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Admission Date: [**2117-10-24**] Discharge Date: [**2117-10-31**]
Date of Birth: [**2080-6-16**] Sex: M
Service: CICU
Dictating for: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.
HISTORY OF PRESENT ILLNESS: This is a 37-year-old male with
cardiac risk factors of mild hypercholesterolemia who had his
first myocardial infarction on [**8-27**] of this year of the
left anterior descending artery (proximally).
The patient had been doing well after discharge. He had been
discharged on Plavix, aspirin, and Coumadin. On the day of
admission, he had been exercising on his bike for 20 minutes
when 20 minutes after exercise he experienced chest pressure,
some shortness of breath, and diaphoresis. He immediately
recognized the symptoms and went by ambulance to [**Hospital6 3426**] where electrocardiogram showed an anterior ST
elevation myocardial infarction with elevation in V1 through
V6. The patient received nitroglycerin, morphine, aspirin,
and heparin and was transferred within one hour to [**Hospital1 1444**] for cardiac catheterization.
Catheterization showed a total occlusion of the left anterior
descending artery at the area of the stent placement. A
balloon angioplasty was performed at the site without
complications, and the patient was sent to the Coronary Care
Unit.
PAST MEDICAL HISTORY: (The patient's past medical history
was significant for)
1. Mild hypercholesterolemia; treated with Zocor.
2. The patient also had an echocardiogram on [**2117-8-31**]
which showed moderate regional left ventricular systolic
dysfunction with an ejection fraction of 30% and
anteroseptal, anterior, and apical kinesis.
MEDICATIONS ON ADMISSION: The patient's home medications
were enalapril 10 mg p.o. once per day, Lopressor 25 mg p.o.
twice per day, Zocor 20 mg p.o. once per day, Coumadin 5 mg
p.o. once per day, aspirin 81 mg p.o. once per day, folic
acid 3 mg p.o. once per day, and Plavix.
ALLERGIES: There were no known drug allergies.
SOCIAL HISTORY: Social history was significant for no
tobacco use. No intravenous drug use. Occasional alcohol.
The patient had been following a regular exercise course. He
is a business manager at [**Hospital1 **].
FAMILY HISTORY: Family history was significant for no early
cardiovascular disease. Two brother are healthy. One sister
with diabetes mellitus.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed vital signs with temperature of 98.3, heart rate
was 81, blood pressure was 105/71, respiratory rate was 20.
In general, the patient was awake and alert, in no acute
distress. Head, eyes, ears, nose, and throat examination
revealed pupils were equal, round, and reactive to light.
Extraocular muscles were intact. No increased jugular venous
pressure. Cardiovascular examination revealed a regular rate
and rhythm with no murmurs and a fourth heart sound. The
abdomen was soft and benign. Lungs were clear to
auscultation anteriorly. Extremities revealed the patient
had a femoral sheath in the right groin with no hematoma and
2+ palpable dorsalis pedis pulses.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
showed white blood cell count was 15,000, hematocrit
was 35.9, platelets were 207. INR was 3.3, PTT was greater
than 150. Creatine kinase was 137, and potassium was
measured at 3.5. Arterial blood gas showed pH of 7.25, PCO2
was 45, and PO2 was 180, with a bicarbonate of 21. The
latest total cholesterol tests from [**2117-8-26**] showed a
total cholesterol of 174, and high-density lipoprotein
was 42, low-density lipoprotein was 108, triglycerides
were 119.
RADIOLOGY/IMAGING: Electrocardiogram measured at [**Hospital6 3426**] showed sinus rhythm with a rate of 81, 3-mm ST
elevations in I, aVL, and V2 through V6; 2-mm ST depressions
in II, III, and aVF.
Electrocardiogram taken after cardiac catheterization at [**Hospital1 1444**] showed sinus rhythm at a rate
of 89, P-R prolongation, decreased ST elevations in V2
through V6, and resolved abnormalities in II, III, and aVF.
A chest x-ray showed no pulmonary edema.
HOSPITAL COURSE: The patient did well. The patient was
started on Plavix, Integrilin, Zocor, aspirin, beta blocker,
and ACE inhibitors.
Serial creatine phosphokinases and troponin I were done with
a peak creatine phosphokinase of 1112 and a peak troponin of
greater than 50.
The patient was taken back for catheterization and evaluation
for brachy therapy. The catheterization revealed no
significant hyperplasia within the stent; and therefore
brachy therapy was not performed. A repeat echocardiogram on
[**2117-10-25**] showed an ejection fraction of 30%,
hypokinesis of the anterior free wall and septum, and
dyskinesis of the apex. A left ventricular mass or thrombus
could not be excluded.
Due to this patient's unusual situation of in-stent
thrombosis while on Coumadin, aspirin, and Plavix,
hypercoagulability studies were pursued. A lupus
anticoagulant test was performed and was found to be
negative.
The right femoral catheter was removed on [**2117-10-27**].
This procedure was significant for the fact that 70 minutes
of pressure had to be held at the site before bleeding
stopped. In addition, the patient had a vagal episode with a
heart rate down to the 50s and systolic blood pressure down
to the 80s. He was given 0.5 mg of atropine and a 500-cc
bolus of normal saline with improvement.
On [**10-29**], the patient was exercising increasing pain in
the right groin area where the catheter had been removed.
The patient was given pain medications, and a CAT scan showed
a hematoma without retroperitoneal bleed, and the patient was
instructed to limit his movement to and from the bathroom.
MEDICATIONS ON DISCHARGE:
1. Metoprolol 25 mg p.o. b.i.d.
2. Zestril 10 mg p.o. q.d.
3. Aspirin 325 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Zocor 20 mg p.o. q.d.
6. Folic acid 3 mg p.o. q.d.
7. Coumadin 5 mg p.o. q.d.
CONDITION AT DISCHARGE: The patient's condition on discharge
was good.
DISCHARGE FOLLOWUP: The patient was instructed to follow up
with his cardiologist.
DISCHARGE DIAGNOSES: In-stent re-thrombosis with resulting
ST elevation anterior wall myocardial infarction.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Last Name (NamePattern1) 43960**]
MEDQUIST36
D: [**2117-10-30**] 14:41
T: [**2117-11-3**] 12:42
JOB#: [**Job Number 43961**]
|
[
"41401"
] |
Admission Date: [**2154-8-6**] Discharge Date: [**2154-8-10**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
Intra-aortic balloon pump
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: Mr. [**Known lastname 46371**] is a [**Age over 90 **] M with a
history of coronary artery disease s/p CABG in [**2124**], CHF with EF
of %, paroxysmal atrial fibrillation not on anticoagulation who
presents with 4 hours of substernal chest pain. He awoke in the
morning feeling well, and worked on his car (changed a bulb,
which involved laying under the car). Afterward he was returning
to his house and he climbed up 10 steps when he had sudden onset
of substernal chest pain. It was [**11-11**] severity, constant. He
took SL nitroglycerin x 4 or 5 doses with no significant relief.
He also took Tylenol and Maalox without improvement. He began to
feel diaphoretic and uncomfortable, so called his family, who
called EMS to bring him to ED.
.
Of note, he has generally been feeling well for the past few
months. He feels his CHF has been under good control, with
minimal edema, orthopnea or PND. However, he does report
increasingly frequent exertional angina (typically with carrying
groceries or walking longer distances) over the past few weeks
for which he has taken SLNG a few times per week.
.
In the ED, his initial vitals were T 97, HR 104, BP 84/50, RR
16, O2 100% 2L NC. An EKG was performed and showed LBBB which
met Sgarbossa criteria for evolving myocardial infarction. He
was given full-dose aspirin and plavix-loaded and taken to the
cardiac cath lab. There, cath revealed complete stenosis of his
RCA graft (felt likely to be old, as wire could not be passed)
and 99% proximal stenosis of his LAD graft. A drug-eluting stent
was placed in this location with subsequent good flow noted.
Given hypotension to SBP in 80s during the procedure, a balloon
pump was placed.
.
On arrival to the floor, he reports feeling significantly better
than earlier in the day and is chest-pain free. He is on 2L O2
by NC but denies SOB at rest. Cannot urinate from the supine
position, but otherwise no complaints at this time.
.
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, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. No dysuria. No
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope. All of the other review of
systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia,
+Hypertension
2. CARDIAC HISTORY:
-CABG: in [**2124**] and 2 vessel SVG stenting in [**2148**] followed by
failed attempt to open an occluded OM branch on [**3-/2149**] due to
persistent angina.
-PERCUTANEOUS CORONARY INTERVENTIONS:
s/p DES to SVG-RCA and SVG-LAD ([**2148**]). SVG to OM known occluded.
3. OTHER PAST MEDICAL HISTORY:
- CAD s/p MI, CABG, PCI as above.
- AAA s/p repair
- Chronic systolic CHF (EF 25-30%)
- Hyperlipidemia
- Chronic kidney disease (baseline creatinine 1.6-2.2)
- s/p L carotid endarterectomy [**2143**]
- s/p cholecystectomy
- GERD
- hearing loss
- Nephrolithiasis
- Mesenteric ischemia (celiac artery stenosis, occluded [**Female First Name (un) 899**])
- Dizziness
- Chronic pleural effusion s/p talc pleuridesis
Social History:
Lives alone, but sons lives within [**Street Address(2) 46372**] and involved
in care. No HHA or other help at home. Quit smoking >40y ago;
used to smoke 3ppd x 20 years. No alcohol. No recreational
drugs.
Family History:
Father died of MI in 70s
Physical Exam:
On Admission:
PHYSICAL EXAMINATION:
HR: 63 BP: 112/50 O2: 100% 3L NC RR:18
Gen: AxO x3
HEENT: no JVP, no carotid bruits, CEA scar on left
CV:distant heart sounds, balloon pump
Resp: CTAB anteriorly
Abd: soft, NT/ND
Ext: cool feet, 1+ DP pulses, no edema bilaterally
Groin: L+R with no signs of ecchymosis or hematoma, slight
oozing
.
On Discharge:
afebrile HR:56-65 BP:102-117/51-59 RR:15-18 O2sat:96-100%RA
Gen: pleasant elderly man, AOx3
HEENT: no JVP
CV: distant heart sounds but nl S1, S2, no murmurs
Lungs: CTAB, no wheezes or rales
Abd: soft, NT/ND
Ext: cool feet, 1+ DP pulses b/l, no edema
Groin: R-sided bruising and ecchymoses with small hematoma,
L-side no hematoma or bruising
Pertinent Results:
Admission Labs:
[**2154-8-6**] 01:30PM BLOOD WBC-8.3# RBC-3.84* Hgb-12.5* Hct-37.1*
MCV-97 MCH-32.5* MCHC-33.6 RDW-15.0 Plt Ct-116*
[**2154-8-6**] 01:30PM BLOOD PT-13.9* PTT-22.2 INR(PT)-1.2*
[**2154-8-6**] 01:30PM BLOOD Glucose-141* UreaN-63* Creat-2.9* Na-139
K-4.3 Cl-103 HCO3-22 AnGap-18
[**2154-8-6**] 05:35PM BLOOD Calcium-8.8 Phos-4.1 Mg-2.4
.
Cardiac Enzymes:
[**2154-8-6**] 05:35PM BLOOD CK-MB-22* MB Indx-10.4* cTropnT-0.52*
proBNP-3678*
[**2154-8-7**] 02:52AM BLOOD CK-MB-41* MB Indx-10.5* cTropnT-1.03*
(PEAK)
.
Discharge Labs:
[**2154-8-10**] 07:00AM BLOOD WBC-4.7 RBC-3.45* Hgb-11.0* Hct-32.6*
MCV-95 MCH-31.8 MCHC-33.6 RDW-15.2 Plt Ct-95*
[**2154-8-9**] 05:04AM BLOOD PT-14.2* PTT-25.6 INR(PT)-1.2*
[**2154-8-10**] 07:00AM BLOOD Glucose-94 UreaN-44* Creat-1.9* Na-141
K-4.3 Cl-105 HCO3-27 AnGap-13
.
Other Results:
EKG ([**8-6**])Regular wide complex tachycardia - possibly
idioventricular rhythm. Compared to the previous tracing of
[**2154-5-31**] wide complex tachycardia is now present.
.
Cardiac Cath ([**8-6**])
1. Native three-vessel coronary artery disease.
2. Occluded SVG-RCA with possible stent fracture.
3. 95% ostial stenosis of SVG-LAD with 40% mid-stent ISR.
4. Successful IABP placement.
5. Successful PCI of the SVG-LAD with a 3.5 x 15 mm Promus DES.
.
TTE ([**8-7**])
EF 30%. Left ventricular cavity dilatation with moderate
regional and global systolic dysfunction c/w multivessel CAD.
Mild-moderate mitral regurgitation. Compared to the prior study
dated [**2153-8-29**], the left ventricular systolic function is
similar. The right ventricle was not well visualized on this
study.
.
ECG ([**8-9**])
Wandering atrial pacemaker. Intraventricular conduction delay.
Brief Hospital Course:
Pt is a [**Age over 90 **]yoM with CAD s/p CABG and prior PCI who presented with
chest pain and EKG changes consistent with inferior wall [**Age over 90 **].
.
# Inferior Wall [**Name (NI) **] - Pt presented with chest pain and EKG
changes consistent with inferior wall MI with peak CKMB of 41
and troponin of 1.03. Pt underwent urgent cardiac
catheterization for revascularization. In the cath lab, initial
angiography revealed an occluded SVG-RCA. Attempts were made to
cross the occlusion with multiple wires. At this point, the
patient's blood pressures dropped, so an IABP was inserted via
the right femoral artery. They then accessed the left femoral
artery, and repeat angiography of the SVG-LAD revealed a 95%
stenosis at its ostium. They treated this lesion with PTCA and
one drug-eluting stent. Final angiography revealed no residual
stenosis, no evidence of dissection and TIMI 3 flow. Patient was
transferred to the CCU for close monitoring. He was stable
enough to be transferred to the floor. Post-procedure Echo
showed EF of 30%, which was similar to his previous baseline. He
was discharged home on an appropriate post-MI regimen including
plavix, aspirin, atorvastatin, and lisinopril. Patient was
trialed on a low-dose beta-blocker but he became quite
bradycardic so it had to be discontinued.
.
# Hypotension - Patient became hypotensive during the procedure
requiring placement of IABP. On arrival to the CCU, pt's
pressures were quite stable, so pt was successfully weaned off
the IABP on [**8-7**]. Pt's blood pressures remained in the low 100s
until the time of discharge, which is likely his baseline as he
was mentating appropriately and clinically quite stable.
.
CHRONIC ISSUES
.
# Congestive Heart Failure: Repeat Echo on this admission showed
essentially no change in pt's EF post-[**Month/Day (4) **] - it remained
depressed at 25-30%. Pt remained euvolemic throughout his stay,
complaining only of some minor shortness of breath when lying
flat. His blood pressures remained in the low 100s, so he could
not be fully re-started on all of his home medications prior to
discharge. His spironolactone was held and his lasix dose was
decreased to 80mg daily at the time of discharge. He was advised
to follow-up with his primary doctor to re-add/titrate these
medications appropriately.
.
# Chronic Renal Failure: Pt's creatinine was initially elevated
post-procedure likely from the contrast load he received, but it
gradually returned to baseline without any further intervention.
.
# Atrial Fibrillation: Pt was consistently bradycardic and in
sinus rhythm post-procedure. His bradycardia prevented us from
successfully starting a beta-blocker on him. He was continued on
amiodarone.
.
TRANSITIONAL ISSUES
.
Pt needs to follow-up with his outpatient cardiologist regarding
the appropriate doses of lasix and spironolactone he needs to be
on given his low blood pressures. A beta-blocker should be
started in him as well if his heart rate can tolerate it.
Medications on Admission:
- Amiodarone 200 mg PO M/W/F
- Isosorbide mononitrate 120 mg PO daily
- Furosemide 80 mg PO QAM, 40 mg PO QPM
- Lisinopril 2.5 mg PO daily
- Nitroglycerin 0.4 mg SL PRN
- Omeprazole 40 mg PO daily
- Pravastatin 40 mg PO daily
- Spironolactone 25 mg PO daily
- Trazodone 50 mg PO QHS
- Aspirin 325 mg PO daily
- Multivitamin 1 tab PO daily
Discharge Medications:
1. amiodarone 200 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
2. isosorbide mononitrate 120 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
3. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes as needed for chest pain: [**Month (only) 116**] eepeat
x 2 tabs. If pain continues, take third tab and call 911.
6. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
7. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ST-elevation myocardial infarction corrected by a drug-eluting
stent to the left anterior descending artery
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
for a heart attack and underwent a procedure in which they
re-opened a blocked vessel in your heart. Your blood pressures
were a bit low during the procedure so you were initially
monitored in the cardiac intensive care unit while a balloon
pump temporarily supported your pressures but that was
successfully removed. You recovered from your procedure well
enough to be sent to the regular hospital floor.
.
The following medications were changed during your
hospitalization:
1. Stop taking your Pravastatin 40mg daily and instead start
taking Atorvastatin 80mg daily to lower your cholesterol.
2. Please start taking Plavix 75mg daily.
3. While you were in the hospital, you were on Furosemide 80mg
daily which is lower than your typical home dose. We would like
for you to weigh yourself tomorrow morning after you urinate and
write down the weight, this will be your baseline weight.
Continue to weigh yourself on the same scale everyday. If you
gain 3lbs in one day a) call Dr. [**Last Name (STitle) **] and b) please take an
additional 40mg of Furosemide (Lasix) that evening.
4. While you were in the hospital, we did not give you your
daily Spironolactone 25mg because your blood pressures were low.
Please do not resume taking your spironolactone until you have
discussed this with Dr. [**Last Name (STitle) **].
5. Please stop taking your omeprazole and start taking
ranitidine 150mg daily for your heartburn.
.
Please continue taking all of your other home medications.
Followup Instructions:
In addition to the following appointments, please call
[**Telephone/Fax (1) 1144**]
to make an appointment with Dr. [**Last Name (STitle) **] in one to two weeks.
.
Department: [**Hospital1 18**] [**Location (un) 2352**]
When: WEDNESDAY [**2154-9-4**] at 8:30 AM
With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: ADULT MEDICINE
When: THURSDAY [**2154-10-17**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 1144**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: RADIOLOGY
When: MONDAY [**2154-11-4**] at 10:00 AM
With: RADIOLOGY [**Telephone/Fax (1) 9045**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
|
[
"5849",
"41401",
"4280",
"2724",
"42731",
"40390",
"5859",
"412",
"V4582"
] |
Admission Date: [**2140-11-15**] Discharge Date: [**2140-12-2**]
Date of Birth: [**2072-1-16**] Sex: M
Service: CT SURGERY
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 67-year-old
male with no known medical history, who presented to an
outside hospital's Emergency Room in [**Month (only) **] with complaints
of right foot swelling, pain and redness. At that time, he
was treated with Cephalexin 500 mg by mouth four times a day
for ten days and, despite this antibiotic course, had
persistent redness and foot pain. He was ultimately seen by
a health care associate, Dr. [**First Name (STitle) **], on [**2140-10-19**], and was given
a second trial of Cephalexin for 14 days, without resolution.
