal defect is seen by 2D
or color Doppler. Left ventricular wall thicknesses and cavity
size are normal. The right ventricular free wall is mildly
hypertrophied. The right ventricular cavity is mildly dilated
with borderline normal free wall function. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. There is no aortic valve
stenosis. The mitral valve appears structurally normal with
trivial mitral regurgitation. RV function unchanged after lung
resection. TEE probe removed after lung resection prior to
esophageal surgery. EGD was perfomed after TEE. No complications
or injuries noted
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted on [**2176-2-14**] for Left thoracotomy and
left lower lobectomy plus lingulectomy. Intercostal muscle flap
buttress. Laparotomy and partial esophagectomy with
esophagogastric anastomosis in the left chest. Tube jejunostomy.
She was Extubated in OR. Overnight she did well.
[**2-15**]: AM hypotension not responsive to 1L fluids (crystalloid +
albumin), levophed started. 1 unit PRBC transfused for Hct 27 w/
appropriate response. Weaned off levophed over 20 hours, with
stable Hct.
[**2-17**]: She had rapid atrial fibrillation to the 170's. She
converted to NSR, with a dilt drip converted to po dilt. CTs to
waterseal, trophic TFs started, epidural out
[**2-18**]: rate controlled on PO dilt. NGT D/C'd. Hypernatremic - TFs
changed to 1/2 strength, D5W started. Her hypernatremia
resolved. The tube feeds were converted to full strength. Her
esophagus study on [**2176-2-21**] revealed no leak. She was started
on a clear liquid diet and advanced to full as tolerated. The
anterior apical chest tube was removed on [**2176-2-23**]. Her pain
was well controlled with Roxicet and motrin. She was followed
by physical therapy throughout her hospital course. Nutrition
recommended Replete with fiber goal 60/hr. She continued to do
well and was discharged to home. She will follow-up with Dr.
[**Last Name (STitle) **] as an outpatient.
Medications on Admission:
Chantix, zocor, codiene
Discharge Medications:
1. Replete with Fiber
3/4 Strength: Goal 90cc/hr [**Month (only) 116**] cycle tube feeds
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month (only) **]: [**11-24**]
Drops Ophthalmic PRN (as needed).
3. Sodium Chloride 0.65 % Aerosol, Spray [**Month/Day (2) **]: [**11-24**] Sprays Nasal
QID (4 times a day) as needed.
4. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Month/Day (2) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*400 ML(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
7. Diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*2*
8. Gabapentin 250 mg/5 mL Solution [**Last Name (STitle) **]: Two (2) mL PO Q8H (every
8 hours).
Disp:*180 mL* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Allcare VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Esophageal Cancer
Lung Cancer
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience:
-Fever > 101, chills, redness or drainage around wound site
-Go directly to the ED if you experience any of the following;
chest pain, acute shortness of breath, intractable
nausea/vomiting, severe pain not relieved by medication, or any
other concerning symptoms.
Take all new medications as prescribed, you may resume all
previous medications unless otherwise directed. Adhere strictly
to the diet as directed. You may cover the chest tube drainage
site with a band-aid.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**3-8**] at 2:30 on the [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 24**].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-ray
Completed by:[**2176-2-27**]
|
[
"2760",
"42731"
] |
Admission Date: [**2112-2-11**] Discharge Date: [**2112-3-15**]
Date of Birth: [**2063-4-12**] Sex:
Service:
ADMISSION DIAGNOSES:
1. Abdominal pain of unknown origin.
2. Human immunodeficiency virus.
3. Hepatitis C.
4. Thrombocytopenia.
5. Anemia.
6. Renal insufficiency.
DISCHARGE DIAGNOSES:
1. Methicillin-resistant Staphylococcus aureus and vancomycin-
resistant enterococcus septicemia.
2. Anemia.
3. Thrombocytopenia.
4. Human immunodeficiency virus disease.
5. Hepatitis C.
6. Renal insufficiency.
ADMITTING HISTORY AND PHYSICAL: Please note, this History
and Physical is as per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3315**] (pager #[**Numeric Identifier 108451**]).
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: A 48-year-old male with HIV, a
CD4 count of 600 in [**2111-10-19**], with a history of
thrombocytopenia who complains of abdominal pain x 4 to 5
months which has worsened in the last several days. He had
previously been worked up at an outside hospital but felt
unsatisfied with his treatment. He does have associated
nausea, and vomiting, and diarrhea. He admits to a weight
loss of 10 to 15 pounds over the previous week. Also admits
to fevers and chills and complains of a rash over his trunk
and leg with positive pruritus, headaches, nose bleeds, and
gingival bleeding that he has noticed.