Due to the lack of resolution, dependent rubor and signs and
symptoms consistent with possible rest pain, he was
ultimately referred to Dr. [**Last Name (STitle) 1476**] for possible vascular
disease consultation. Ultimately the patient received
impedance platysmography as well as an arteriogram that
showed significant disease that warranted an operation. He
was brought to the operating room on [**2140-11-17**], where he
underwent a cross-femoral-to-femoral left-to-right bypass
including bilateral common femoral artery and endarterectomy
and bilateral profundoplasty and then a right
cross-femoral-to-posterior tibialis bypass graft utilizing a
non-reversed greater saphenous vein with Dr. [**Last Name (STitle) 1476**]. At
the end of the operation, the patient had Dopplerable right
pulse which was the posterior tibial being monophasic. The
patient was cared for in the postoperative Surgical Intensive
Care Unit due to the complexity of the case and the long
length of the patient's intubation, he was maintained on
ventilatory support for several days.
PAST MEDICAL HISTORY: Ethanol, which he takes eight to ten
beers per day, tobacco greater than 50 pack years of smoking,
peripheral vascular disease, onychomycosis.
PAST SURGICAL HISTORY: Appendectomy, two different aborted
intra-abdominal procedures for presumed cancer, as well as
herniorrhaphy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Keflex, Lotrimin.
LABORATORY DATA: Hematocrit 40, BUN and creatinine 5 and
.7. Chest x-ray showed no acute cardiopulmonary disease.
Electrocardiogram on admission was normal sinus rhythm with
occasional premature atrial contractions. Heart rate was 88,
otherwise normal, no evidence of Q wave or ST segment change
or T wave inversion.
HOSPITAL COURSE: The patient's postoperative course and
overall hospital course were remarkable for failure to
extubate. He had respiratory failure on postoperative day
one, requiring emergent intubation. He was maintained on
full ventilatory support postoperatively. On postoperative
day one, his hematocrit was 31. He had a BUN and creatinine
of 5 and .5. He was noted to be hypotensive and very
tachycardic. No electrocardiogram changes were seen, other
than sinus tachycardia to the 120s to 140s. His low blood
pressures were treated with volume and ultimately he was
given Lopressor for his tachycardia. He was initially also
given delirium tremens prophylaxis with an Ativan drip.
Electrocardiogram just showed sinus tachycardia at 108,
normal axis, with normal intervals.
By postoperative day number two, he had persistent
tachycardia. He was actually started on diuresis, and given
increased titration of Lopressor.
On postoperative day number three, he had enzymes that were
sent to rule out a possible myocardial infarction, that
showed a CPK of 454 and 395, as well as an MB fraction of 6.9
and 6.6, and a troponin-I greater than 50 x 2. Given this,
it looked like he had a possible non-Q wave postoperative
myocardial infarction. Chest x-ray at that time additionally
showed evidence of congestive failure. He was ultimately
referred to the Cardiology service, who recommended a bedside
transthoracic echocardiogram, which showed severe global
hypokinesis with an ejection fraction of 25%, and mildly
decreased systolic function. It was a relatively poor study,
so no regional wall motion abnormalities could be assessed.
He was begun on a heparin drip and also given aspirin and
beta blockade as needed. Lower extremity noninvasives were
also performed at that time, that showed no evidence of
thrombosis.
On [**2140-11-22**], his enzymes peaked. His troponin-Is were again
greater than 50. Electrocardiogram showed sinus rhythm at
33, with normal axis, normal intervals, and he had 1 to 2 mm
ST segment depressions across the precordial leads V2 through
V5. Given this, as well as the setting of a temperature
spike, he was pancultured, including blood cultures, line
cultures, etc. His Swan-Ganz catheter was changed. He had
resiting of all of his line sticks.
On postoperative day number six from the femoral-femoral
bypass, etc., he was noted to have a hematocrit of 29, a
white count of 10, BUN and creatinine of 15 and .6. His
pulmonary artery pressures were 46/21, with a wedge of 15.
Cardiac output was 4.5, and an index of 2.5, systemic
vascular resistance of 1400. Sputum cultures from [**2140-11-21**]
ultimately revealed Moraxella and E. coli that were sensitive
to Levaquin, and he was therefore treated for a presumptive
pneumonia. His white count was 12,000 at this time.
On [**2140-11-25**], the Cardiology consult service performed a
cardiac catheterization showing elevated left ventricular end
diastolic pressures, trace mitral regurgitation, an ejection
fraction of 30%. A ventriculogram study showed
anterolateral, apical, and apical inferior wall motion
abnormalities, consistent with a left dominant or left main
disease. The left main coronary artery was eccentric and
severely calcified, with an 80% lesion as well as the left
anterior descending having a 90% proximal lesion. The left
circumflex was 80% stenosed. Given this severe three vessel
disease and left main of approximately 80 to 90% stenosis,
the Cardiothoracic Surgical service was consulted on
[**2140-11-25**]. Cardiac Surgery therefore suggested that the
patient undergo a coronary artery bypass graft, given the
severe three vessel disease and left main disease.
He was transferred to the Cardiac Critical Care Unit and was
ultimately taken to the operating room on [**2140-11-27**], where he
underwent a coronary artery bypass graft x 2, including
saphenous vein graft to the oblique marginal, and saphenous
vein graft to the left anterior descending. The patient came
off pump with a mean arterial pressure of 70, CVP of 21, and
pulmonary artery pressure of 36. He was in sinus tachycardia
at 100, and he was on milrinone drip.
Postoperatively from the coronary artery bypass graft, he was
taken to the Cardiac Surgical Recovery Unit, where his
postoperative hematocrit was 29. He had a potassium of 4.4,
BUN and creatinine of 6 and .4. He was still intubated,
sedated on propofol, being maintained on Neo-Synephrine .5
mcg/kg/minute. He was additionally transfused two units of
packed red cells and two units of fresh frozen plasma. He
was A-paced at 90. He had an arterial blood gas with a gas
on 100% of 7.41, 39, 106, 24, -1. Chest tube had put out 435
for one, and 280 for a second. As a consequence, his
propofol was weaned. He was extubated, and his milrinone was
maintained. Aspirin was placed. Lopressor was held for some
hypotension issues. Neo-Synephrine was removed once a
transfusion was complete.
On postoperative day number two, he remained in the CSRU.
The milrinone that had been started post-transfusion and
post-Neo-Synephrine removal was ultimately weaned off by
postoperative day number two. His hematocrit was noted to be
27, white count went down to 9000. He continued his
Levaquin. BUN and creatinine were 11 and .4. Neurological
status was intact. Lopressor 12.5 mg by mouth twice a day
was started. He was given lasix for diuresis. His Swan-Ganz
catheter was removed. Ultimately he was given a cardiac
diet, and it was recommended that he continue his Levaquin
for a total of ten day treatment for presumed Moraxella and
E. Coli pneumonia that was picked up post-vascular bypass
procedure.
By postoperative day number three, the patient was
transferred to the floor, where he remained afebrile, in
sinus rhythm. He was no longer being paced. He did have
problems with postoperative delirium status post coronary
artery bypass graft. Given his significant vascular history
and his complicated hospital course, it was felt that these
mental status changes were probably acute delirium
superimposed on a chronic vascular dementia. The patient was
treated with as needed Haldol and restraints. His hematocrit
was 32, with a white blood count of 10,000. BUN and
creatinine were 10 and .4.
By postoperative day number four, he was ambulating well with
Physical Therapy. He was given a rehabilitation screening.
He was kept on aggressive pulmonary toilet and given
incentive spirometry, albuterol and Atrovent nebulizers,
chest physical therapy. He was continued on Levaquin.
Lopressor was titrated to keep his heart rate under 100.
By postoperative day number five, the patient was afebrile,
stable. His sternum had no evidence of drainage. He had
staples intact. He was ambulating at a Level II,
approximately 75 to 200 feet distance using a wheelchair
assistance. The left lower extremity showed some evidence of
possible erythema, but it was felt that the Levaquin should
give him adequate coverage. His hematocrit at this time was
32, his BUN and creatinine were 10 and .5. He was therefore
deemed to go to discharge. Chest x-ray showed resolving
bilateral pleural effusions, left vascular engorgement, as
compared to prior studies during his hospital course, and no
evidence of acute pulmonary edema.
CONDITION ON DISCHARGE: Stable, afebrile. The sternum is
intact.
DISCHARGE STATUS: He will be discharged to rehabilitation
facility.
DISCHARGE DIAGNOSIS:
1. Postoperative non-Q wave myocardial infarction status
post a femoral-femoral, femoral-to-posterior tibial bypass
graft on the right lower extremity, as well as status post a
coronary artery bypass graft x 2 for significant three vessel
coronary artery disease and left main disease
2. Postoperative delirium, presumed delirium superimposed on
a vascular dementia
3. Non-Q wave myocardial infarction
4. Peripheral vascular disease
5. Alcohol abuse
6. 50 pack year smoking history
DISCHARGE MEDICATIONS: Lopressor 100 mg by mouth twice a
day, lasix 20 mg by mouth every morning, K-Dur 20 mEq by
mouth once daily, aspirin 325 mg by mouth once daily,
Levaquin 500 mg by mouth once daily for a total of a ten day
course to continue for five more days, albuterol and Atrovent
metered dose inhaler two puffs every four hours as needed,
Haldol 2 to 4 mg by mouth every eight hours as needed,
Protonix 40 mg by mouth once daily.
FO[**Last Name (STitle) 996**]P: He will see Dr. [**Last Name (Prefixes) **] in six weeks from the
time of discharge. He should see a primary care physician or
[**Name Initial (PRE) **] cardiologist in three to four weeks. He will have his
wound check done at his rehabilitation facility. No heavy
lifting over ten pounds for one month, no driving for one
month.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2140-12-1**] 21:30
T: [**2140-12-2**] 00:00
JOB#: [**Job Number 27291**]
|
[
"9971",
"41071",
"4280",
"41401"
] |
Admission Date: [**2166-8-11**] Discharge Date: [**2166-8-15**]
Date of Birth: [**2140-8-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 25 yo man with no significant PMH presents to ED s/p fall
and headache. He had a fall on saturday , [**2166-8-9**] at around 7
pm. He was going down the stairs and slipped,. he hit his head
on
the back. the height from which he fell was about [**3-20**] steps,
approx 7 feet as per patient. He did not lose consciousness, did
not notice any symptoms such as headache, nausea , vomiting
immediately after fall. He immediately got up and was
asymptomatic till yesterday afternnon about [**11-15**] pm. He noticed
mild dull headache , which kept on increasing and did not
respond
to OTC pain killers. the headache was more on right side than
left. due to this he went to OSH today, was found to have EDH
and
was sent to [**Hospital1 18**].
Past Medical History:
PMHx: GERD
Social History:
Social Hx: works for fishing comp, does not smoke, 1-2 beers per
week. no drug abuse
Family History:
Family Hx: not significant
Physical Exam:
PHYSICAL EXAM:
O: T:99.1 BP: 135 / 77 HR:70 R 16 O2Sats 100 RA
Gen: WD/WN, comfortable, NAD.
HEENT: tenderness on palpation on right parietotemporal area.
Pupils: [**1-15**] BL reactive symmetric EOMs- Full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**1-14**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
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 [**3-18**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 1
Left 2 2 2 2 1
Toes mute bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Gait -normal, Rhombergs sign negative
Upon Discharge
Exam nonfocal
Pertinent Results:
NCHCT [**8-11**] shows Right temporoparietal fracture with large
epidural and smaller subdural hemorrhage and associated mass
effect, all not significantly changed compared to a few hours
prior.
NCHCT [**8-12**] IMPRESSION:
Unchanged large right epidural hematoma and small right subdural
hematoma.
NCHCT [**8-14**]
IMPRESSION:
1. Stable appearing right-sided apical hematoma.
2. No evidence of hydrocephalus.
3. Possible right-sided subdural hematoma versus right
transverse sinus
thrombosis.
NCHCT [**8-15**]
Stable epidural hematoma
Brief Hospital Course:
25M admitted for close clinical observation of mental status s/p
fall with epidural hematoma. He was admitted to the ICU and
later transferred to step down unit then floor with serial
stable head CTs. He has tolerated PO diet, pain is controlled,
ambulated without difficulty.
Medications on Admission:
Zantac 150 [**Hospital1 **]
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**11-15**]
Tablets PO Q4H (every 4 hours) as needed for headache.
3. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 1 months.
Disp:*90 Capsule(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*
Discharge Disposition:
Home
Discharge Diagnosis:
R Epidural Hematoma
R temporal bone fx
Discharge Condition:
Neurologically intact
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.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
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 1 wk.
??????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.
Completed by:[**2166-8-15**]
|
[
"53081"
] |
Admission Date: [**2172-9-16**] Discharge Date: [**2172-11-12**]
Date of Birth: [**2133-6-2**] Sex: M
Service: NMED
Allergies:
Demerol
Attending:[**First Name3 (LF) 5341**]
Chief Complaint:
HA,vomiting, L sided hemiparesis
Major Surgical or Invasive Procedure:
Craniotomy with brain tumor resection
PEG tube placement
History of Present Illness:
39 yo man with metatstatic renal cell CA, lungs, single met to
brain, c/b seizure d/o, none since [**2172-9-4**], had SRS yesterday,
developed HA last night, vomiting this AM, left sided
hemiparesis worsened over the day. Came to ED, started on
Decadron and mannitol. Also reloaded with 600 mg Dilantin. MRI
shows hemmorhagic met s/p SRS with surrounding edema and 1 cm
shift. Tumor size the same with central necrosis. He is stable
now on Decadron and Mannitol and Dilantin. Hemiparesis
resolving. Some remaining slurred speech and bilat CN 6 deficit,
as well as some impaired position sense in arm/face and
decreased use of L trap. Also hyperrelexive in L leg +/- arm.
Now on floor with stable vitals.
Past Medical History:
1. renal cell carcinoma dx [**11-8**], met to lung and
brain, s/p nephrectomy [**11-8**]
2. Hypertension
Social History:
He is married with a daughter. [**Name (NI) **] doesn't smoke or drink EtOH.
No drugs. His wife and daughter are very involved in his care.
Family History:
Significant for hypertension and diabetes
Physical Exam:
T afeb BP 139/93 HR 82 RR 16 O2 sat
General appearance: well appearing
Heart: regular rate and rhythm without murmurs, rubs or gallops
Lungs: clear to auscultation bilaterally.
Abdomen: soft, NT
Extremities: no clubbing, cyanosis or edema
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues.
Mental Status: The patient is inattentive with digit span
forwards of 5. He is drowsy appearing but keeps his eyes open
throughout the exam. He repeats well and though his speech is
sparse, he is fluent and can name high frequency objects.
Cranial Nerves: Visual acuity was not tested. The visual fields
appear full to threat. The optic discs are difficult to
visualize
due to inattention. Eye movements are normal, the pupils react
normally to light, both directly and consensually. Sensation on
the face appears intact to light touch, pin prick. There is an
obvious left facial droop, less so with smiling. Hearing is
intact to finger rub. There is no nystagmus. The palate elevates
in the midline. The tongue protrudes in the midline and is of
normal appearance. The sternocleidomastoid and trapezius muscles
are intact bilaterally.
Motor System: There is an obvious left pronator drift, and fine
movements are slowed on the left.
D T B WE FE FF IP HS Q TA [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 938**]
R 5 5 5 5 5 5 5 5 5 5 5 5
L 4+ 4+ 5 4+ 4- 4 4 4 5 5 5 5
Reflexes: The tendon reflexes are present, but slightly brisker
on the left with a few beats triceps clonus, and spread to
finger
from the brachioradialis jerk. There is no ankle clonus. The
plantar reflexes are flexor bilaterally.
Sensory: Sensation appears intact to pin prick, light touch, and
position sense in all extremities and trunk but he is fairly
inattentive.
Coordination: There is no ataxia on the right with the
finger/nose test.
Gait and stance: deferred
Pertinent Results:
[**2172-9-16**] 05:30PM BLOOD WBC-7.2 RBC-4.12*# Hgb-13.8* Hct-37.2*
MCV-90# MCH-33.5*# MCHC-37.1* RDW-15.6* Plt Ct-235
[**2172-9-16**] 05:30PM BLOOD Neuts-75.0* Lymphs-17.3* Monos-7.3
Eos-0.2 Baso-0.1
[**2172-9-16**] 05:30PM BLOOD Plt Ct-235
[**2172-10-1**] 06:20AM BLOOD WBC-16.5* RBC-3.91* Hgb-13.1* Hct-36.4*
MCV-93 MCH-33.4* MCHC-35.9* RDW-14.3 Plt Ct-296
[**2172-10-1**] 06:20AM BLOOD Plt Ct-296
[**2172-9-16**] 05:30PM BLOOD PT-13.0 PTT-21.5* INR(PT)-1.1
[**2172-9-16**] 05:30PM BLOOD Glucose-132* UreaN-22* Creat-1.0 Na-137
K-4.3 Cl-99 HCO3-24 AnGap-18
[**2172-9-17**] 06:30AM BLOOD ALT-57* AST-29 AlkPhos-104 TotBili-0.5
[**2172-9-16**] 05:30PM BLOOD Calcium-10.6* Phos-2.9 Mg-2.0
[**2172-9-21**] 03:30PM BLOOD Albumin-4.5
[**2172-9-15**] 08:05AM BLOOD Phenyto-9.8*
[**2172-9-30**] 06:15AM BLOOD Phenyto-18.0
[**2172-10-1**] 06:20AM BLOOD Phenyto-PND
MRI initial ([**9-17**]):
Presumed central necrosis and hemorrhage within the right
posterior frontal metastatic tumor, with accompanying increase
in surrounding edema and mass effect.
MRI repeat([**9-21**]):
1) Unchanged appearance of rim enhancing mass within the right
cerebral hemisphere resulting in a large amount of vasogenic
edema with leftward shift of the mid-line by approximately 1.5
cm.
2) Stable appearance of a focus of T2 prolongation in the left
posterior parietal lobe, of unknown significance. This finding
does not appear neoplastic, as there is no associated contrast
enhancement of a definable mass.
Chest CT ([**9-25**]):
1) Interval progression of metastatic disease with increase in
size of left lower lobe pulmonary masses, interval development
of new bilateral adrenal masses, and new 5 mm left lower lobe
pulmonary nodule.
2) No evidence of pneumonia.
3) New low attenuation lesion within the left kidney, which is
only partially imaged on this study, concerning for a
metastasis. CT of the abdomen can be performed for further
evalutation.
Head CT [**11-4**]:
There are multiple masses in the brain parenchyma with
associated surrounding vasogenic edema, most pronounced in both
cerebral hemispheres. There is a mild amount of rightward shift
of the normal midline structures. There is no evidence of a
metastatic lesion to the skull. There are post-operative changes
from a right temporal craniotomy.
Brief Hospital Course:
Mr [**Known lastname **] was admitted to manage cerebral edema that occurred
s/p stereotactic radiosurgery for his brain met.
The following issues were addressed druing this admission:
1.Neuro: An ititial MRI showed a significant amount of edema
surrounding a hemorrhagic brain met s/p SRS. A 1 cm midline
shift had resulted, causing his symptoms. He was initially
started on Dexamethasone 6IV q6h and Mannitol 25 q6. After an
initial improvement, he began to worsen on exam. This included
a L facial droop, slurred speech, weak L shoulder, almost
totally plegic L upper extremity, weak LLE, position sense and
light touch impaired in L arm, leg spared. He also had other
mild deficits. As a result, his mannitol was titrated up ,and
when this didn't improve matters, his decadron was increased to
10 mg IV q6h. A repeat MRI was obtained which showed no cahnge
in the edema or midline shift. Neurosurgery was also
reconsulted and decided that no surgical intervention was needed
at the time. He then began to turn around, and his symptoms on
exam began to slowly improve. He improved slowly, with strength
returning to his LLE and LUE. His left soulder and his LUE in
general were the slowest to recover. He gradually decreased his
facial droop and regained full power in his LLE. His LUE gained
strength, but was not at full power on discharge. He was also
having trouble ambulating due to a persistent lean to the left.
As he improved, the mannitol was gradually weaned to off, and
his decadron was slowly dropped to a final dose of 6 mg q8h.
His exam was essentially stable for the next few days as his
medicines were titrated down. On the following day, he was
noted to be more lethargic than normal and to be less aware of
his surroundings. He did have periods of clarity though, and
could carry on a conversation and answer normally. He then had
an episode of vomiting, and what appeared like a period of
unresponsiveness to his nurse. A head CT was performed which
was ultimately read as worsening edema and possible herniation,
but was initially ambiguous. Regardless, he had clinically
worsened, and vomited several times. He also had 2-3 episodes
of tonic seizure activity followed by post-ictal
nonresponsiveness. He was given 1 mg Ativan and his
neuro-oncologist was called and was en route. He was closely
monitored and had stable vitals with an O2 saturation in the
high 90s. He then proceeded to have a unilateral dilation of
his right pupil which indicated acute herniation. He was then
quickly treated with 100 g IV mannitol and a total of 18 mg IV
decadron. Before this was totally in, he also had dilation of
his left pupil. Soon after medication administration, he was
intubated, hyperventilated, and with this resuscitation, his
pupils returned to their normal diameter and were equal. He had
to be sedated on a propofol drip due to constant rigors, and was
sent for immediate neurosurgery. He went for right frontal
craniotomy with resection of tumor to treat uncal herniation of
right insular mass with edema. He was treated in the SICU from
[**2172-10-1**] until [**2172-10-6**], he was then treated by the neurosurgery
team until [**2172-10-16**] at which time he was transferred back to the
oncology/medicine service. At the time when he was transferred
back to medicine he was having fevers and tachycarcia. Blood
cultures were negative and he was started on Levofloxacin,
Flagyl, and Vancomycin. He was afebrile on antibiotics and they
were continued for 3 days. After the antibiotics were stopped
he was febrile again and they were restarted for a 10 day
course.
He was noted to have a decrease in his mental status. An LP
was done which was negative. Ampicillin was added to his
antibiotics for possible Listeria. Blood cultures and urine
cultures remained negative. His mental status continued to
decrease and he was started on manitol. His aggitation
increased and he was treated with round the clock Haldol. His
brain metastasis were treated with 5 days of whole brain XRT.
After the third dose of XRT he had some improvement of his
mental status, however it decreased again after his 4th dosage
of XRT. He had a PEG placed during his XRT as he was no longer
able to feed himself adequately. Throughout this time he had
microseizures.
Over the next week and a half after his WBXRT was complete his
mental status remained unchanged with possibly some minor
improvment. A repeat head CT showed increased edema and
increased midline shift. He was very gradually weaned off of
the Manitol over the next 10 days. After his antibiotics course
was complete they were stopped and he spiked a fever. At that
time he had blood cultures with one set of corynebacterium and
one set positive for coagulase negative staph. These were felt
to be contaminant however he was continued on 10 days empiric
antibiotics. He had a PICC line placed on [**2172-11-6**] for access.
He was started on Megace for treatment of his renal cell
carcinoma. He will now be discharged to a [**Hospital1 1501**] for further
monitoring and treatment. He will continue on Antibiotics,
Steroids, seizure prophylaxis, and PEG Tube feedings.
2.Seizure prophylaxis: He had been on dilantin before this
admission, and was continued on his dose of 300 [**Hospital1 **]. He had
daily levels checked, with a goal of 15 or greater. This proved
to be difficult to attain. This may be due to the fact that
decadron can increase the metabolism of dilantin and he was on
high doese of the steroid. He was gradually moved up on
dilantin, as he was requiring frequent one time doses in
addition to his standing dose. He eventually got to 500 [**Hospital1 **].
As his decadron was weaned though, his level began to increase,
and we started to back down on his doses. His albumin was
normal, so free dilantin levels were not checked. He was
continued on Keppra and Dilantin for seizure prophylaxis post
neurosurgery.
3.HTN: He was put on his home dose of metoprolol and maintained
good BPS throughout without issue.
4.Nausea:He experienced some nausea on and off during the
admission. This was treated well with prn Zofran. It became
less of an issue later in the admission, as it had resolved.
5.Pain control/HA: He had a severe headache due to his edema.
Initially, he was given dilaudid, but we needed a good neuro
exam, so this was stopped. He was treated with Tylenol
initially, then high doses of Vioxx. After he began improving,
and did so for several days, his HA improved. We also added some
oxycodone at this point as he was clearly getting better nad we
could afford to use narcotics to control his pain. He had some
additional pains in his back and neck as he nearly slipped in
the bathroom and feels that he pulled a muscle in his back. The
neck tension is probably a combination of HA pain and anxiety.
He treated these well with hot packs.
After neurosurgery he was less responsive. We continued to
treat his pain with Oxydodone as needed. His aggitation was
treated with Haldol around the clock with extra given PRN as
needed.
6.Cancer: He was initially considered a possible cure, as his
brain met will likely disappear after the SRS, his kideny is
removed, and his lung mets are shrinking post-therapy and could
be resected. However, he had a low grade fever and a CXR
followed by chest CT were obtained. They were negative for
pneumonia, but did show a new lung met as well as bilateral
adrenal mets. This likely means he is no longer totally
cureable and that his treatment will need to be altered.
He has undergone 5 days of WBXRT for brain metastasis. At
this time he will be discharged to a nursing facility that can
observe him. His mental status has changed a great deal from
baseline. It is felt that this is due to a combination of
seizure effect, brain metastasis, and brain edema from WBXRT.
There is some hope that his mental status changes may resolve
over time. He will follow up with Dr.[**Name (NI) 54350**] office in one
month to determine further treatment options.
Medications on Admission:
1. Dexamethasone 4mg [**Male First Name (un) 239**]
2. Lorazepam prn
3. Oxycodone prn
4. Ranitidine 150mg [**Hospital1 **]
5. Toprol 50 mg [**Hospital1 **]
6. Dilantin 200mg in the morning, 300mg in the afternoon
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QD (once a day) as needed.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig:
Three (3) Packet PO TID (3 times a day).
9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QPM (once
a day (in the evening)).
11. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO Q8H
(every 8 hours) as needed.
12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
13. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
16. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
17. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
18. Phenytoin 100 mg/4 mL Suspension Sig: Four [**Age over 90 1230**]y
(450) mg PO Q8H (every 8 hours) as needed for oral dosing:
please hold feeds for an hour prior to giving Phenytoin and an
hour after dose.
19. Megestrol Acetate 40 mg/mL Suspension Sig: Four Hundred
(400) mg PO QD (once a day).
20. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
21. Haloperidol 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed.
22. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Regular insulin sliding scale to
cover blood sugars.
23. Vancomycin HCl 10 g Recon Soln Sig: One (1) g Intravenous
Q12H (every 12 hours) for 10 days.
24. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 10 days.
25. Levofloxacin in D5W 500 mg/100 mL Piggyback Sig: One (1)
Intravenous Q24H (every 24 hours) for 10 days.
26. Haloperidol Lactate 5 mg/mL Solution Sig: Four (4) mg
Injection TID (3 times a day).
27. Dexamethasone Sodium Phosphate 10 mg/mL Solution Sig: One
(1) Injection Q6H (every 6 hours).
28. Ondansetron HCl 2 mg/mL Solution Sig: One (1) Intravenous
Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 54351**] - [**Location (un) 5503**]
Discharge Diagnosis:
Cerebral edema after stereotactic radiosurgery resulting in
multiple neurological deficits, headache, and nausea/vomiting.
Renal cell carcinoma metastatic to lungs and brain.
Hypertension
Seizure disorder
Discharge Condition:
Patients mental status has deteriorated markedly from admission.
He currently responds to pain only. He can move all
extremities L>R. He does moan frequently but has no verbarl
responses and does not follow basic commands. He requires
assistance with all activities of daily living. He is fed by
PEG tube. There is no evidence that he is actively seizing at
this time.
Discharge Instructions:
Please call your doctor or return to the hospital if you
experience any fevers, hypotension, or uncontrollable pain.
Come to appointment at [**Hospital1 18**] on [**11-30**].
Continue all medications.
Followup Instructions:
Have an MRI at 8:30 AM on [**2172-11-30**] [**Hospital Ward Name 23**] [**Location (un) **]
Follow up in Dr.[**Name (NI) 54350**] office Monday [**11-30**] at 11:00
AM, [**Hospital Ward Name 23**] [**Location (un) **].
Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Where: [**Hospital6 29**]
NEUROLOGY Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2172-11-30**] 11:00
|
[
"4019"
] |
Admission Date: [**2183-2-6**] Discharge Date: [**2183-2-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Chest pain, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an 87 yo F with metastatic lung CA refractory to
chemo, hx breast CA, COPD, recent admission for demand ischemia
who presented with complaints of heart burn. The patient has a
history of lung CA and followed Dr. [**Last Name (STitle) 17535**], and has undergone
partial wedge ressection, chemo, and XRT with continued disease
progression. The patinet also has a substantial smoking history,
and continues to smoke. She has had recent mild COPD flares,
with symptoms of fatigue, dyspnea, and wheezes, with improvement
on a prednisone taper.
The patient was recently admitted to the [**Hospital1 18**] from [**1-6**] -
[**1-7**]. She presented with complaints of SOB, and was treated
with IV solumedrol and avelox. Cardiac makers were cycled due to
precordial TWI, with a midly elevated troponin I at 1.10. She
was transfered to the [**Hospital1 18**] for cardiac catheterization, which
showed no focal lesions. Her elevated cardiac markers were
attributed to demand ischemia, and she was treated through
medical management.
She was seen recently by per PCP and was doing well in follow
up. Of note, Omeprazole was d/c'd and replaced with ranitidine
to avoid interaction with Plavix. Over the last three days, she
has been experiencing increasing fatigue, nausea, and decreased
appetite. She complains of feeling an acid like burn in her
stomach. She denies any frank chest pain, shortness of breath
from baseline, fevers. Similar to prior, she endorses symptoms
of fatigue and a non-productive cough. With these symptoms, she
was reffered to the ED for evaluation.
On arrival to the ED, T 97.1, BP 84/55, HR 94, 100% on 4L. She
was given 2L of NS, and SBP quickly improved to 100 and has
remained there since. She was given a dose of CTX and ASA 325mg.
She was admitted to the MICU for further management.
Past Medical History:
- nonsmall cell lung cancer, s/p lung surgery x 2, chemo and
radiation (last Chemo on [**2182-6-15**])
- h/o breast ca on right s/p lumpectomy, no further treatment
- COPD
- hypothyroidism
- hyperlipidemia
- hypertension
- chronic headaches
- mitral regurgitation
- [**Date Range 499**] polyps
- GERD
- anemia
- hyperglycemia (secondary to steroid use)
- caridac demand ischemia with cath [**12-23**] with 2 vessel
non-obsructive CAD.
Social History:
Lives alone in a senior home on the [**Location (un) 448**]. She is a widow
and has no children. Niece is health care proxy. Smoked for 70
years and currently smokes 4 ciggarettes a day. No EtOH or drug
use.
Family History:
Twin sister with lung cancer, other sister with [**Name2 (NI) 499**] cancer,
two others with cardiac disease; one brother with cardiac
disease and one with [**Name2 (NI) 499**] cancer; mother w/ cardiac disase and
father died of PNA.
Physical Exam:
(Upon arrival to the floor)
T= 97.8 BP=106/56 HR=103 RR=16 O2=97%
GENERAL: Pleasant, thin, well appearing in NAD,
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
NECK: Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= flat
LUNGS: Diffuse End-Expiratory Wheezes. Otherwise CTAB with good
air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-15**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission Labs:
[**2183-2-6**] 03:45PM WBC-7.9 RBC-5.32 HGB-9.8* HCT-32.7* MCV-61*
MCH-18.4* MCHC-30.0* RDW-15.9*
[**2183-2-6**] 03:45PM NEUTS-78.0* LYMPHS-12.5* MONOS-5.7 EOS-3.5
BASOS-0.3
[**2183-2-6**] 03:45PM PLT COUNT-328#
[**2183-2-6**] 03:45PM CK-MB-NotDone
[**2183-2-6**] 03:45PM cTropnT-0.03*
[**2183-2-6**] 03:45PM CK(CPK)-40
[**2183-2-6**] 03:45PM UREA N-37* CREAT-1.7* SODIUM-141
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-16
[**2183-2-6**] 03:50PM LACTATE-1.9
Studies:
[**2183-2-6**] Transthoracic ECHO:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size and free wall motion are normal. There is no
mass/thrombus in the right ventricle. The aortic valve leaflets
are mildly thickened (?#). There is no aortic valve stenosis.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no systolic anterior motion of the
mitral valve leaflets. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate pulmonary artery systolic hypertension.
Normal biventricular cavity sizes with preserved global
biventricular systolic function.
[**2183-2-6**] EKG - Sinus rhythm. There is borderline resting sinus
tachycardia. Borderline left axis deviation. Possible prior
inferior myocardial infarction. Relatively low limb and lateral
precordial voltage. Non-specific ST-T wave change. Compared to
the previous tracing of [**2183-1-6**] repolarization abnormalities
are less apparent.
[**2183-2-6**] AP CXR - IMPRESSION:
1. New increased area of opacity in the left upper lobe may
represent pneumonia or progression of neoplastic disease.
Multifocal ill-defined pulmonary opacities represent patient's
known metastatic lung cancer.
2. Grossly stable right pleural effusion-thickening.
[**2183-2-7**] PA & LAT CXR - Nevertheless, the pre-existing bilateral
opacities, likely to represent a combination of malignant and
inflammatory disease, have increased in extent. The cardiac
silhouette is unchanged, the right pleural effusion is
distributed in a slightly different manner, but its overall
extent is unchanged. Moderate tortuosity of the thoracic aorta.
Brief Hospital Course:
Mrs. [**Known lastname 17536**] is a 87 year old female with a history of COPD,
CAD, metastatic NSCLC, who presented with chest pain, likely
secondary to worsening GERD symptoms, and was found to be
hypotensive.
# Hypotension: Hypotensive to 80s on presentation, but had
resolved and remained stable with IVF hydration. Did not require
pressors. Most likely volume depletion in the setting of
nausea/vomiting and poor PO intake, as well agressive
antihypertensive regimen in the setting of 25 lb weight loss. No
evidence of cardiogenic shock, with normal TTE, no EKG changes,
and essentially stable cardiac markers. Additionally, no
evidence of active infection, without fever, white count, and no
concerning infiltartate on CXR. Blood pressure medications were
held in the ICU and on the floor and her blood pressure remained
well controlled with SBP 110 - 140. Given her stable blood
pressure and tachycardia with ambulation, as well as known CAD,
her atenolol was restarted on discharge. Her lisinopril and
hydrochlorothiazide/spironolactone were not restarted.
# Heartburn: Given recent discontinuation of PPI, her symptoms
were most likely from uncontrolled reflux. Given her known CAD,
she was ruled out for an MI. EKG was without ischemic changes
and cardiac markers did not rise above 0.03. She was restarted
on a PPI since plavix was on for medical management of CAD. Both
the PCP and oncologist were emailed by the ICU team.
# Shortness of breath / COPD flare. The patient's symptoms were
difficult to distinguish from those caused by her underlying
lung cancer. Advair and albuterol were continued per home
regimen along with standing atrovent nebs in the ICU. The
patient was started on a Predisone taper. On the floor her
wheezing improved on this regimen and she kept her oxygen
saturation above 90% on room air with ambulation on the day of
discharge. Additional possible etiologies for her shortness of
breath include anemia and pulmonary embolism. In discussing the
latter possibility with the patient, she decided that if she had
a pulmonary embolism she would not want anticoagulation. As the
patient's symptoms improved with transfusion and prednisone and
she did not want anticoagulation, further evaluation for PE was
not initiated.
# Anemia: The patient was transfused 1 unit of PRBCs for a
hematocrit drop to 26. There was no evidence of gross blood
loss. She will have an outpatient lab draw 1 week following
discharge with results faxed to her PCP to ensure that her
anemia is not worsening.
# Acute Renal Failure: Likely prerenal from volume depletion.
Her creatinine returned to baseline in response to IV fluids.
Her UA was without evidence of infection or intrinsic renal
dysfunction.
# Non-small cell lung cancer. Per the most recent oncology note
(Dr. [**Last Name (STitle) 3274**], the patient's disease is progressing despite
optimal medical management. She is still doing sufficiently well
to live independently, but consideration to initiating hospice
may be appropriate in the near future. She has decided against
further chemotherapy.
# Hypothyroidism. Synthroid was continued per home regimen.
# Code Status: The patient expressed her wishes to be DNR/DNI
and not undergo invasive procedures going forth.
Medications on Admission:
1. Ranitidine 75mg [**Hospital1 **]
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aldactazide 25-25 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for cough/SOB.
11. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a
day for 12 days: Take 40 mg for 3 days, followed by 30 mg for 3
days, followed by 20 mg for 3 days, followed by 10 mg for 3
days.
Disp:*30 Tablet(s)* Refills:*0*
12. Crestor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day
for 8 days: Take 3 tablets for 2 days; then 2 tablets for 3
days, then 1 tablet for 3 days.
Disp:*15 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Please draw CBC and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] at
[**Telephone/Fax (1) 6443**].
11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis
- Hypotension
- COPD Excerbation
- Metastatic Non-Small Cell Lung Cancer
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital with a low blood pressure and
increased shortness of breath, likely due to a COPD flare. We
have stopped several of your blood pressure medications and your
blood pressure has stayed in a good range. Your shortness of
breath has improved with treatment of your COPD flare.
The following changes have been made in your medications.
- Stop taking lisinopril and aldactazide (hydrochlorothiazide
and spironolactone).
- Stop taking ranitidine
- Restart omeprazole
- Take prednisone as prescribed to finish treating your COPD
flare.
Weigh yourself every morning, call your physician if your weight
goes up more than 3 lbs.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**0-0-**]
Date/Time:[**2183-2-18**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6887**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2183-2-25**] 1:15
|
[
"5849",
"41401",
"4240",
"2859",
"3051",
"2449",
"53081",
"4019",
"2724"
] |
Admission Date: [**2179-4-14**] Discharge Date: [**2179-4-20**]
Date of Birth: [**2179-4-14**] Sex: F
Service: NEONATOLOGY
HISTORY: Baby Girl [**Known lastname **] was born at 37 6/7 weeks
gestation by spontaneous vaginal delivery after an induction
for intrauterine growth restriction and a non-reassuring
fetal heart rate pattern. She was born to a 23-year-old
gravida IV, para I now II woman, whose prenatal screens are
blood type A positive, antibody negative, rubella immune, RPR
nonreactive, hepatitis surface antigen negative, group B
strep unknown. Rupture of membranes occurred four and a half
hours prior to delivery, with clear fluid. There was no
intrapartum fever or sepsis risk factors. The second stage
of labor lasted only six minutes. The infant emerged
vigorous. Apgars were 8 at one minute and 9 at five minutes.