PAST MEDICAL HISTORY: Significant for HIV disease x 14 years
(for which he has stopped antiretroviral therapy),
thrombocytopenia, hepatitis C, question cirrhosis.
MEDICATIONS AT HOME: Include Protonix, oxycodone, 3
antiretroviral's that he discontinued 2 months ago, and
Ultram.
ALLERGIES: The patient has no known drug allergies.
FAMILY HISTORY: Significant for diabetes and CHF in his
mother. His father died of unknown causes.
SOCIAL HISTORY: He lives with his mother in [**Name (NI) 669**]. He
denies any alcohol, smoking, or drug use. He has been clean
for 2 years. Previously he has used cocaine and heroin IV,
and he is currently sexually active with women.
REVIEW OF SYSTEMS: As per HPI.
PHYSICAL EXAMINATION: Temperature of 100.6, pulse of 103,
blood pressure of 123/76, respiratory rate of 20, pulse
oximetry of 97% on room air. Generally, a chronically ill
male. Appears in no acute distress. HEENT with question of
macroglossia. Mucous membranes are dry. Extraocular movements
intact, and PERRLA intact. Neck is supple with no
lymphadenopathy. Cardiovascular with a regular rate and
rhythm, slightly tachy, [**12-24**] blowing murmur heard. Abdominal
exam with generalized tenderness noted in the superior
portion of the abdomen. Dull to percussion, but no shifting
dullness, and no masses appreciated. Rectal exam is guaiac
negative, as per the emergency department resident, no masses
noted. Extremities with 1 to 2+ pitting edema to the knee.
Neuro exam reveals alert and oriented x 3. A vague and poor
historian. Ambulates well. Skin with diffuse raised white
papules, pruritic, without drainage noted on the back of his
legs bilaterally.
LABORATORY DATA ON ADMISSION: Sodium of 135, potassium of
3.9, chloride of 104, bicarbonate of 25, BUN of 18,
creatinine of 1.4, glucose of 97. ALT of 96, AST of 468,
amylase of 41, alkaline phosphatase of 102, lipase of 33,
total bilirubin of 3.0, albumin of 2.4. White blood cell of
7.7, hematocrit of 29.5, platelets of 48. UA showed some
small blood and occasional bacteria.
RADIOLOGIC STUDIES: Ultrasound of his abdomen showed no
ductal dilatation, mild gallbladder wall edema which probably
relates to hepatitic disease as per radiology resident.
Chest x-ray showed low volumes with segmented atelectasis in
the right middle lobe.
HOSPITAL COURSE: The patient was admitted to the floor, at
which time he spiked a temperature to 104.1 in the first
couple hours. He was started on ceftriaxone. An ID consult
was obtained as well as a hepatobiliary consult. His
ceftriaxone was switched over to IV vancomycin as per ID. He
was diagnosed as having had gram-positive cocci bacteremia.
Aggressive fluid resuscitation was used to maintain his blood
pressure, and the patient was transferred to the medical
intensive care unit. The septicemia was identified as being
staph aureus.
On hospital day 4, Kaposi sarcoma was identified on his left
foot by infectious disease. The previously mentioned leg
culture revealed later that the staph aureus that grew out
was MRSA. More history was gained from the ID consult as they
had access to his records from his workup at an outside
hospital. His stool had been negative for C. diff, he had a
negative EGD; and a CT at that time had shown a large
gallbladder, hardened wall, and a diffuse collection around
the pancreas. Retroperitoneal density and retroperitoneal
adenopathy were also noted. In light of the MRSA positive
cultures his antibiotic coverage was expanded to include
vancomycin, ceftriaxone, and Flagyl. The patient was
transfused up to a hematocrit of 30, and an echo was ordered
to assess for endocarditis.
On [**2-15**], hospital day 4, the patient's CD4 count was
identified as being 158; down significantly from the previous
value of 602. The patient remained afebrile for hospital day
3 and hospital day 4. At the end of hospital day 4 the
patient was transferred to the floor out of the intensive
care unit while a tolerating a p.o. diet. The patient's
central line was discontinued and a PICC line was placed for
long-term antibiotic therapy. On the floor, the patient's
antibiotic coverage was changed to Flagyl and vancomycin. The
patient continued to remain afebrile. On [**2112-2-17**] the
patient underwent a TEE to evaluate for possible SBE. No
vegetations were found. On the night of [**2-17**] the patient
became lethargic and was started on rifamycin for possible
encephalopathy. The patient underwent a bone scan on [**2112-2-18**] which showed no evidence of osteomyelitis.