She went to the Newborn Nursery, where she was noted to be
grunting at the time of admission and, at five hours of age,
she was transferred to the Newborn Intensive Care Unit for
persistent respiratory distress. Her birth weight was 3100
grams (75th percentile for gestational age), her birth length
was 49.5 cm (75th percentile), and her head circumference 35
cm (90th percentile).
PHYSICAL EXAMINATION: Reveals a vigorous, non-dysmorphic,
term-appearing infant. Anterior fontanel open and flat,
sutures approximated. A small unilateral cleft lip, palate
intact. Mild grunting, however, intermittently quiet.
Breath sounds equal with quiet. No flaring, some head
bobbing. Pink and well perfused. Normal S1, S2 heart
sounds, no murmur. Femoral and brachial pulses +2 and equal.
Abdomen soft. Clavicles intact. Normal spine examination,
normal extremity examination. Term female external
genitalia, and tone slightly decreased generally.
HOSPITAL COURSE BY SYSTEM:
1. Respiratory: The infant required nasal cannula oxygen
until day of life three, when she weaned to room air, and has
remained there since that time. Her chest x-ray was
consistent with retained fetal lung fluid. On examination,
her respirations are comfortable, and her lung sounds are
clear and equal.
2. Cardiovascular: She has remained normotensive throughout
her Newborn Intensive Care Unit stay. She has normal S1, S2
heart sounds, no murmur. She is pink and well perfused.
3. Fluids, electrolytes and nutrition: Enteral feeds were
begun at the time of delivery. She is breast feeding. She
did have some trouble with latching on, and is currently
bottle feeding, and she has tried a variety of nipples, but
is now taking adequate volume with a well-coordinated suck
and swallow. She has been taking breastmilk ad lib volumes by
bottle - up to 75-80cc. Mother plans on trying to
breastfeeding again at home.
Her weight at the time of discharge is 2960 grams.
She was evaluated by Plastic Surgery nurse, [**First Name8 (NamePattern2) 40699**] [**Last Name (NamePattern1) **]
from [**Hospital3 1810**] Plastic Surgery team. The plan is
for her to be seen at [**Hospital1 **] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 40701**] at one
month of age, and surgery for repair of the cleft lip at
approximately three months of age.
4. Gastrointestinal: She has been treated with phototherapy
for physiologic hyperbilirubinemia. Her peak bilirubin on
[**2179-4-17**] was total 16.0, direct 0.3. Her bilirubin on the day
of discharge was
5. Hematology: Her hematocrit at the time of admission was
54, platelets 389,000. She has received no blood products
during this Newborn Intensive Care Unit stay.
6. Infectious Disease: Ampicillin and gentamicin were begun
at the time of admission for sepsis risk factors. The
antibiotics were discontinued after 48 hours when the blood
cultures remained negative and the infant was clinically
well.
The patient was found to be positive for vancomycin resistant
enterococcus on surveillance cultures done in the NICU 2 days
ago. The parents were informed of these results and informed
of the implications of this including the very low risk of any
clinical infection in their baby but the need to inform other
healthcare providers regarding the colonization status. It is
anticipated that this organism will most likely be cleared
from the GI tract over the next several months.
7. Sensory: Hearing screen was performed with automated
auditory brain stem responses, and the infant passed in both
ears.
8. Psychosocial: Mother has been very involved in the
infant's care throughout the Newborn Intensive Care Unit
stay.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: The infant is being discharged home with
her parents.
PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of [**Hospital 2312**] Pediatrics, address [**Apartment Address(1) 41118**], [**Location (un) 538**], [**Numeric Identifier 41119**],
telephone number [**Telephone/Fax (1) 37109**].
CARE RECOMMENDATIONS:
1. Feedings: On an ad lib schedule, breast feeding or
Enfamil 20 calories/ounce.
2. Medications: The infant is discharged on no medications.
3. A state newborn screen was sent on [**2179-4-19**].
4. Immunizations received: The infant has received
hepatitis B vaccine on [**2179-4-19**].
5. Immunizations recommended: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks gestation; (2) Born
between 32 and 35 weeks, with plans for day care during
respiratory syncytial virus season, with a smoker in the
household, or with preschool siblings; or (3) With chronic
lung disease.
Influenza immunization should be considered annually in the
fall for pre-term infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
6. Follow-up appointments:
a. Follow up with primary pediatric care provider within one
week of discharge.
b. Follow up with the Plastic Surgery team at [**Hospital1 **],
telephone number [**Telephone/Fax (1) 41120**], at one month of age.
DISCHARGE DIAGNOSIS:
1. Term female newborn
2. Status post transient tachypnea of the newborn due to
retained fetal lung fluid
3. Sepsis ruled out
4. Minor left cleft lip
5. Hyperbilirubinemia
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2179-4-20**] 00:42
T: [**2179-4-20**] 00:59
JOB#: [**Job Number 41121**]
|
[
"V053"
] |
Admission Date: [**2157-8-19**] Discharge Date: [**2157-8-21**]
Date of Birth: [**2092-4-12**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Droperidol / Gadolinium-Containing Agents / Demerol
/ Morphine / Haldol / Cardizem / Protonix / epinephrine / IV
Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 3565**]
Chief Complaint:
? Anaphylaxis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65 yo woman with a questionable history of systemic mastocytosis
and CAD s/p CABG who presented from the radiology suite where a
code blue was called in the setting of iodine administration.
The patient had been in the radiology suite receiving IV
contrast for a CT pancreas when she developed acute chest pain,
shortness of breath and diffuse itching. Given her history of
anaphylaxis a CODE BLUE was called. Patient was alert and
responsive, was satting 100% on RA though in clear distress.
She was given IV benadryl 75 mg, IV solumedrol 50 mg,
epinephrine IM, racemic epinephrine nebulizer and IV famotidine.
Patient's respriatory status waxed and waned over the course of
the code, but no crowding of the oropharynx was observed and
patient was intermittently stridirous, but also noted to be
holding her breath for short periods of time followed by a
series of rapid deep breaths with good airation. VS during the
code were 158/72, 102 (sinus) sating 100% on face mask and room
air. She was admitted to the ICU for further monitoring.
On arrival to the MICU, patient's VS: 97.9, 137/65, 84, 25, 96%
RA. Patient was speaking in full sentances though clutching at
her chest saying that she could not breath.
Past Medical History:
-CABG [**12/2156**]
- Mast Cell Degranulation Syndrome (Not mastocytosis)
- Primary allergist: [**First Name8 (NamePattern2) 21734**] [**Last Name (NamePattern1) **]
([**Hospital1 112**]; [**Telephone/Fax (1) 21735**]; [**E-mail address 21761**])
- Also seen by Dr. [**First Name (STitle) **]
([**Location (un) 511**] Allergy Asthma and Immunology; [**Telephone/Fax (1) 21748**])
- Portacath [**3-8**] - removed for MRSA infection, re-placed [**2151-6-9**]
- syncope attributed to orthostatic hypotension with positive
tilt table testing [**6-11**]
- Hypothyroidism
- Histrionic personality disorder
- ADHD/depression/anxiety
- Erosive rheumatoid arthritis
- GERD, gastritis and esophagitis on EGD [**2151-1-8**]
- Paradoxical Vocal Cord Dysfunction on fiberoptic laryngoscopy
- s/p hysterectomy and oophorectomy
- left wrist cellulitis concerning for necrotizing fasciitis s/p
fasciotomy
- s/p cholecystectomy
- s/p tonsillectomy
Social History:
Patient denies history of alcohol, tobacco, or drug use. She
used to work as an ED tech. Lives alone. Her PCP is her proxy.
Family History:
Mother died of MI at 76. Sister with breast cancer and bilateral
mastectomy and thyroid cancer. Brother with [**Name2 (NI) 21778**] and
hyperlipidemia.
Physical Exam:
Physical Exam:
Vitals: 97.9, 137/65, 84, 25, 96% RA
General: Alert, oriented, complainging of chest pain, violently
itching face and chest
HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
[**2157-8-19**] 04:49PM WBC-5.5 RBC-4.28 HGB-12.8 HCT-37.5 MCV-88
MCH-29.8 MCHC-34.0 RDW-14.9
[**2157-8-19**] 04:49PM PLT COUNT-223
[**2157-8-19**] 04:49PM GLUCOSE-133* UREA N-9 CREAT-0.8 SODIUM-142
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-27 ANION GAP-13
[**2157-8-19**] 04:49PM estGFR-Using this
[**2157-8-19**] 04:49PM CK(CPK)-63
[**2157-8-19**] 04:49PM CK-MB-2 cTropnT-<0.01
[**2157-8-19**] Radiology CHEST (PORTABLE AP)
Heart size and mediastinum are stable in this patient after
median sternotomy and CABG. Lungs are essentially clear except
for minimal atelectasis at the left lower lung, unchanged since
[**2157-8-3**]. No definitive evidence of aspiration
demonstrated. Calcified mediastinal lymph nodes are seen.
Port-A-Cath catheter tip is at the level of mid low SVC.
[**8-19**] CT Scan:
FINDINGS: A 2-mm left lower lobe pulmonary nodule (2:3) is
stable since
[**2154-10-27**] and is benign. Minimal scarring is seen in the
lingula. Mild
coronary arterial calcification is present.
No focal liver lesions are seen. Mild prominence of the
intrahepatic biliary
tree and CBD, relates to the post-cholecystectomy status. The
adrenal glands
are normal. Mild asymmetric urothelial enhancement is seen in
the right renal
pelvis/ureter, more pronounced in the proximal right ureter
where a focal area
of more marked mural enhancement is seen(3A:83). There is no
frank
hydronephrosis though prominence of the renal pelvis is noted.
The left
kidney is unremarkable.
A 6-mm hypodense lesion in the proximal pancreatic body (3A:67)
and a 6-mm
lesion in the distal pancreas (3A:66), correspond to two of the
cystic lesions
seen in the prior MRI. Additional smaller lesion seen on MRI
are not
visualized in the current study. There is no evidence of
abnormal
enhancement within or adjacent to these lesions, which are
compatible with
dilated side branches as in side branch IPMN. The main
pancreatic duct is
nondilated. Again seen are multiple non-enhancing hypodense
lesions in the
spleen, consistent with simple cysts. The spleen is normal in
size measuring
10.3 cm. The stomach and imaged portion of the small and large
bowel loops are
unremarkable. The abdominal aorta has moderate atherosclerotic
calcification
without aneurysmal dilation. No significant retroperitoneal or
mesenteric
lymphadenopathy is seen. No free fluid is seen.
IMPRESSION:
1. Two 6-mm cystic lesions in the body of the pancreas,
correspond to the
lesions seen on previous MRI study. Additional smaller lesions
are not
visualized. No areas of abnormal enhancement are identified.
These most likely
represent side branch IPMNs. Please note that noncontrast MRI
can be
performed for follow up of these lesions (suggest next follow up
noncontrast
MRCP in one year).
2. Splenic cysts.
3. Asymmetric urothelial enhancement in the right kidney, more
pronounced in
the proximal right ureter, may relate to mild inflammatory
change or pyelitis.
However, urothelial tumor can not be entirely excluded.
Recommended
urinalysis including urine cytology for further assessment.
4. Severe allergic reaction to iodinated contrast media
requiring code blue
and admission to ICU for further evaluation and management.
Brief Hospital Course:
TRANSITIONAL ISSUES FROM MICU:
- Patient was counseled to seek therapy re. panic attacks.
- Patient to follow up with outpatient urology and PCP [**Last Name (NamePattern4) **].
potential UTI
MICU COURSE
? Anaphylaxis: Patient was treated in a code blue setting for
acute airway compromise after receiving ionodated CT contrast.
Received antihistamines, solumedrol and epinephrine in that
setting. Was never hypoxic or hypotensive. Patient was
maintained on home regimen of antihistamines and telemetry/O2
monitoring. Troponins were negative. Patient had no further
acute events, although requested IV benadryl, which was provided
as a slow infusion prn.
Foul smelling urine with evidence of kidney inflammation on
imaging: Patient wanted to leave the hospital today because she
will be going to outpatient urology tomorrow. Patient was
provided with printed records of her imaging studies to take
with her. UA was also performed (which showed 23 WBCs, LG leuks,
but no nitrites).
Hypothyroidism: Continued home levothyroxine.
ADHD/depression/anxiety: Continued home antidepressents.
Erosive rheumatoid arthritis: Held Enbrel and MTX while in
hospital as is q weekly dosing.
GERD: Stable, continued home PPIs.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
2. Aripiprazole 1 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 3.125 mg PO DAILY
hold for SBP <90 or HR <60
5. Clopidogrel 75 mg PO DAILY
6. cromolyn *NF* 100 mg/5 mL Oral QID
please give 30mL
7. Duloxetine 60 mg PO DAILY
8. Ferrous Sulfate 650 mg PO DAILY
9. Fexofenadine 180 mg PO BID
10. FoLIC Acid 1 mg PO DAILY
11. Furosemide 40 mg PO DAILY
12. Gabapentin 600 mg PO TID
13. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
14. Levothyroxine Sodium 25 mcg PO DAILY
15. Lorazepam 1 mg PO DAILY PRN nausea
16. Methadone 5 mg PO TID
17. Methotrexate 22.5 mg PO 1X/WEEK (FR) [**Last Name (NamePattern4) 2974**]
18. Montelukast Sodium 10 mg PO DAILY
19. Multivitamins 1 TAB PO DAILY
20. Omeprazole 40 mg PO DAILY
21. Polyethylene Glycol 17 g PO DAILY:PRN constipation
22. Promethazine 25 mg PO Q8H:PRN nausea
23. Ranitidine 300 mg PO HS
24. Rosuvastatin Calcium 40 mg PO DAILY
25. Vitamin D 1000 UNIT PO DAILY
26. Zolpidem Tartrate 10 mg PO HS
27. etanercept *NF* 50 mg/mL (0.98 mL) Subcutaneous qweek
Discharge Medications:
1. Acetaminophen-Caff-Butalbital 1 TAB PO Q6H:PRN headache
2. Aripiprazole 1 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 3.125 mg PO DAILY
hold for SBP <90 or HR <60
5. Clopidogrel 75 mg PO DAILY
6. Duloxetine 60 mg PO DAILY
7. Ferrous Sulfate 650 mg PO DAILY
8. Fexofenadine 180 mg PO BID
9. FoLIC Acid 1 mg PO DAILY
10. Furosemide 40 mg PO DAILY
11. Gabapentin 600 mg PO TID
12. HYDROmorphone (Dilaudid) 2 mg PO Q6H:PRN pain
13. Levothyroxine Sodium 25 mcg PO DAILY
14. Lorazepam 1 mg PO DAILY PRN nausea
15. Montelukast Sodium 10 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Omeprazole 40 mg PO DAILY
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. Promethazine 25 mg PO Q8H:PRN nausea
20. Ranitidine 300 mg PO HS
21. Rosuvastatin Calcium 40 mg PO DAILY
22. Vitamin D 1000 UNIT PO DAILY
23. Zolpidem Tartrate 10 mg PO HS
24. cromolyn *NF* 100 mg/5 mL Oral QID
please give 30mL
25. etanercept *NF* 50 mg/mL (0.98 mL) Subcutaneous qweek
26. Methadone 5 mg PO TID
27. Methotrexate 22.5 mg PO 1X/WEEK (FR) [**Last Name (NamePattern4) 2974**]
Discharge Disposition:
Home
Discharge Diagnosis:
Please keep your appointment with your urologist on [**2157-8-22**] and
inform him of your CT scan results.
Please see your PCP within [**Name Initial (PRE) **] week of discharge to follow-up the
results of your CT scan and urinalysis.
Discharge Condition:
Stable
Mental status wnl
Fully ambulatory
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted to [**Hospital1 18**] for a possible allergic raection to
iodine during your CT scan. Your respiratory status stabilized
and you were deemed appropriate for discharge on hospital day 2.
Please continue your home medications as prescribed.
Followup Instructions:
Department: RHEUMATOLOGY
When: THURSDAY [**2157-10-6**] at 2:30 PM
With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], 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: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2157-11-15**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2157-8-22**]
|
[
"311",
"2449",
"53081",
"V4581",
"V4582"
] |
Admission Date: [**2190-9-22**] Discharge Date: [**2190-9-27**]
Date of Birth: [**2136-12-24**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Iodine; Iodine Containing / Tape / Ibuprofen /
Levofloxacin
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53yo F with diabetes type 1 c/b neuropathy w/chronic foley in
place, morbid obesity, wheelchair-bound, hypertension, coronary
artery disease s/p CABG, diastolic CHF, recent admission for
flash pulmonary edema, and sarcoidosis complicated by chronic
tracheostomy on 2.5 L/[**First Name3 (LF) **] trach collar at home who p/w shortness
of breath. The pt reports her sxs began abruptly this morning at
home. She noted shortness of breath with associated HA and
nausea (vomited several times) but no chest pain, palpitations,
fevers, chills, cough or wheezing. The pt presented to the ED
where initial vitals were HR 100, 181/105, 97% on 10L. She was
given morphine, Zofran, NTG and a single dose of Lasix.
Consideration to a CTA of the chest was made however the pt
declined because she did not feel she could lie flat and did not
want to be placed on a vent. She was then admitted to the MICU
for further care.
Past Medical History:
1. DM type 1 since age 16 diagnosis (c/b neuropathy,
gastroparesis, nephropathy, retinopathy)
2. Sarcodosis ([**2175**])
3. Tracheostomy - [**3-13**] upper airway obstruction, sarcoid.
4. Arthritis - wheel chair bound
5. Neurogenic bladder
6. Sleep apnea
7. Asthma
8. Hypertension
9. Cardiomyopathy - diastolic dysfunction
10. Pulmonary hypertension
11. Hyperlipidemia
12. CAD s/p CABG [**2179**](SVG to OM1 and OM2, and LIMA to LAD)
last c. cath [**2187-2-28**]: widely patent vein grafts to the OM1 and
OM2, widely patent LIMA to LAD(distal 40% anastomosis lesion).
13. VRE, MRSA - unknown sources
14. s/p cholecystectomy
[**97**]. s/p appendectomy
16. Chronic low back pain-disc disease
17. Morbid obesity
18. Persistent left breast cellulitis
Social History:
Lives alone, has monogamous partner lives 15 [**Name2 (NI) **] away, denies
ethanol, tobacco use.
Family History:
No hx of CAD, diabetes in cousin and uncle
Father had MI in his 60s
Physical Exam:
Vitals: T: 99 BP:86/76 P:72 R:12 SaO2: 965 2L NC 02
Gen: Chronically ill appearing adult female, no acute distress.
HEENT: PERRL, EOMI. Dry MM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD. No tenderness with
palpation.
Chest: Distant breath sounds but no crackles or wheezes.
Cor: Normal S1, S2. RRR. No murmurs appreciated.
Abdomen: Soft, non-tender and non-distended. +BS, no HSM.
Extremity: Warm, without edema. 2+ DP pulses bilat.
Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact
in all extremities. Sensation intact grossly.
Pertinent Results:
[**2190-9-22**] 02:15PM BLOOD WBC-10.8 RBC-4.28 Hgb-12.3 Hct-37.3
MCV-87 MCH-28.8 MCHC-33.0 RDW-13.7 Plt Ct-210
[**2190-9-27**] 05:55AM BLOOD WBC-8.1 RBC-3.41* Hgb-10.1* Hct-29.2*
MCV-86 MCH-29.6 MCHC-34.6 RDW-13.7 Plt Ct-175
[**2190-9-22**] 02:15PM BLOOD PT-12.1 PTT-22.6 INR(PT)-1.0
[**2190-9-22**] 02:15PM BLOOD Glucose-246* UreaN-43* Creat-1.3* Na-133
K-4.3 Cl-94* HCO3-29 AnGap-14
[**2190-9-27**] 03:43PM BLOOD Glucose-118* UreaN-29* Creat-0.9 Na-135
K-3.9 Cl-92* HCO3-36* AnGap-11
[**2190-9-22**] 02:15PM BLOOD ALT-63* AST-66* CK(CPK)-218* AlkPhos-183*
TotBili-0.7
[**2190-9-22**] 02:15PM BLOOD cTropnT-<0.01
[**2190-9-23**] 11:31AM BLOOD CK-MB-10 cTropnT-0.08*
[**2190-9-22**] 02:15PM BLOOD Albumin-3.9 Calcium-9.4 Phos-3.5 Mg-1.8
[**2190-9-27**] 03:43PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.3
Brief Hospital Course:
53 yo female with MMP admitted with increasing SOB and oxygen
requirement.
#Shortness of breath/Hypoxia: DDx includes dCHF in setting of
elevated BP, cardiac ischemia, PE or asthma/sarcoid flair. On
admission was satting adequately on 10L, however pt is at clear
risk for respiratory decompensation. In ED and on arrival to
MICU, importance of CTA was discussed with pt, however she
refused because she stated she could not tolerate the nausea
with IV contrast administration. She was admitted to the ICU for
further care. A heparin drip was started given suspicion of
pulmonary embolus vs cardiac ischemia. Patient was ruled out for
myocardial infarction and lower extremity DVT's were ruled out
with bilateral ultrasound. Heparin was discontinued. No evidence
of fluid overload on clinical examination and shortness of
breath resolved without diuresis. Patient was discharged on home
dose of oxygen at 2.5L delivered by trach mask during the day
and 10L at night for comfort due to sleep apnea. The etiology of
these symptoms remains unclera, however they had completely
resolved with minimal intervention.
#HTN: Pt hypertensive at admission with systolic blood pressures
in the 180's yet is on a minimal antihypertensive regimen at
home. Attempt to gain better BP control with IV meds (hydral)
while uptitrating home regimen. Held [**Last Name (un) **] in setting of possible
CTA. Blood pressures remained low after hydralazine with
systolic pressures in the 90-110 range. All home meds were
reinitiated with BP's in the 110 systolic range.
#ARF: Pt with mildly elevated Cr from baseline (1.0->1.3) on
admission. Suspect pre-renal etiology given pt??????s nausea and poor
PO intake. Consider gentle hydration if no improvement, although
some reluctance to do this in setting of acute lung process.
Patient was given gentle fluid resuscitation and renal function
improved.
#Sarcoid: Pt may have sarcoid flair, although acute onset argues
against this. For now, continue home inhaled steroids and
bronchodilators.
#UTI:Patient has indwelling Foley for urinary retention with
frequent urinary tract infections with multi drug resistant
organisms in the past. She was initially started on zosyn and
the Foley was changed. Urine culture revealed similar resistance
profile to prior infections and she was started on macrobid once
renal function improved.
Medications on Admission:
Aspirin 325 mg daily
Benztropine 1 mg TID
Citalopram 30 mg daily
Docusate Sodium 100 mg [**Hospital1 **]
Fluticasone 110 mcg/Actuation two puffs [**Hospital1 **]
Insulin Glargine 62 units at bedtime.
Furosemide 40 mg [**Hospital1 **]
Lidocain to mucus membranes [**Hospital1 **]
Lorazepam 2 mg QHS PRN
Losartan 25 mg daily
MVI
Metoclopramide 10 mg QIDACHS (20mg, 10mg, 20mg, 10mg)
Metoprolol Tartrate 50 mg [**Hospital1 **]
Gabapentin 300 mg TID
Omeprazole 20 mg [**Hospital1 **]
Salmeterol 50 mcg/Dose Disk with Device [**Hospital1 **]
Simvastatin 20 mg daily
Hydrocodone-Acetaminophen 5-500 mg 1-2 tabs TID PRN
Slow-Mag 64 mg three tabs [**Hospital1 **]
Psyllium one packet TID
Humalog 100 unit/mL Solution Subcutaneous
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Benztropine 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Insulin Glargine 100 unit/mL Cartridge Sig: Sixty Two (62)
units Subcutaneous at bedtime.
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
9. Losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO WITH
LUNCH AND AT BEDTIME ().
12. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO WITH
BREAKFAST AND DINNER ().
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
16. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
17. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
18. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
19. Psyllium Packet Sig: One (1) Packet PO TID (3 times a
day).
20. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
PRN (as needed).
21. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 13 days.
Disp:*25 Capsule(s)* Refills:*0*
22. Mag 64 64 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO three times a day.
23. Humalog 100 unit/mL Solution Sig: Sliding scale
Subcutaneous with meals.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA
Discharge Diagnosis:
Primary:
Hypoxia, etiology undetermined
Acute Renal Failure
Urinary Tract Infection
Secondary:
Diastolic Heart Failure
Obstructive Sleep Apnea
Sarcoidosis
Hypertension
Discharge Condition:
Good. Hemodynamically stable and afebrile. Satting 96% on 2.5
Liters
Discharge Instructions:
You were admitted to the hospital with shortness of breath. It
was thought that this was likely due to your high blood pressure
at that time, however it is not entirely clear. You improved
however during hospitalizations and were much improved at the
time of discharge.
You were treated for a urinary tract infection and should
continue antibiotics.
The following changes were made to your medications:
1)Added macrobid 100mg twice daily for 13 days after discharge
You should return to the emergency department if you should
develop shortness of breath, fevers >101 F, chills, abdominal
pain, nausea, vomiting, chest pain, or any other symptoms that
are concerning to you
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2190-10-4**] 2:50
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2190-10-20**] 2:20
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2190-11-8**] 2:45
Completed by:[**2190-9-28**]
|
[
"5849",
"5990",
"4280",
"4019",
"32723",
"2724",
"4168",
"49390",
"V4581"
] |
Admission Date: [**2121-11-12**] Discharge Date: [**2121-11-26**]
Service: SURGERY
Allergies:
Lopressor / Niacin / Cardura
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Right hemicolectomy
PPM placement due to tachy-brady syndrome
History of Present Illness:
This is a [**Age over 90 **] year old male who presented initially to Neurology
with 2 days of a dull headache. He has a history of artrial
fibrillation and was on coumadin for a-fib. He reported falling
at home in the bathroom and
striking his head 2 days prior to presentation. He was found to
have an acute right subdural hematoma. He was admitted and due
to his SDH his coumadin was disontinued. One day after his
admission to Neurology, he reported an acute onset of
generalized, diffuse abdominal pain. He denied any nausea and
emesis.
Past Medical History:
1. Lumbar L3 compression fracture; status post fall in [**Month (only) **]
of [**2115**] with multiple falls since that point.
2. Delirium.
3. Coronary artery disease; S/P 4 vessel CABG [**2105**] with a left
internal mammary artery to left anterior descending artery,
saphenous vein graft to posterior descending artery, and
saphenous vein graft to first obtuse marginal and 3rd obtuse
marginal. Catheterization in [**2114-8-9**] demonstrated patency
of the grafts. An echocardiogram in [**2116-1-9**] with mild
LVH, left ventricular ejection fraction of greater than 55%, 1
to 2+ mitral regurgitation, and moderate pulmonary artery
systolic hypertension.
3. Hypertension; refractory (on multiple agents).
4. Paroxysmal atrial fibrillation (on Coumadin).
5. Abdominal aortic aneurysm.
6. Chronic renal insufficiency
7. Bilateral renal artery stenosis.
8. Bilateral carotid artery stenosis.
9. Gastroesophageal reflux disease.
10. Lumbar spinal stenosis.
11. Status post cholecystectomy in [**2071**].
12. Status post transurethral resection of prostate in [**2096**].
13. History of hernia repair in [**2110**].
14. Chronic obstructive pulmonary disease.
Social History:
-Tobacco history: quit 50 yrs ago
-ETOH: remote alcohol use
-Illicit drugs: none
Family History:
Father and brother had diabetes mellitus. The patient's brother
is deceased after myocardial infarction x2.
Physical Exam:
on admission:
PE: 102.9, 119, 156/68, 21, 95% on room air
Gen: mild distress, alert and oriented x 3
HEENT: PERRL, EOMI, anicteric, mucus membranes dry
Neck: supple
Chest: tachycardic, lungs clear, sternotomy scar
Abdomen: soft, distended, tender to palpation diffusely but
mainly focused in RLQ, no rebound
Rectal: loose stool, guaiac negative, no masses
Ext: palpable pedal pulses bilaterally, no edema
on discharge:
PE: 98.7, 72, 130/62, 20, 100/2L
Gen: alert and oriented, somewhat tired and drowsy
HEENT: PERRL, EOMI, anicteric, MMM
NECK: supple , no LAD, no JVD
Chest: lungs clear, decreased breath sounds on bases
Abdomen: soft, incisional tenderness,+BS incision c/d/i with
steri strips in place
Extremities: +1 edema
Pertinent Results:
[**2121-11-12**] 08:37AM CK(CPK)-63
[**2121-11-12**] 08:37AM CK-MB-NotDone cTropnT-0.02*
[**2121-11-12**] 08:37AM TSH-2.2
[**2121-11-12**] 03:45AM GLUCOSE-115* UREA N-34* CREAT-1.5* SODIUM-141
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
[**2121-11-12**] 03:45AM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-2.0
[**2121-11-12**] 03:45AM HCT-27.3*
[**2121-11-12**] 03:45AM PT-15.7* PTT-31.8 INR(PT)-1.4*
[**2121-11-12**] 01:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2121-11-12**] 01:00AM URINE RBC-0 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-0
[**2121-11-11**] 11:22PM GLUCOSE-106* NA+-139 K+-5.0 CL--102 TCO2-23
[**2121-11-11**] 11:15PM UREA N-38* CREAT-1.8*
[**2121-11-11**] 11:15PM estGFR-Using this
[**2121-11-11**] 11:15PM CK(CPK)-62
[**2121-11-11**] 11:15PM CK-MB-NotDone
[**2121-11-11**] 11:15PM WBC-6.6 RBC-3.79* HGB-11.9* HCT-35.4* MCV-93
MCH-31.4 MCHC-33.6 RDW-14.2
[**2121-11-11**] 11:15PM NEUTS-73.8* LYMPHS-16.3* MONOS-8.3 EOS-1.2
BASOS-0.4
[**2121-11-11**] 11:15PM PT-26.0* PTT-35.8* INR(PT)-2.5*
[**2121-11-11**] 11:15PM PLT COUNT-196
[**2121-11-11**] 11:15PM FIBRINOGE-476*
CT head ([**2121-11-17**])
NON-CONTRAST HEAD CT: Again demonstrated is the relatively acute
right
subdural hematoma, with maximal thickness of 13 mm layering over
the right
temporoparietal convexity (2:17), not significantly changed
since the most
recent exam. There is also blood layering in the right
suboccipital region,
over the right tentorial leaflet, extending anteriorly. Blood is
also seen in
the temporal [**Doctor Last Name 534**] of the right lateral ventricle, grossly
unchanged. There is
no significant shift of the midline structures. Prominence of
the ventricles
and sulci is stable and consistent with age- appropriate volume
loss. There is
asymmetric decreased size of the right lateral ventricle and
effacement of the
right-sided cerebral sulci likely secondary to mass effect from
the right
subdural hematoma, also grossly stable.
No lytic or blastic osseous lesion is seen. The visualized
mastoid air cells
are clear. There is mucosal thickening and air-fluid level in
the right and a
mucus retention cyst in the left maxillary sinus; the air-fluid
level in the
right maxillary sinus appears new over the series of studies.
IMPRESSION:
1. Unchanged right subdural hematoma, with only slight mass
effect on the
right lateral ventricle and effacement of the subjacent sulci,
and no
significant shift of midline structures.
2. No new hemorrhage.
3. Worsening right maxillary sinus mucosal sinus disease with
new air-fluid
level; clinical correlation for evidence of acute sinusitis is
suggested.
ECHO ([**2121-11-20**])
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%). [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.] No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Moderately thickened aortic valve leaflets. No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Moderate (2+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate [2+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are moderately thickened. There is no aortic valve stenosis.
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse.
Moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate mitral and tricuspid regurgitation. Moderate pulmonary
hypertension.
Brief Hospital Course:
This [**Age over 90 **]-year-old gentleman was admitted to the General Surgical
Service for evaluation and treatment of abdominal pain. He
recently fell at home and suffered a subdural hematoma and was
initially admitted to the neurosurgical service. Two days after
his admission, he had an acute onset of abdominal pain following
reversal of his anticoagulation for atrial fibrillation. A CT
scan, as well as physical exam
and history all pointed towards an ischemic colon with portal
venous gas evident on the imaging. This was a situation that was
deteriorating fast. After a detailed and
fair and balanced assessment of the risk profile, the patient
decided to pursue an operative approach and we decided to
proceed emergently with a exploratory laparotomy.
Postoperatively, the patient was transferred to the intensive
care unit. A stat head CT ordered as per neurology didn't show
any interval change. The patient remained intubated overnight,
sedated on propofol gtt. hemodynamically stable.
He was extubated on POD1 without any incident and transferred to
the floor.
Neuro: s/p fall with R SDH, he had a simple partial seizure in
the ED where he received 2 mg of ativan and was loaded with
keppra. Repeated head CTs showed an unchanged right subdural
hematoma, with mass effect, but no shift of
midline structures or herniation. The patient remained stable
without any focal nuerological deficits.
CV: The patient has a history of a-fib, hypertension,
hypercholesterolemia and carotid stenosis. In the first
postoperative days he remained stable hemodynamically with rate
control home medications atenolol and nifidepine. He triggered
[**2121-11-20**] at 0230 for chest pain associated with SOB and
diaphoresis. An ECG showed ST-segment depressions in V4/V5.
Given 2 mg morphine, SL NTG x1, metoprolol 10 mg IV, furosemide
20 mg IV. Pt had resolution of sx and ST-segment depressions. BP
then 140/80.Trop peaked at 0.13. The mild elevation in troponin
likely represented demand ischemia given recent stressors and
surgery.
In the following days he had intermittent Afib alternating with
episodes of sinus bradycardia with long conversion pauses.
Cardiology was consulted and it was felt that he would benefit
form PPM placement, which would allow for better control of his
ventricular rate in atrial fibrillation.
A permanent pacemaker was placed. The patient did well after the
procedure. He had some hypertensive episodes in the following
days. His Valsartan dose was increased from 120 to 160mg)and he
was restarted on the beta blocker. He might require further
titration and adjustment of his blood pressure medications.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet and incentive spirometry were encouraged throughout
hospitalization.
GI/GU/FEN: s/p right colectomy, large midline incision.
Post-operatively, the patient was made NPO with IV fluids. Diet
was advanced when appropriate, which was well tolerated.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary. Docusate was given for
bowel regimen. The patient failed two voiding trials (most
recent one on [**2121-11-24**]). A foley was put back and remained in
place.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible, but is not back to his
baseline level yet. He will still need long term
anticoagulation, although this is currently being held due to
recent subdural hemorrhage. He will follow up with Neurosurgery
on [**2121-12-3**].
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Furosemide 20 mg daily
Simvastatin 40 mg daily
Aspirin 325 mg daily
Vit C 250mg [**Hospital1 **]
MVI daily
Terazosin 10 mg
Atenolol 25 mg
Nifedipine 90 mg
Valsartan 120 mg
Omeprazole daily
Warfarin 4 mg (T/Th/Sa/[**Doctor First Name **]) and 3mg (M/W/F)
Alendronate 35mg qweek
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for Breakthrough pain.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q2HRS
() as needed for prn SBP > 160.
11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Subdural hemorraghe
Focal ischemia of the right colon
Discharge Condition:
stable
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-18**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please call the office of Dr. [**First Name (STitle) **] / neurosurgeon to be seen
in 2 weeks ( on or about [**2121-12-3**] ) with a CT scan of the brain
to evaluate your sub dural collection. [**Telephone/Fax (1) **] thank you
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**]
Please follow up with General Surgery (Dr. [**Last Name (STitle) **] in 3 weeks
after discharge. Call [**Telephone/Fax (1) 1231**] for an appointment.
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2121-12-1**]
2:00
Completed by:[**2121-11-26**]
|
[
"2762",
"42731",
"40390",
"496",
"2720",
"412",
"V5861",
"V4581",
"V4582"
] |
Admission Date: [**2122-8-14**] Discharge Date: [**2122-8-21**]
Date of Birth: [**2046-6-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2122-8-17**]
1. Urgent coronary artery bypass graft x4 with left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to right coronary and obtuse marginal 1 and 2
arteries.
2. Endoscopic harvesting of the long saphenous vein.
[**2122-8-14**] Cardiac Catheterization
History of Present Illness:
76M with recent history of intermittent chest pain on exertion
which recently evolved into chest pain at rest. He p/t an OSH
where EKG showed ST depressions and a LBBB. He was transferred
to [**Hospital1 **] for cath which revealed three vessel CAD. He is referred
for cardiac surgical evaluation.