Over the following couple of days the patient remained
afebrile, although he developed severe anasarca; and on [**2112-2-22**] he tried to pull out his PICC line, which had to be
replaced. Psychiatry saw the patient and determined that he
was in delirium (mild) which was due to multifactorial's
including AIDS, effects of opiates, resolving sepsis, and
hepatic encephalopathy. One of the possibilities raise by
psychiatry was surreptitious drug use within the hospital.
For this, the patient's urine was tested and turned up
positive only for opiates which he had been receiving for
analgesia while in the hospital.
On [**2112-2-26**] cultures came back from his PICC line that
were positive not only for MRSA but also VRE. For this ID was
consulted again, and they recommended discontinuing the
current PICC line and adding dactinomycin to cover both VRE
and MRSA. So, consistent with these recommendation, on [**2112-2-26**] vancomycin was discontinued and dactinomycin was
initiated.
On [**2112-2-27**] the patient complained of increased fluid
in his lower extremities, scrotum, and abdomen. In order to
control this edema, his furosemide dose was increased and the
patient was continued on his dactinomycin. On the 12th,
surgery was also consulted for possible lymph node biopsy to
rule out lymphoma to explain his thrombocytopenia and his
lower extremity edema. At that time, surgery felt that any
biopsy would carry with it a significant risk of
complications. Interventional radiology attempted a lymph
node aspiration which showed MRSA but was an inadequate
sample to rule out lymphoma. The patient remained stable and
on current therapy until [**2112-3-2**] at which time he
spiked to a temperature of 101.9. The white blood cell count
of the patient dropped from 7 to 2.1, and his platelets
dropped from 39 to 22. Hematocrit was 26.7. UA was sent which
was positive for yeast. His Foley was discontinued, and the
patient was started on Diflucan and levofloxacin empirically.
Blood cultures subsequently found gram-negative rods in his
blood, and he failed his trial of void for which a Foley was
re-placed with a 22 French coude catheter, and ceftazidime
was added to the antibiotic regimen. The patient had also
been started on lactulose p.o.
On [**3-3**], surgery was re-consulted for possible cellulitis
in the lower extremity. At that time, surgery felt that he
needed emergent I and D with possible hip disarticulation.
Once again surgery noted that due to his thrombocytopenia,
his immunocompromised status, and for other reasons he was an
extremely high surgical risk. After discussion with the
family, the family wished to proceed with the I and D of the
lower extremity despite the high risk. In preparation for the
surgery patient was transfused platelets, FFP, and
cryoprecipitate infusions. This action was in response to a
spike to 104 on the night of [**3-2**] and a blood
pressure drop at that time to 90/30. The patient had received
3 liters of crystalloid boluses in order to maintain his
blood pressure. His right lower extremity had developed 3+
pitting edema and erythema. PO Flagyl and ciprofloxacin IV
were also added to his antibiotic regimen at that time. On
the morning of [**3-3**] lactate was noted at 9.7. The patient
was also relocated to the MICU, then to the SICU when surgery
had agreed to take the patient to the OR for the I and D. At
this point the patient's antibiotic regimen included
clindamycin, dactinomycin, fluconazole, metronidazole,
meropenem. Later on [**2112-3-3**] the patient was taken to
surgery for his I and D; after which he was relocated to the
SICU again.
On the afternoon of [**2112-3-4**] the patient was taken back
to the OR for more debridement of the right lower extremity
with a diagnosis now of necrotizing fasciitis of the right
leg and scrotum. The patient remained critically ill in the
SICU over the remainder of [**3-4**] and [**3-5**] but without
apparent expansion of the fasciitis.
On the night of [**2112-3-5**] the patient received 2 units
of platelets, 6 units of FFP, and 3 units of packed red blood
cells; but his wounds continued to soak their bandages with
blood. On the remainder of the 20th there was noted to be no
further bleeding from his wounds. The patient was judged to
be stable though critical and was followed closely.
On [**3-7**] the results of previous blood cultures came back
positive for Enterobacter which was consistent with the urine
culture earlier as well as a candidal positive culture from a
swab taken in the OR from the right thigh. The patient was
then noted to have poly organism infection, as well as
thrombocytopenia, and coagulopathy which were multifactorial.
The patient's blood pressure had been maintained
postoperatively on propofol, Levophed, Pitressin; and
maintaining his blood pressure became more of a problem on
postoperative day [**6-22**] (which was [**2112-3-10**]). Necrotic
tissue was noted on the right lower extremity, and it was
debrided at the bedside on both [**3-9**] and [**2112-3-10**];
debridement of necrotic muscle. Still necrotic tissue formed
and patient had to be debrided again, with each debridement
raising the problems of more bleeding in this severely
thrombocytopenic patient.
On [**2112-3-11**] the patient was again transfused 4 units of
packed red blood cells, 2 units of platelets, 3 units of FFP,
and cryoprecipitate in order to maintain hemodynamic and
coagulation status.
On [**3-12**], propofol and fentanyl were discontinued. The
patient was being maintained solely on Levophed and Pitressin
for blood pressure support; but once again platelets dropped
precipitously down to 19 from 50.
On [**3-14**], the patient's renal and hepatic failure
continued to worsen as well as progressive necrosis noted in
his lower extremity, and the team decided to discuss with the
family the futility of ongoing aggressive measures in this
patient and ongoing care which in their opinion would futile.
During this time, on the morning of [**3-15**], the patient
became hemodynamically unstable again. His FiO2 was increased
to 100%. His ABG showed increasing metabolic acidosis. Later
in the morning of [**2112-3-15**] the patient's lower
extremity dressing was reinforced. Hematocrit was noted to be
down to 17. The patient was transfused a total of 10 units of
packed red blood cells that night, 3 units of platelets, and
7 units of FFP. The patient also required increasing doses of
pressors in order to maintain blood pressure. Later in the
morning, after long meeting with family, the patient was made
a DNR. The patient continued to require increasing doses of
pressors with less response. The patient expired on [**2112-3-15**] at 9:40 a.m.
DISPOSITION: Patient expired.
DISCHARGE INSTRUCTIONS: Not applicable.
FOLLOWUP: Not applicable.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**], M.D. [**MD Number(2) 12418**]
Dictated By:[**Last Name (NamePattern1) 5032**]
MEDQUIST36
D: [**2112-6-26**] 16:56:52
T: [**2112-6-26**] 18:29:39
Job#: [**Job Number 108452**]
|
[
"78552",
"5845",
"99592",
"40391",
"4280",
"51881",
"3051"
] |
Admission Date: [**2132-1-29**] Discharge Date: [**2132-2-8**]
Date of Birth: [**2072-9-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2132-1-29**] Cardiac Catheterization
[**2132-1-31**] Tooth Extraction
[**2132-2-4**] Aortic Valve Replacment utilizing a [**Street Address(2) 65560**].
[**Male First Name (un) 923**] mechanical valve
History of Present Illness:
This is a 59M with HTN X 20 years admitted to [**Hospital3 1443**]
on [**2132-1-27**] with near syncope x 2. CK/Trop (-) x3. Head CT showed
mild cerebral atrophy, carotid u/s showed minimal plaque. Stress
test was done. 5 minutes into [**Doctor First Name **] protocol the patient's blood
pressure dropped to 60/30, pt became diaphoretic and ashen and
EKG showed 4mm ST depressions ant/lat. Patient transferred to
[**Hospital1 18**] for cardiac catheterization.
Past Medical History:
Aortic Stenosis, Hypertension, History of Nosebleeds, Bilateral
Carpel Tunnel Syndrome - s/p Wrist Surgery, Syncope, s/p
Appendectomy
Social History:
Patient works for Reebok. He is a non-smoker and denies
excessive ETOH intake. He lives with his mother.
Family History:
Family history of CAD, unknown age
Physical Exam:
PE T99, BP116/82, HR 83, R20, O2sat 97%RA
GEN: NAD, lying on back (s/p cath)
HEENT: MMM, OP clear
Heart: nl rate, S1S2, III/VI crescendo/ decrescendo murmur LUSB,
no parvus et tardus
Lungs: CTA b/l
Abd: soft, round protuberant, no bruits
Ext: 2+DP, no edema
Groin: right groin cite c/d/i
Pertinent Results:
[**2132-1-29**] Cardiac Catheterization: 1. Selective coronary
angiography of his right dominant system revealed no
angiographic evidence of flow limiting coronary artery disease.
2. Resting hemodynamics revealed elevated left sided filling
pressures and a reduced CI of 2.2 L/min/m2. 3. There was a
70mmHg gradient across the aortic vavlve upon pullback of the
cathter from the left ventricle to the aorta. The calculated
valve area is 0.63 cm2. Left ventriculography revealed and EF of
57% and 1+ Mitral regurgitation.