Past Medical History:
Past Medical History:
Hypertension
Hyperlipidemia
DMII
LBBB
CAD (2vd in [**2117**])
BPH
Nephrolithiasis
PAD
Past Surgical History:
[**2117-7-5**]- Right femoral endarterectomy with patch angioplasty
[**2116-10-21**]- left fem-[**Doctor Last Name **] bypass, CFA endarterectomy
[**2105**]- left knee meniscus repair
right ankle surgery
Social History:
Race: caucasian
Last Dental Exam: 2 months ago
Lives with: wife
Occupation: retired electrician
Tobacco: quit 40yrs ago
ETOH: 2beers/day (more when the [**Company **] play)
Family History:
Family History: father, mother brother- all died following MI
(although not premature CAD)
Physical Exam:
Pulse: 67 Resp: 16 O2 sat: 100% 2L
B/P Right: Left: 148/77
Height: 5'9" Weight: 72.6kg
General: NAD, WG, WN, appears stated age
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] well healed scar left
medial LE, mid leg to groin (s/p fem-[**Doctor Last Name **] bypass)
Edema none
Varicosities: None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: cath Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
Admission
[**2122-8-14**] 03:00PM PT-13.7* PTT-31.4 INR(PT)-1.2*
[**2122-8-14**] 03:00PM PLT COUNT-186
[**2122-8-14**] 03:00PM WBC-7.3 RBC-4.37* HGB-13.4* HCT-38.5* MCV-88
MCH-30.7 MCHC-34.8 RDW-12.8
[**2122-8-14**] 03:00PM TRIGLYCER-164* HDL CHOL-37 CHOL/HDL-3.9
LDL(CALC)-74
[**2122-8-14**] 03:00PM %HbA1c-7.5* eAG-169*
[**2122-8-14**] 03:00PM ALBUMIN-3.9 CHOLEST-144
[**2122-8-14**] 03:00PM cTropnT-<0.01
[**2122-8-14**] 03:00PM ALT(SGPT)-18 AST(SGOT)-19 CK(CPK)-49 ALK
PHOS-58 AMYLASE-96 TOT BILI-0.4
[**2122-8-14**] 03:00PM GLUCOSE-129* UREA N-11 CREAT-0.8 SODIUM-138
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
Discharge
[**2122-8-21**] 04:30AM BLOOD WBC-8.3 RBC-3.64* Hgb-11.2* Hct-32.0*
MCV-88 MCH-30.8 MCHC-35.0 RDW-13.1 Plt Ct-204#
[**2122-8-21**] 04:30AM BLOOD Plt Ct-204#
[**2122-8-17**] 11:35AM BLOOD PT-15.1* PTT-39.3* INR(PT)-1.3*
[**2122-8-21**] 04:30AM BLOOD Glucose-143* UreaN-12 Creat-0.9 Na-139
K-4.1 Cl-104 HCO3-24 AnGap-15
[**2122-8-21**] 04:30AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.1
Radiology Report CHEST (PA & LAT) Study Date of [**2122-8-21**] 9:44 AM
Final Report: Compared to [**2122-8-19**], the lung volumes have
improved and there is clearing of atelectasis within the lung
bases. There are persistent small bilateral pleural effusions.
Linear opacity in the right lower lung and slightly
heterogeneous opacity in the left retrocardiac region likely
represent atelectasis/scar. Heart size is within normal limits.
Small dense round opacity at the left lung base was seen
pre-operatively and likely represents a granuloma or vessel on
end overlying the rib.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Brief Hospital Course:
A/P: 76yoM with h/o CAD, HTN, DM, PAD s/p L fem-[**Doctor Last Name **] bypass
transferred from [**Hospital1 **]-[**Location (un) 620**] for catheterization after he
presented there on [**8-13**] pm with substernal chest pain.
Cardiac catheterization on [**8-14**] revealed three vessel disease,
mild systolic hypertension, mild LV diastolic dysfunction, and
normal LV systolic function. He was referred to cardiac surgery
for revascularization.
On [**8-17**] he was brought to the opeating room for coronary artery
bypass grafting. Please see operative report for details, in
summary he had:
1. Urgent coronary artery bypass graft x4 -- left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to right coronary and obtuse
marginal 1 and 2 arteries.
2. Endoscopic harvesting of the long saphenous vein. His bypass
time was 67 minutes with a crossclamp time of 58 minutes.
He tolerated the operation well and was transferred
post-operatively to the cardiac surgery ICU in stable condition.
He remained hemodynamically stable in the immediate post-op
period, he woke from anesthesia neurologically intact and was
extubated. On POD1 he continued to be hemodynamically stable and
was transferred to the stepdown floor for further recovery and
physical therapy. All tubes, lines and drains were removed per
cardiac surgery protocol. He was seen by [**Last Name (un) **] diabetes center
for his elevated HgbA1C and was started on Glyburide.
The remainderof his hospital course was uneventful. On POD4 he
was ready for discharge home with visiting nurses. He is to
follow up with Dr [**Last Name (STitle) 7772**] in 3 weeks.
Medications on Admission:
enalapril 10mg [**Hospital1 **]
Lopressor 50mg [**Hospital1 **]
Simvastatin 60 mg daily
asa 325mg daily
Omega 3 fish oil
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. 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*
5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
8. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary Artery Bypass Grafting x4
Hypertension, Hyperlipidemia, Diabetes Mellitus 2, Left Bundle
Branch Block, Benign Prostatic Hypertrophy, Nephrolithiasis,
Periperal Arterial Disease, Right femoral endarterectomy with
patch angioplasty([**6-25**]),left fem-[**Doctor Last Name **] bypass([**10-24**]), CFA
endarterectomy([**2105**]), left knee meniscus repair, right ankle
surgery
Discharge Condition:
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema
Discharge Instructions:
Discharge Instructions
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Recommended Follow-up:
You are scheduled for the following appointments
Surgeon:[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2122-9-14**]
1:15
Cardiologist: [**Last Name (LF) **], [**First Name3 (LF) 122**] [**Telephone/Fax (1) 5068**] on [**2122-9-21**] @ 2:30
in [**Location (un) 620**]
Primary Care Dr [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15048**], MD Phone:[**Telephone/Fax (1) 9347**]
Date/Time:[**2122-9-11**] 10:30
**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:[**2122-8-21**]
|
[
"41401",
"5990",
"4019",
"25000",
"2724"
] |
Admission Date: [**2113-2-9**] Discharge Date: [**2113-2-16**]
Service: MEDICINE
Allergies:
Cisatracurium
Attending:[**First Name3 (LF) 3151**]
Chief Complaint:
2 episodes of dark brown stools
Major Surgical or Invasive Procedure:
NG Lavage [**2113-2-9**]
EGD [**2113-2-14**]
Colonoscopy [**2113-2-14**]
Central Venous Line [**2113-2-11**]
History of Present Illness:
Mr. [**Known lastname 83312**] is an 88M with CAD, afib on warfarin, AS, and h/o
GIB who presented on [**2-9**] with melena x2. In the ED, VS: 96.2,
54, 136/69, 96% RA. He was trace guiac positive on rectal exam.
He was started on protonix and admitted for further workup.
.
Since admission, Hcts have trended down from 31.3->27.1, for
which he received 1 units PRBCs this AM. NG lavage was negative.
He was taken to EGD today but unable to get the procedure [**2-20**]
acute onset of low back pain. Per his daughter this has not
happened before. He was given 2mg of dilaudid which made him
very groggy.
.
Back on the floor, he was hypotensive to the 70's initially with
improvement to the 80's systolic following NS boluses. With
time, his mental status did improve back to baseline. MICU was
called to evaluate given persistent hypotension. Of note, urine
culture obtained [**2-9**] has grown >100,000 E coli. SBPs improved
from 80's to low 100's overnight following IVF resuscitation.
.
On floor eval, patient denied any further chest, back, or
abdominal discomfort, cough, diarrhea. He had some recent
dysuria and hematuria.
Past Medical History:
1. Hypertension
2. Permanent atrial fibrillation
-on coumadin
3. Chronic renal insufficiency
-Baseline creatinine 1.5-1.7
4. Hypercholesterolemia
5. Multiple knee replacements
6. Aortic stenosis
- moderate echo [**6-24**]
7. Coronary artery disease
-OM BMS [**2103**]
-neg P-MIBI [**6-24**]
-EF >55%
8. Elevated homocysteine
9. Hematuria (S/p TURP)
10. [**First Name9 (NamePattern2) **] [**Last Name (un) 2902**]
11. Arthritis
12. Gout
13. GI bleeding
14. Dementia
Social History:
Mr. [**Known lastname 83312**] grew up in the [**Hospital3 4414**] in [**Location (un) 86**]. He was the 3rd
of 7 children in a very tight-knit family. He has been working
in a pharmacy since the age of 12, and after graduating from
high school ([**Location (un) 86**] English High School) and college, he
attended [**State 350**] College of Pharmacy and was a pharmacist
in [**Location (un) 86**] for 56 years and retired 10-12 years ago. He was very
happily married for 61 years, and has 2 daughters and 3
grandchildren. His wife passed away last year following a fall
and leg injury that became infected. He presently lives in an
apartment that joins the home of his younger daughter and
son-in-law in [**Name (NI) 16848**], MA. He uses a walker to navigate the
house and outside, although he is able to climb up and down
stairs. He has never used tobacco, and drinks 3-4 oz of wine
once a week (Sunday) and holidays. He is active both physically
through gardening and intellectually through [**Location (un) 1131**] and writing
avidly. He follows a salt-free diet and eats vegetables he grows
in his garden seasonally in addition to a well-balanced diet.
Family History:
1. Father was a smoker who died in his 60s of lung cancer
2. Mother suffered from chronic peripheral edema and died in her
80s of MI
3. a sister died of liver cancer
4. another sister had a blood disorder: patient could not recall
the name
Patient reports no family history of colon cancer, prostate
cancer, diabetes, CAD, or depression.
Physical Exam:
Vitals - T:97 BP:142/60 sitting and 130/60 standing HR: 45
sitting 59 standing (asymptomatic) RR: 18 02 sat: 99%RA
GENERAL: Pleasant, well appearing male in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. L eye
red, No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP= 9cm
LUNGS: good air movement biaterally, crackles heard b/l bases
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**1-20**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2113-2-9**] 08:16PM CK(CPK)-277*
[**2113-2-9**] 08:16PM CK-MB-6 cTropnT-0.11*
[**2113-2-9**] 08:16PM WBC-4.8 RBC-3.23* HGB-10.9* HCT-30.8* MCV-95
MCH-33.8* MCHC-35.4* RDW-15.6*
[**2113-2-9**] 08:16PM PLT COUNT-120*
[**2113-2-9**] 05:50PM WBC-5.4 RBC-3.48* HGB-11.7* HCT-33.6* MCV-97
MCH-33.8* MCHC-34.9 RDW-15.6*
[**2113-2-9**] 05:50PM PLT COUNT-132*
[**2113-2-9**] 02:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2113-2-9**] 02:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2113-2-9**] 11:30AM GLUCOSE-97 UREA N-50* CREAT-1.8* SODIUM-141
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-34* ANION GAP-13
[**2113-2-9**] 11:30AM cTropnT-0.11*
[**2113-2-9**] 11:30AM proBNP-6332*
[**2113-2-9**] 11:30AM WBC-5.6 RBC-3.26* HGB-11.0* HCT-31.3* MCV-96
MCH-33.7* MCHC-35.1* RDW-15.4
[**2113-2-9**] 11:30AM NEUTS-78.8* LYMPHS-14.4* MONOS-5.5 EOS-1.2
BASOS-0.3
[**2113-2-9**] 11:30AM PLT COUNT-135*
[**2113-2-9**] 11:30AM PT-19.5* PTT-31.1 INR(PT)-1.8*
[**2113-2-8**] 10:40AM GLUCOSE-90
[**2113-2-8**] 10:40AM UREA N-52* CREAT-1.7* SODIUM-139
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-34* ANION GAP-11
[**2113-2-8**] 10:40AM estGFR-Using this
[**2113-2-8**] 10:40AM ALT(SGPT)-32 AST(SGOT)-41* ALK PHOS-82 TOT
BILI-1.1
[**2113-2-8**] 10:40AM ALBUMIN-4.2 CALCIUM-9.2 PHOSPHATE-2.4*
CHOLEST-148
[**2113-2-8**] 10:40AM HDL CHOL-50 CHOL/HDL-3.0 LDL([**Last Name (un) **])-89
[**2113-2-8**] 10:40AM TSH-13*
[**2113-2-8**] 10:40AM FREE T4-1.0
[**2113-2-8**] 10:40AM [**Doctor First Name **]-NEGATIVE
[**2113-2-8**] 10:40AM WBC-5.1 RBC-3.20* HGB-10.6* HCT-31.4* MCV-98
MCH-33.1* MCHC-33.7 RDW-14.8
[**2113-2-8**] 10:40AM NEUTS-75.0* LYMPHS-15.4* MONOS-8.1 EOS-1.2
BASOS-0.3
[**2113-2-8**] 10:40AM PLT COUNT-122*
[**2113-2-8**] SPEP normal
Cryoglobulins pending
.
Micro:
[**2113-2-13**] IMMUNOLOGY HCV VIRAL LOAD-not detecctedFINAL
INPATIENT
[**2113-2-13**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negativeFINAL INPATIENT
[**2113-2-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-11**] URINE URINE CULTURE-FINAL INPATIENT
[**2113-2-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2113-2-11**] BLOOD CULTURE Blood Culture, Routine-FINAL
{ESCHERICHIA COLI}; Anaerobic Bottle Gram Stain-FINAL; Aerobic
Bottle Gram Stain-FINAL INPATIENT
[**2113-2-10**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT
[**2113-2-9**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
.
Studies:
[**2113-2-9**] CXR:
Patchy opacity within the left lower lobe which could represent
atelectasis or aspiration with associated small pleural
effusion. Developing infection is not excluded.
.
[**2113-2-10**] CT GU:
1. Normal kidneys without hydronephrosis or calculi.
2. Pancreatic head calcifications, which can be seen as sequelae
of chronic pancreatitis. No evidence of acute pancreatitis.
2. Extensive diverticulosis of the sigmoid colon, without
evidence of acute diverticulitis.
3. Unchanged cholelithiasis without evidence of acute
cholecystitis.
4. Splenic calcifications consistent with prior granulomatous
infection.
5. Redemonstration of atherosclerotic calcification throughout
the aorta and major branches.
.
[**2112-2-13**] Echo:The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The aortic valve
leaflets (?#) are severely thickened/deformed. There is moderate
aortic valve stenosis (area 1.1cm2). Mild to moderate ([**1-20**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-20**]+) mitral regurgitation
is seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion.
Compared with the prior report (images unavailable for
comparison) of [**2110-12-3**], the ventricle is less vigorous, but
without definite regional dysfunction. The severity of aortic
stenosis, aortic regurgitation, and mitral regurgitation are
similar.
CLINICAL IMPLICATIONS:
Based on [**2111**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
[**2113-2-13**] CXR: Consolidation at the left lung base has progressed
with a persistent small left pleural effusion. The right lung
remains clear, and there is no pneumothorax. The pulmonary
vascularity remains stable. A right jugular central venous line
ends in the lower SVC, unchanged.
.
[**2112-2-14**] EGD: small dulefoy lesion coiled
colonoscopy:2 sessile polyps removed, pathology pending
Brief Hospital Course:
This 88M with h/o afib on warfarin, CAD, AS, and GIV presented
with 2 dark BM worked up for GI bleed with complicated hospital
course by urosepsis.
.
# GI bleed: Admitted with 2 dark guiac positive stools on
coumadin. Had been worked up prior for massive GI bleeds with no
etiology found. Hct trended down slightly, HD stable, GI was
consulted with plan to scope him. Cdiff negative stools. Started
IV PPI [**Hospital1 **], held coumadin. Initially q6 hcts, 2 large bore IVs,
maintained active T+S. Given 2 units of PRBCs and 2 FFP prior to
scope to reverese INR. First scope attempt was [**2113-2-8**] but
patient developed acute back pain. Likely [**2-20**] renal stones, UTI,
early presentation of sepsis. Transferred to MICU for sepsis
treatment as below. When called out of MICU, underwent
colonoscopy which showed two polyps that were removed and an EGD
which showed dulefoy lesion likely accounting for guaic positive
stools, subsequently clipped. Hct stable post procedure. Changed
PO PPI 40mg to daily.
.
#Bacteremia/hypotension: Most likely secondary to E coli
urosepsis(Blood and urine cultures positive) Patient transferred
to MICU where CVL was placed and Ceftriaxone was started.
Hypotension resolved with IVF resuscitation. There was concern
over pneumonia on CXR but the L lung base opacity was stable and
more likely to represent atelectasis vs. small pleural effusion.
He does have any upper resp symptoms or fever with improving
leukocytosis so more likely to be atelectasis, possibly volume
overload more likely than pneumonia. Ceftrixone would cover most
PNA bacteria. Survellience Blood cultures negative to date.
Switched to PO levaquin to complete 2 week course.
.
# CHF: Echo from [**11-24**] LVEF 55%, slightly volume overloaded by
exam, BNP in 6000s which is at baseline. Repeat echo "the
ventricle is less vigorous, but without definite regional
dysfunction. The severity of aortic stenosis, aortic
regurgitation, and mitral regurgitation are similar" EF 50-55%,
held lasix. Monitored I/Os, monitored daily weights. Remained
mostly euvolemic except some trace pretibial edema which
improved with elevation.
.
# Blue fingers: likely vasoconstriction, concern for cold blue
but blanching fingers for ischemia, but no signs of embolic
lesions, consider cryoglobulinemia which was pending upon
discharge. HEPC VL not detected. Gloves for comfort.
.
#CKD: Patient has Cr baseline 1.5, continued gentle hydration,
renally dosed meds, followed urine output. Held lasix and can be
restarted as outpatient.
.
#Afib:rate controlled without nodal agents, previously on
coumadin, tele picking up ~2 sec pauses. EP consulted for
concern over pacemaker but will hold off for now as he is
asymptomatic and pauses <3sec. Will follow with cards as
outpatient. Coumadin was discontinued indefinitely as he now has
GI bled multiple times.
.
#CAD: no chest pain, no acute EKG change, cardiac enzymes
stable, monitored on tele.
.
#BPH: continued home medication regimen
.
#hypothyroid: TSH elevated, followed as outpatient, continued
current synthroid at current dose.
.
#General Care: IVF for gentle hydration, replete lytes prn,
clear cardiac diet advanced to regular after GI bleed
stabilized, PPX: PPI, pneumoboots, ACCESS: PIV, CVL into R IJ,
CODE: full, confirmed, CONTACT: dtr [**Name (NI) **] [**Telephone/Fax (1) 101962**], [**Name2 (NI) **]rged
home with PT.
Medications on Admission:
Allopurinol 100 daily
Calcitriol 0.25 mcg MWF
Warfarin
Darbepoetin 60mcg q2 wk
Donepezil 10 daily
Finasteride 5 daily
Tamsulosin 0.4 daily
Lasix 60 daily
Levothyroxine 25 daily
Protonix 40 daily
Kcl 10meq daily
Pravastatin 40 daily
Pyridostigmine 60 TID
Tramadol 50mg q8h
Ferrous sulfate 160 [**Hospital1 **]
Folate
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR
(Monday -Wednesday-Friday).
6. Levothyroxine 50 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: One (1) PO Q8H
(every 8 hours).
9. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
12. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
8 days.
Disp:*8 Tablet(s)* Refills:*0*
13. Aranesp (Polysorbate) 60 mcg/0.3 mL Syringe Sig: One (1)
Injection q2weeks.
14. Ultram Oral
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Primary Diagnosis:
GI bleed
bradycardic atrial fibrillation
urosepsis
.
Secondary Diagnosis:
Myasthenia [**Last Name (un) **]
Discharge Condition:
Stable, ambulating
Discharge Instructions:
You were admitted after your had a large dark bowel movement
which was concerning for bleeding from your GI tract. We
monitored you and had the gastroenterologists follow you. We
checked your stool and made sure you did not have C.Difficle in
your stool. After another dark bowel movement, the GI doctors
decided to [**Name5 (PTitle) **] in side your stomach to see if there was any
evidence of bleed. They found a small area in your upper GI
tract that may have explained your symptoms. You also had 2
polyps removed on your colonoscopy. We then monitored your
blood counts and found you to be stable. We also had the
cardiologist come assess you because of your slow rhythm. They
believe that you do not currently need a pacemaker but you
should continue to follow up with your cardiologist so they can
asses if you will need one in the future. You also stayed in
the intensive care unit because you developed a urinary tract
infection and bacteria got into your blood stream. We treated
this with antibiotics and your infection improved. You were
cleared by physical therapy to go home but you will still need
some physical therapy when you go home.
.
Please stop your lasix and potassium until your primary care
doctor or cardiologist resumes them. Please continue to take
Levaquin for 8 more days for your infection. We stopped your
coumadin since you have now had multiple episodes of recurrent
GI bleeding and the risks to bleed again are much greater than
your overall risk for stroke. Please continue with your Aranesp
injections.
.
Please follow up with your primary care doctor to adjust your
synthroid dose.
.
Please continue to follow up with your primary care doctor and
your cardiologists as scheduled.
.
If you develop any of the following, chest pain, shortness of
breath, dizziness, fever, chills, nausea, vomiting, or
increasing dark bowel movements please call your doctor or go to
your local emergency room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2113-3-1**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2113-3-2**] 8:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2113-8-8**] 10:20
Completed by:[**2113-2-16**]
|
[
"2851",
"99592",
"5845",
"78552",
"486",
"5180",
"40390",
"5859",
"2875",
"42731",
"V5861",
"41401",
"V4582",
"4241",
"2449",
"2720",
"V1582"
] |
Admission Date: [**2183-7-9**] Discharge Date: [**2183-7-12**]
Date of Birth: [**2133-7-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Bactrim
Attending:[**First Name3 (LF) 31499**]
Chief Complaint:
unresponsive on couch x3 days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49M with history of HIV (CD4 119, VL 175 in [**5-8**]), HCV,
cirrhosis, varices, portal vein thrombosis, splenomegaly,
substance abuse, gout who presented from home b/c he had been
unable to get up from his couch for 3 days. He presented to the
ED extremely lethargic and borderline unresponsive, requiring
NRB to maintain SaO2 > 95%. An LP was performed and blood
cultures were obtained. An initial CXR was performed which was
negative for infiltrate. A CT abd/pelvis was performed that
revealed no acute process, chronic changes as described below,
and bilateral basilar PNA vs. atelectasis, as well as a nodular
opacity at the right base. Serum tox screen was negative but
urine tox was positive for methadone, cocaine and benzos. The
patient remained lethargic, was noted to have pinpoint pupils,
and subsequently was given Narcan, with signficant improvement
in his mental status.
.
The patient was to be transferred to a geneal medicine team but
while he was being transferred to the floor he became
hypotensive to the 90s. He was subsequently transferred to the
ICU. The patient reports he had binged on cocaine 3 days prior
and developed an "arthritis flare". He had so much pain in his
shoulders he could not get off the couch and could not reach out
to eat or drink anything. He took ~8 klonopin ("strongest dose")
and 80 mg of methadone to help with the pain. His girlfriend
finally brought him in after 3 days. He denies fevers,
headaches, SOB, N/V, abd pain, diarrhea, dysuria or hematuria.
He did have some chills and developed a non-productive cough 4
days ago.
Past Medical History:
-- HIV/AIDS dx in [**2163**], CD4 nadir 95 in [**2179**]
-- H/o zoster
-- H/o positive toxo IgG in [**2180**]
-- H/o positive CMV IgG in [**2180**]
-- H/o positive Hep A ab in [**2183**]
-- H/o positive Hep B core AB in [**2183**] (with neg sAB, neg
antigen)
H/o negative RPR in [**2183**]
-- Negative PPD in [**2183**]
-- Osteomyelitis L knee 10 years ago [**3-6**] IVDA
-- Portal vein thrombosis seen on CT in [**2183**]
-- Hepatitis C, s/p varices, portal gastropathy, splenomegaly
-- Esophageal varices s/p banding
-- Gout (dx age 18; hx of tophi removal; on allopurinol in the
past. Was seen in [**Hospital **] Clinic [**2182-3-5**].)
-- Substance abuse (mostly IV heroin, benzos, cocaine)
[**Hospital **] Medical noncompliance
Social History:
Pt lives alone and is unemployed. 2 PPD x 20 yrs. No current
ETOH use (last use 15 yrs ago). Polysubtance abuse - daily
heroin, occasional methadone, cocaine, and benzos; currently
does not use heroin while on methadone. Contracted HIV and Hep C
from IVDA.
Family History:
Non-contributory
Physical Exam:
VS: 98.7 | 58 | 92/58 | 14 | 95% 4L NC
.
GEN: awake, alert, answering questions appropriately
HEENT: OP clear, MM dry, Anicteric.
COR: RRR, nl S2 S2, no m/r/g
CHEST: decreased breath sounds at bases, few rhonchi at left
lung base
ABD: soft, NT, mildly distended with hypoactive BS. No
hepatomegaly.
EXT: multiple bruises present on BLE. No c/c/e. Warm, well
perfused.
L knee: swollen and hot compared to the right, with no erythema,
unable to fully flex knee [**3-6**] to pain
Neuro: PERRL, EOMI, CN 2-12 intact, muscle strength grossly
intact
Pertinent Results:
[**2183-7-8**] 02:30PM PT-15.5* PTT-27.0 INR(PT)-1.4*
[**2183-7-8**] 02:30PM PLT COUNT-78*
[**2183-7-8**] 02:30PM NEUTS-77.9* LYMPHS-15.5* MONOS-5.8 EOS-0.4
BASOS-0.5
[**2183-7-8**] 02:30PM WBC-7.7# RBC-4.29*# HGB-13.2*# HCT-39.0*#
MCV-91 MCH-30.8 MCHC-33.9 RDW-15.4
[**2183-7-8**] 02:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-7-8**] 02:30PM ALBUMIN-4.1 CALCIUM-8.6 MAGNESIUM-2.2
[**2183-7-8**] 02:30PM CK-MB-NotDone cTropnT-<0.01
[**2183-7-8**] 02:30PM LIPASE-22
[**2183-7-8**] 02:30PM ALT(SGPT)-14 AST(SGOT)-15 ALK PHOS-54
AMYLASE-27 TOT BILI-1.0
[**2183-7-8**] 02:30PM CK(CPK)-91
[**2183-7-8**] 05:10PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-0 POLYS-0
LYMPHS-90 MONOS-10
[**2183-7-8**] 05:10PM CEREBROSPINAL FLUID (CSF) PROTEIN-46*
GLUCOSE-79
[**2183-7-8**] 07:05PM TYPE-ART PO2-190* PCO2-49* PH-7.32* TOTAL
CO2-26 BASE XS--1
[**2183-7-8**] 07:51PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.0
LEUK-NEG
[**2183-7-8**] 07:51PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-POS
[**2183-7-8**] 07:51PM URINE HOURS-RANDOM
..
.
[**2183-7-9**] 12:05PM JOINT FLUID NUMBER-MOD SHAPE-ROD LOCATION-I/E
BIREFRI-NEG COMMENT-c/w monoso
[**2183-7-9**] 12:05PM JOINT FLUID WBC-[**Numeric Identifier **]* RBC-7500* POLYS-81*
LYMPHS-1 MONOS-2 MACROPHAG-16
.
[**2183-7-8**] - UPRIGHT AP VIEW OF THE CHEST: Heart is normal in size
with a left ventricular configuration. The aorta is mildly
tortuous. Pulmonary vascularity is normal, and the lungs are
clear. There are no effusions or pneumothorax. The osseous
structures are unremarkable. Right internal jugular central
venous catheter has been removed in the interval.
.
[**2183-7-8**] HEAD CT - There is no evidence of an intracranial
hemorrhage. There is no shift of normally midline structures,
mass effect, or hydrocephalus. The [**Doctor Last Name 352**]-white matter
differentiation is preserved, with no cerebral edema. There is
no fracture. The included portions of the paranasal sinuses, as
well as the mastoid air cells and middle ear cavities are clear;
there are bilateral conchae bullosa. Incidentally noted is a
punctiform radiodensity in the right globe.
.
[**2183-7-8**] - ABD/PELVIS CT:
1. Persistent thrombus seen in the left and main portal veins,
as well as within the distal aspect of the superior mesenteric
vein. The appearance is similar to the prior study.
2. Nonspecific mesenteric stranding, unchanged since the prior
study.
3. Persistent splenomegaly. 5-mm heterogenous lesion within the
splenic parenchyma is stable as compared to the prior study.
4. Aspiration versus atelectasis at the lung bases, there is a
more nodular opacity at the right base, which could represent
pneumonia.
Brief Hospital Course:
The patient was intially admitted to the MICU for concerns of
his fever and mental status changes. His hospital course by
problem list is as follows.
.
1) Hypotension - In the ED, he transiently dropped his systolic
blood pressures into the mid 90s, resulting in ICU admission.
Upon further review of his past records, this blood pressure
appears to be near his baseline. He did not demonstrate any
shock physiology, and continued to mentate well with normal
urine output despite this. After admission, his blood pressures
were consistently stable in the low 100s-130s systolic.
.
2) Fever - possible sources included the basilar atelectasis vs
aspiration pneumonia seen on abdominal CT (but patient was
without cough, shortness of breath, tachypnea); his L knee
effusion (found to be gout on arthrocentesis), blood cultures
(growing sparse G+ cocci, coag negative in [**2-7**] bottles, thought
to be a contaminant), or a urine which grew out 10,000 CFU of
enterococci (with no pyuria on his UA). He also had an LP in the
ED which was negative. Based on this clinical picture, the
patient was thought to have fever intially due to gout. His
fevers resolved promptly on admission to the hospital, and he
remained asymptomatic and afebrile throughout his course. Per ID
reccs (who are familiar with the patient) and ECHO was obtained
to r/o endocarditis. This was negative. The patient was
discharged on an additional 7 day course of amoxicillin for his
enterococcus UTI, repeat u/a showed no bacteria or WBCs.
.
3) Mental status changes - Patient had negative LP, head CT, no
other signs of infection (as above). He did have significant
recent substance abuse. Upon admission, his mental status had
cleared and remained so throughout his stay. This was attributed
to his substance abuse. A social work/substance abuse consult
was obtained.
.
4) Gout - crystal proven by L knee arthrocentesis performed on
HD#1. He was restarted on his home dose of allopurinol, also
started on colchicine, prednisone 30mg qd x 2 days, 20 mg x 1
days, with significant symptomatic relief. He then will resume
home dose of 5 mg daily.
.
5) ARF - the patient initially presented with a new creatine to
2.1. This rapidly improved with IVF, his urine electrolytes
showed a FeNA < 0.01, and was therefore attributed to prerenal
azotemia. His creatinine remained stable throughout the rest of
his admission.
.
6) HIV/AIDS - the patient's HAART medications were intially held
due to his ARF, but restarted at home doses on HD#2. He remained
on his azithromycin and bactrim prophylaxis throughout the
admission.
Medications on Admission:
-- azithromycin 1200mg PO qweek
-- dapsone 100 qd
-- Kaletra 2 tabs [**Hospital1 **]
-- Epzicom 1 tab daily
-- Tenofovir 300mg Daily
-- Nadolol 40mg PO QD
-- allopurinol 300 qd
-- prednisone 5 qd (for gout)
-- compazine (to be given before Kaletra)
-- methadone
-- colace
-- protonix
Discharge Medications:
1. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO QWEEK
(MONDAY) ().
2. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO BID
BEFORE KALETRA ().
4. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
9. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble
PO DAILY (Daily).
10. Lopinavir-Ritonavir 200-50 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
11. Abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Lamivudine 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO twice a
day for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Polysubstance abuse
Urinary tract infection
HIV
Hepatitis C
Discharge Condition:
stable
Discharge Instructions:
Please take your medications including the antibiotic you were
prescribed as directed. Follow up with your regular infectious
disease clinic next week as scheduled below.
It is very important that you do not use recreational drugs.
Please don't hesitate to seek medical care if you develop any
fever, chills, weakness, urinary burning or any other concerning
symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 7805**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2183-7-18**]
10:30
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2183-8-12**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2183-8-12**] 11:00
Completed by:[**2183-7-12**]
|
[
"5849",
"5990"
] |
Admission Date: [**2102-6-12**] Discharge Date: [**2102-6-16**]
Date of Birth: [**2044-7-15**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Hismanal / Iodine; Iodine Containing / Neurontin
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Hematemesis and hypotension
Major Surgical or Invasive Procedure:
EGD x 2
History of Present Illness:
57M PMH HIV, lymphoma in remission, GERD BIBA with hematemesis
and hypotension. He reports fatigue and burning epigastric pain
over the past two days. His partner found him the morning of
admission having vomited coffee ground emesis and called EMS.
Denies melena, BRBPR. No history of GI bleeding in the past. He
did undergo EGD and colonoscopy in [**2100**] revealing esophagitis
and a colonic adenoma. No other lesions found at that time.
.
In the ED, VS: T 98.3 BP: 64/42 HR: 119 RR: 18 SaO2: 95%RA.
- Cordis placed.
- Given 4L NS.
- Hematocrit 20.8 from baseline 37.7 [**2102-5-15**].
- Given 2 units uncrossmatched blood.
- FAST exam: question free fluid in the abdomen.
- Given protonix 40 mg IV, levofloxacin 750 mg IV, flagyl 500 mg
IV.
.
No further episodes of hematemesis since presentation to the ED.
He currently denies chest pain, shortness of breath,
lightheadedness, abdominal pain, nausea, vomiting. Denies
fevers, chills.
Past Medical History:
1. HIV, diagnosed in [**2074**] - CD4 288, VL < 50 [**2102-5-15**].
2. Stage III non-Hodgkin's lymphoma [**2089**], status post m-BACOD.
3. Stage III Hodgkin's disease [**8-/2092**], status post ABVD, had
recurrence stage IA Hodgkin's disease right neck. He was treated
with 1 [**2-8**] cycles of British MOPP, discontinued due to systemic
side effects and which was followed by a course of XRT.
4. Anal biopsies demonstrating low grade squamous
intraepithelial lesion as well as high grade squamous
intraepithelial lesion.
5. Grade III esophagitis due to reflux.
6. Iron deficiency anemia.
7. Status post lumbar laminectomy.
8. Status post appendectomy.
9. Hypothyroidism.
10. Hyperlipidemia.
11. History of herpes zoster.
12. Chronic pain status post MVA/zoster.
Social History:
Lives with partner who is HCP. [**Name (NI) **] alcohol, smoking, or drug use.
Family History:
Non-contributory.
Physical Exam:
VS: T: 98.9 BP: 110/70 HR: 98 RR: 18 SaO2: 98% 2L NC
GEN: NAD
HEENT: AT, NC, PERRLA, EOMI, anicteric, OP with dried blood, MM
dry
Neck: Supple
CV: RRR, nl s1, s2, no m/r/g
PULM: CTAB, no w/r/r with good air movement throughout
ABD: Soft, NT, ND, + BS, no HSM
EXT: Warm, dry, +2 distal pulses BL
NEURO: Sleepy, oriented x 2, confused at times, CN II-XII
grossly intact, MAEW
.
EKG: ST 115, PAC. NA/NI. No ST-T changes.
Pertinent Results:
[**2102-6-12**]
WBC-20.3*# Hgb-7.3*# Hct-20.8*# MCV-89 RDW-14.3 Plt Ct-284
Neuts-83.3* Bands-0 Lymphs-14.7* Monos-1.7* Eos-0.1
Baso-0.1
PT-14.5* PTT-30.9 INR(PT)-1.3*
Glucose-155* UreaN-132* Creat-2.0* Na-133 K-4.8 Cl-99 HCO3-16*
AnGap-23*
ALT-19 AST-38 CK(CPK)-238* AlkPhos-49 TotBili-0.1 Lipase-45
Calcium-9.1 Phos-5.0*# Mg-1.7
Lactate-4.0*
.
Blood cultures [**6-12**]: [**4-11**] coag negative staph; [**2-10**] yeast ->
candidia [**Month/Day (4) 563**]
Followup cultures (8 bottles) final negative.
.
EGD ([**6-12**]): Esophagus: Granular, sclerosed appearing mucosa was
noted in the distal esophgaus with scant red blood. No bleeding
lesion was seen.
Stomach: Clotted blood was seen in the stomach the full stomach
body could not be assessed due to resdual material. The
visualized fundus, body and antrum were normal.
Duodenum: Clotted blood was seen in the duodenum. Normal
mucosa was noted.
.
CXR ([**6-12**]): No evidence of pneumonia, mild bibasilar atelectasis.
.
ECG ([**6-12**]): ST 115, PAC. NA/NI. No ST-T changes
Brief Hospital Course:
A/P: 57M PMH HIV, h/o lymphoma in remission, GERD with grade III
esophagitis p/w acute UGIB and hypotension, admitted to the
MICU.
.
# UGIB: Initially hypotensive with SBP 60's as per HPI.
Received blood and fluid resuscitation (7 units PRBCs total this
admission; 2 were emergency crossmatch). Admitted to MICU. EGD
[**6-12**] with the above results. On [**6-13**] patient had reported
hematocrit drop from 27 to 18; received 2 units and subsequent
hematocrits >30 and stable (?erroneous value). EGD was done
again in light of hematocrit drop, again showing esophagitis but
no other lesions. Last transfusion on [**2102-6-13**]. GI and surgery
followed patient during admission. Source of bleed appeared to
be esophagitis, as no other upper lesions noted. PPI was
continued with [**Hospital1 **] dosing and sucralfate started. Patient was
also asked to avoid chloral hydrate (had been taking at home for
sleep), which can cause gastritis.
.
# Coag negative staph bacteremia. [**4-11**] cultures were positive
from [**6-12**], initially thought to perhaps be a contaminant but
further bottles then became positive. Started vanco on [**6-13**].
Patient with recent root canal and given amox; ?source. TTE was
done without evidence of vegetation. Given low suspicion of
endocarditis, TEE was not done. Surveillance cultures were all
negative. Planned to treat patient with a 14 day course of IV
vancomycin; midline placed. However, prior to arrangements
being made for home IV antibiotics, then patient insisted on
leaving AMA. Midline pulled and patient placed on suboptimal
regimen of levofloxacin PO x 14 days. He was informed that his
treatment regimen was not ideal and could lead to persistent
bacteremia and associated poor outcomes, but refused to stay
until arrangements could be made (if they could be at all given
his insurance).
.
# Fungemia. On [**2102-6-15**] PM, [**2-10**] blood cultures from [**2102-6-12**] turned
positive for budding yeast. He was given a dose of caspofungin.
Possible portal of entry from subclinical esophagitis and entry
to bloodstream during GI bleed. The seriousness of fungemia was
discussed with him, as well as needs to continue IV antifungal
treatments. As above, he insisted on leaving on [**2102-6-16**], against
medical advice. He appeared to have good understanding of his
disease and its risks (patient also a former nurse) but felt
that further workup was unnecessary and he had had his mind set
on leaving that day. Efforts to look for source sites were
attempted; he had CT torso (no evidence of source for his
fungemia). Ophthalmology was also consulted for dilated eye
exam, to which he initially agreed but then refused once they
arrived. He also refused to stay in house for ID consult. As
above, with him leaving AMA and no home IV treatment possible,
he was discharged home on a planned 2 week course of
fluconazole. Following discharge, blood cultures were followed
and the yeast was determined to be [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] (high
resistance rates to fluconazole). Both patient and PCP made
aware of this on [**2102-6-19**]. Per PCP and patient, planning for
very close followup over the next several weeks to include blood
cultures, daily temperature checks, etc. Patient refused return
to the hospital for IV treatment and further workup. Of note, 8
further bottles of blood cultures were negative (now final).