[**2132-1-31**] Echocardiogram: 1. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. 2. The ascending aorta is moderately dilated. 3. The
aortic valve leaflets are severely thickened/deformed. There is
moderately severe aortic valve stenosis. Trace aortic
regurgitation is seen. 4. The mitral valve leaflets are mildly
thickened.
[**2132-2-7**] 05:55AM BLOOD Hct-25.0*
[**2132-2-6**] 07:10AM BLOOD WBC-14.9* RBC-3.02* Hgb-9.3* Hct-26.1*
MCV-87 MCH-30.7 MCHC-35.5* RDW-13.9 Plt Ct-156
[**2132-2-8**] 06:20AM BLOOD PT-20.4* PTT-37.7* INR(PT)-2.0*
[**2132-2-7**] 07:24PM BLOOD PT-17.6* PTT-41.8* INR(PT)-1.6*
[**2132-2-7**] 05:55AM BLOOD PT-14.8* PTT-29.1 INR(PT)-1.3*
[**2132-2-7**] 05:55AM BLOOD K-4.2
[**2132-2-6**] 07:10AM BLOOD Glucose-128* UreaN-15 Creat-0.7 Na-135
K-4.4 Cl-102 HCO3-26 AnGap-11
[**2132-2-4**] 06:05AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.1
[**2132-1-30**] 06:25AM BLOOD Triglyc-175* HDL-55 CHOL/HD-2.9
LDLcalc-68
Brief Hospital Course:
Mr. [**Known lastname 65561**] was admitted and underwent cardiac catheterization
which revealed normal coronary arteries. It confirmed aortic
stenosis with a 70mmHg gradient across the aortic valve. The
calculated valve area was 0.63 cm2. Left ventriculography
revealed an LVEF of 57% and there was 1+ mitral regurgitation.
Further evaluation included an echocardiogram and dental
consultation. The [**Known lastname **] again showed severe aortic stenosis with
trace AI. There was mildly thickened mitral valve leaflets, and
only trivial MR.
[**First Name (Titles) **] [**Last Name (Titles) **] was also notable for a normal aortic root diameter, and
a moderately dilated ascending aorta, measuring 4.0 centimeters.
Dental consultation revealed poor oral hygiene with several
cracked teeth and tooth extraction was recommended. On [**1-31**], tooth extraction was performed without complication. His
preoperative course was also remarkable for unexplained fevers.
He was empirically maintained on intravenous antibiotics. Pan
cultures were obtained but no infectious etiology was
identified. Head CT scan was notable for findings consistent
with sinusitis which may have explained his fevers. Once his
fevers improved, he was cleared for surgery.
On [**2-4**], Dr. [**Last Name (STitle) **] performed an aortic valve replacement
with a [**Street Address(2) 65560**]. [**Male First Name (un) 923**] mechanical valve. His ascending
aorta was not replaced as it appeared smaller than 4.0
centimeters on visual inspection with good tissue quality. The
operation was otherwise uneventful and he transferred to the
CSRU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated. He weaned from
inotropic support without difficulty. He maintained stable
hemodynamics and transferred to the SDU on postoperative day
two. Beta blockade was resumed and advanced as tolerated. He
remained in a normal sinus rhythm without atrial or ventricular
arrhythmias. Warfarin was started and dosed for a goal INR
between 2.0 -3.0. Over several days, he made clinical
improvements with diuresis as medical therapy was optimized. He
was cleared for discharge to home on postoperative day four. He
will follow up with Dr. [**Last Name (STitle) 41442**] for outpatient Warfarin dosing.
Medications on Admission:
Lotrel qd, Aspirin qd
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. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours
as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO qpm: Take as
directed by MD. Daily dose may vary according to INR. Goal INR
is 2.0 - 3.0.
Disp:*90 Tablet(s)* Refills:*2*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
10. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 weeks: Take 40mg twice daily for 1 week, Then
20mg twice daily for 1 week.
Disp:*42 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
So. Coast VNA
Discharge Diagnosis:
Aortic Stenosis - s/p mechanical AVR, Dilated Ascending Aorta,
Hypertension, History of Nosebleeds, s/p Wrist Surgery, History
of Syncope
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions. Dr. [**Last Name (STitle) 41442**] will monitor your Warfarin as
an outpatient. Adjust for goal INR between 2.0 - 3.0.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**2-27**] weeks. Local PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 41442**] in [**12-28**] weeks. Dr. [**Last Name (STitle) 41442**] will arrange follow up with
local cardiologist as an outpatient.
Completed by:[**2132-2-8**]
|
[
"4241",
"4019",
"2859"
] |
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