.
# Hypotension: SBP 60s on arrival; primarily hypovolemic with
?septic component as above. Followup callout to the floor, his
SBP was in the low 90s but he was asymptomatic, not tachycardic.
SBPs recorded from outpatient notes generally ~110, but patient
reports BPs in 90's usually. Random cortisol in unit was 28.4.
.
# Leukocytosis: initially thought to be a stress response. Then
with 3/4 cultures positive for staph as above, also yeast as
above. CXR without infiltrate and UA negative.
.
# Delirium: Noted in the MICU in the setting of massive GIB and
bacteremia. The patient's baseline mental status per partner is
oriented x 3 but occasionally confused. Nonfocal neurologic
examination and once on medical floor he was back to baseline
per partner. [**Name (NI) **] last onc outpatient notes - increasing fatigue
and slurred speech. Valium was held.
.
# Acute renal failure: Likely prerenal. Baseline creatinine
1.0-1.1. Resolved.
.
# HIV: CD4 288, VL < 50 [**2102-5-15**]. Continued Atripla.
.
# Thrombocytopenia. Likely consumptive/dilutional given bleed
and resuscitation. Improved.
.
# Chronic pain: Chronic BLE pain thought due to zoster/MVA.
Continued lidocaine patch and amitriptyline.
.
# Depression: No active issues. Continued effexor.
.
# Hypothyroidism: No active issues. Continued levothyroxine.
.
# Hyperlipidemia: No active issues. Continued lipitor.
.
# CODE: DNR/DNI, confirmed with patient and HCP
.
# COMMUNICATION: Patient, partner [**Name (NI) 565**] [**Name (NI) 566**] (HCP)
.
Medications on Admission:
Omeprazole 40 mg [**Hospital1 **]
Topamax 200 mg QHS
Lipitor 80 mg DAILY
Amphetamine Salt Combo 5 mg (sig unavailable)
Atripla 600 mg-200 mg-300 mg one tablet QHS
Valium 10 mg DAILY PRN
Amitriptyline 150 mg QHS
Levoxyl 175 mcg DAILY
Lidoderm 5 % Patch one patch to each foot bilaterally
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to each
foot.
2. Topiramate 200 mg Tablet Sig: One (1) Tablet PO once a day.
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amitriptyline 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
6. Venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
7. Dextroamphetamine 5 mg Tablet Sig: Three (3) Tablet PO QAM
(once a day (in the morning)).
8. Dextroamphetamine 5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed for insomnia.
10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
11. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO once a
day.
12. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day): avoid taking with levothyroxine (stagger medications by
at least 2 hours).
Disp:*120 Tablet(s)* Refills:*0*
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
14. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed
Esophagitis, grade III
Bacteremia, coag negative staph
Fungemia
.
HIV/AIDS
Hypovolemic shock
Delerium
Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted after vomiting blood. You were given blood
products and fluids and improved. Your endoscopy showed
evidence of significant irritation of the esophagus. You were
also found to have a bacterial infection in your blood, which
was treated for several days with IV antibiotics. On the day
before discharge, you were noted to have yeast in the blood. We
recommended that you stay in the hospital for IV antibiotics and
to get you set up for home antibiotics; however, you chose to do
oral therapy at home.
.
Return to the hospital or call your doctor if you note blood in
your stools or vomit, abdominal pain, lightheadedness, shortness
of breath or chest pain, fever > 101, or any new symptoms that
you are concerned about.
.
Since you were admitted, we have made the following changes to
your medications:
- please do not take CHLORAL HYDRATE. You can take CLONAZEPAM
or other sleeping medications if you are having insomnia.
- you will receive 2 oral medications for infection:
levofloxacin and fluconazole. It is possible that these
medications will not be sufficient to treat your bloodstream
infection.
- we have also started SUCRALFATE for the stomach.
Followup Instructions:
You have the following upcoming appointments at [**Hospital1 18**]:
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 568**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2102-7-21**] 3:15
[**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2102-8-7**] 11:30
.
PCP appt with Dr. [**Last Name (STitle) 571**]: Monday [**6-19**] at 2:40pm
|
[
"2724"
] |
Admission Date: [**2140-5-8**] Discharge Date: [**2140-5-12**]
Date of Birth: [**2140-5-4**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 66093**] is the former
1.875 kg product of a 33 and [**2-20**] week gestation pregnancy,
born to a 26 year-old, Gravida VI, Para II now III woman.
Prenatal screens: Blood type 0 positive, antibody negative,
Rubella immune, RPR nonreactive, hepatitis B surface antigen
negative, Group beta strep status unknown. The mother's
medical history is complicated by asthma, gastroesophageal
reflux disease, irritable bowel syndrome and anxiety panic
disorder. Her medications during pregnancy were Percocet,
Albuterol, Protonix and Ambien. She experienced ruptured
membranes 10 days prior to delivery. She was transferred from
[**Hospital 1474**] Hospital to the [**Hospital1 69**]
maternal fetal medicine service. She was managed expectantly
until the day of delivery when there was strong suspicion for
chorioamnionitis. She underwent induction of labor. The
infant was born by spontaneous vaginal delivery. She had
apnea at birth and required bagged mask ventilation. Apgars
were 3 at 1 minute, 5 at 5 minutes and 8 at 10 minutes. She
was admitted to the NICU for treatment of prematurity and
respiratory distress.
PHYSICAL EXAMINATION: Upon admission to the Neonatal
Intensive Care Unit, weight was 1.875 kg, 50th percentile.
Length 41.5 cm, 50th percentile. Head circumference 30 cm,
25 to 50th percentile. General: Non dysmorphic, preterm
infant in mild respiratory distress. HEENT: Normocephalic.
Anterior fontanel open and flat. Positive red reflex
bilaterally. Neck supple without masses. Chest: Lungs
coarse breath sounds bilaterally with crackles.
Cardiovascular: Regular rate and rhythm. No murmur. Femoral
pulses +2. Abdomen soft, soft loops, positive bowel sounds.
Three vessel cord. Spine midline. No sacral dimple.
Clavicles intact. Hips stable. Anus patent. Genitourinary:
Normal preterm female. Neuro: Decreased tone in upper and
lower extremities.
HOSPITAL COURSE:
1. Respiratory: This baby was intubated shortly after
admission to the Neonatal Intensive Care Unit. She
received 1 dose of Surfactant. She was extubated to
continuous positive airway pressure on the day of birth.
She weaned to room air by day of life #2 and has
continued in room air through the rest of her Neonatal
Intensive Care Unit admission. She has had rare episodes
of apnea and bradycardia. Her baseline respiratory rate
is 30 to 60 breaths per minute with oxygen saturations
greater than 97%.
2. Cardiovascular: This baby girl has maintained normal
heart rates and blood pressures. No murmurs have been
noted. Baseline heart rate is 140 to 160 beats per minute
with a recent blood pressure of 80/51 with a mean of 60
mmHg.
3. Fluids, electrolytes and nutrition: This baby was
initially n.p.o. Enteral feeds were started on day of
life #2 and gradually advanced to full volume. At the
time of discharge, she is taking 150 cc/kg/day of breast
milk by gavage feeds. She also attempts breast feeding.
Her discharge weight is 1.935 kg. Serum electrolytes were
sent twice in the first week of life and were within
normal limits.
4. Infectious disease: Due to the prolonged rupture of
membranes, concern for maternal chorioamnionitis, this
infant was evaluated for sepsis upon evaluation to the
Neonatal Intensive Care Unit. A complete blood count was
within normal limits. A blood culture was obtained prior
to starting IV Ampicillin and Gentamycin. Blood culture
was no growth at 48 hours. A lumbar puncture was
performed on day of life #2 with normal results. Due to
the maternal history, a 7 day course of antibiotics was
given which completed on [**2140-5-11**].
5. Gastrointestinal: This baby was treated for unconjugated
hyperbilirubinemia with phototherapy. Peak serum
bilirubin was on day of life #4, total of 10.0 over 0.3
mg/dl for 9.7 mg/dl indirect. Most recent bili was 4.7
total over 0.2 mg/dl direct on [**2140-5-12**].
6. Hematologic: Hematocrit at birth was 51.9%. This baby
did not receive any transfusions of blood products.
7. Neurology: The low tone noted upon admission resolved
and the baby has maintained a normal neurologic exam
through the rest of her Neonatal Intensive Care Unit
admission.
8. Sensory: Audiology: Hearing screening has not yet been
performed.
9. Psychosocial: There is a complex social situation. This
mother has 2 sons with joint custody with their fathers.
They do not live with her. This is the first baby for
this couple. There was a positive toxic screen for
cocaine in [**3-21**]. A 51-A was followed but screened out at
the time because the mother did not have any of the
children in her custody. A meconium tox screen was sent
on this new baby on [**2140-5-7**] but the sample was of
insufficient quantity for analysis. [**Hospital1 190**] social work has been involved with this family.
The social worker is [**Name (NI) 553**] [**Name (NI) **] and she can be reached at
[**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to [**Hospital 1474**] Hospital for
continuing level II care.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 1617**], MD, [**Street Address(2) 56163**],
Office 200-W, [**Hospital1 1474**], [**Numeric Identifier **]. Phone number [**Telephone/Fax (1) 56164**].
CARE AND RECOMMENDATIONS:
1. Feeding: Breast milk 150 cc per kg per day by gavage.
2. No medications.
3. Car seat position screening is recommended prior to
discharge.
4. State newborn screen was sent on [**2140-5-7**] with no
notification of abnormal results to date.
5. No immunizations administered.
6. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following three
criteria: (1) Born at less than 32 weeks; (2) Born between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity at 33 and [**2-20**] week gestation.
2. Respiratory distress syndrome.
3. Presumed sepsis.
4. Unconjugated hyperbilirubinemia.
5. Rule out in-utero drug exposure.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], MD [**MD Number(1) 36250**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2140-5-12**] 02:29:45
T: [**2140-5-12**] 04:54:42
Job#: [**Job Number 66094**]
|
[
"7742",
"V290"
] |
Admission Date: [**2126-8-29**] Discharge Date: [**2126-8-31**]
Date of Birth: [**2069-5-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending:[**First Name3 (LF) 3256**]
Chief Complaint:
ETOH withdrawal and chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 57M with history of EtOH abuse, MI, cardiomyopathy, Afib,
HTN, hepatitis B/C states that one hour prior to arrival he
started having left sided chest pain. The patient is homeless
and was cold, wet, and sleeping on a bench when he felt a sudden
onset substernal pressure as well as left arm numbness. He took
nitroglycerin, and that did not immediately relieve the pain.
There was associated shortness of breath. States that he is
taking a total of one quart of Listerine daily, with the last
intake the morning of admission.
Past Medical History:
Atrial fibrillation
Tachycardia induced cardiomyopathy (since resolved)
ETOH abuse with cirrhosis
Hypertension
2.5-cm cystic lesion in pancreatic tail ([**2121**])
Colonic polyposis
s/p knee replacement
Hepatitis B/C/ETOH, grade 3 fibrosis
Social History:
Homeless, lives on the street in [**Location (un) **] Corner. Smokes 2ppd
for 44yrs. Drinks listerine, 1 medium bottle per day for the
past 4-5 years. Denies current IVDU. Previously did IV cocaine
in the remote past. Denies taking painkillers.
Family History:
Positive for coronary artery disease (details unknown) and
hypertension. His father had an aortic aneurysm. There is a
history of cancer of the brain and the breast.
Physical Exam:
On Admission to the ICU
114, 161/100, 18, 98
General Appearance: Awake. Tremulous. NAD. Disheveled w body
odor.
HEENT: PERRL, no nystagmus
Cardiovascular: Normal S1 S2, no m/r/g, JVP non-elevated
Respiratory: CTAB, no rhales, rhonci, or wheezes
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: 2+ pulses through out, no edema
Neurologic: CN II-XII intact, Good strength in upper
extremities,
patient reports difficulty moving lower extremities [**12-19**] prior
injuries
SKIN: No rash or tenderness to percussion over thorax
Pertinent Results:
[**2126-8-31**] 06:11AM BLOOD WBC-4.2 RBC-3.34* Hgb-11.5* Hct-33.9*
MCV-101* MCH-34.4* MCHC-33.9 RDW-13.9 Plt Ct-106*
[**2126-8-30**] 03:29AM BLOOD PT-12.0 PTT-26.6 INR(PT)-1.0
[**2126-8-31**] 06:11AM BLOOD Glucose-93 UreaN-11 Creat-0.6 Na-137
K-4.6 Cl-101 HCO3-26 AnGap-15
[**2126-8-31**] 06:11AM BLOOD Calcium-9.0 Phos-2.8 Mg-1.8
[**2126-8-31**] 06:11AM BLOOD ALT-97* AST-307* AlkPhos-120 TotBili-1.5
[**2126-8-29**] 05:00AM BLOOD cTropnT-<0.01
[**2126-8-29**] 10:55AM BLOOD cTropnT-<0.01
[**2126-8-29**] 05:41PM BLOOD CK-MB-2 cTropnT-<0.01
[**2126-8-29**] 05:00AM BLOOD ASA-NEG Ethanol-214* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
ECG [**2126-8-29**]
Sinus rhythm. Borderline low voltage in the limb leads. Compared
to the
previous tracing of [**2126-7-28**] the rate is slower.
CXR [**2126-8-29**]
IMPRESSION: No acute intrathoracic process though the
costophrenic angles
were partially excluded.
Brief Hospital Course:
Patient is a 57yo homeless man with history of EtOH abuse,
myocardial infarction, cardiomyopathy, atrial fibrillation (not
on coumadin), hypertension, hepatitis B and C, who presented in
the ED complaining of left-sided chest pain, and became
tremulous.
.
ACTIVE ISSUES:
# Chest pain: history suggestive of ACS (substernal chest pain,
left arm pain), but ECG showed no acute ischemic changes and TnT
was <0.01 x3. Pneumonia was unlikiely given the lack of fevers
and CXR with no infiltrates. Most likely etiology is
costocondritis; resolved in the ED.
.
# Alcohol withdrawal: In the ED patient became agitated,
diaphoretic, and increasingly tachycardic. CXR was unremarkable.
He was given 3mg ativan, 15mg of diazepam for CIWA>10, and was
transferred to the MICU for management of alcohol withdrawal. He
received B12 and Folic Acid. In the MICU he was afebrile,
hypertensive to 161/100, tachycardic to 114, and was somewhat
tremulous and diaphoretic. He was placed on Diazepam 5 mg PO
Q1H:PRN for CIWA > 14. He was otherwise comfortable and stable,
no longer reported any chest pain, and was speaking in full
sentences, and was alert and oriented to person, place, and
date. He was restarted on his home metoprolol and diltiazem
dose, and was started on B12, folic acid, and thiamine. The
next morning the patient was requiring less diazepam (5mg
q4H:PRN for CIWA>14) and was no longer tachycardic,
hypertensive, tremulous or diaphoretic. He was therefore
transferred to the floor. On the floor he was initially
comfortable and stable, and his diazepam requirement decreased
to 5mg q8H: PRN for CIWA>10. Social work was consulted given
frequent admissions for alcohol abuse. However, on the morning
of [**2126-8-31**] he was dissatisfied with his lunch and became
agitated. Despite receiving 2 doses of 5mg diazepam q2H, he
continued to be agitated and abusive to nursing staff, and
stated in no uncertain terms that he wanted to leave. The risks
of leaving while undergoing treatment for alcohol withdrawal
were explained to the patient, including seizures and death;
however, he insisted on leaving and left the hospital against
medical advice.
.
# Tachycardia (sinus): unresponsive to IV fluids in ED. Likely
due to EtOH withdrawal. Patient was placed on telemetry; home
metoprolol, diltiazem were continued; he received maintenance IV
fluids at 100cc/hr and Diazepam for EtOH withdrawal (as per
above).
.
INACTIVE ISSUES
# Hypokalemia: admission K 2.7, possibly due to long-standing
alcoholism accompanied by vomiting and diarrhea, as well as this
patient's use of HCTZ and furosemide. K was trended daily and
repleted as necessary.
.
# Anemia, thrombocytopenia: Hct was stable in low 30's. Iron
studies ([**3-27**]) had shown Iron 203, TIBC 239, Transferrin 184,
ferritin 278, B12 407, folate 15.6. Plt 102, which is
approximately at the patient's baseline. Both anemia and
thrombocytopenia are likely due to alcohol-induced bone marrow
suppression, though on this admission B12 was wnl (308). CBC was
monitored; thiamine, folate were given daily.
.
#. Back pain: chronic for about 13yrs; no surgical intervention
per neurosurg (see last d/c sum). Pain was controlled with
lidocaine patches.
.
#. Hepatitis B/C: alcoholic pattern. Has h/o grade 3 fibrosis.
Outpatient management was recommended.
.
#. Atrial fibrillation: not on coumadin due to risks with
homelessness. Patient reports receiving prior cardioversion. ECG
is sinus here.
- Continue metoprolol and diltiazem
TRANSITIONAL ISSUES
None - patient left AMA.
Medications on Admission:
One Multivitamin by mouth daily
Toprol XL: one 25mg tablet by mouth daily
Omeprazole: one 20mg tablet by mouth daily
HCTZ: one 50 mg tablet by mouth daily
Folic Acid: one 1mg tablet by mouth daily
Vitamin B1: one 100mg tablet by mouth daily
Diltiazem XR: one 120mg tablet by mouth daily
Furosemide: one 20mg tablet tablet by mouth daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
6. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Alcohol withdrawal
Secondary: atrial fibrillation, hypertension, liver cirrhosis,
hepatitis C.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 14879**],
You were admitted to the [**Hospital1 18**] for chest pain on [**8-29**].
Your tests showed you did not suffer from a heart attack, but
you experienced symptoms of alcohol withdrawal and were admitted
to the hospital. You were given Diazepam to help with withdrawal
symptoms, and you became more calm; however, on [**8-31**] you
chose to leave the hospital against medical advice (AMA). The
risks of leaving were explained to you; these incluse worsened
alcohol withdrawal, seizure, and death.
Followup Instructions:
Please follow-up with your regular primary care physician.
|
[
"42731",
"4019",
"42789",
"412"
] |
Admission Date: [**2197-5-17**] Discharge Date: [**2197-5-25**]
Date of Birth: [**2125-10-20**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tetracycline Analogues /
Tussionex
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
Worsening dyspnea and atrial fibrillation
Major Surgical or Invasive Procedure:
BiPap
History of Present Illness:
71M h/o COPD, afib on A/C, CAD, HTN, hypercholesterolemia,
pericarditis in [**2192**] presenting with 2 week history of worsening
SOB, increased cough, and increased sputum production. The
patient says his exercise tolerance has decreased significantly:
he was previously able to walk a few blocks, but in the past 2
weeks became SOB just walking to the bathroom. He said he had
some R sided chest pain at the end of his cough, no cp on
exertion. He also noted increasing edema in his legs
bilaterally. He also said he had a "pressure" feeling in his
head, which he associates with a fib. Denies fever/chills/night
sweats, no n/v/d. He saw his PCP on [**Name9 (PRE) 766**] [**5-15**] and was started
on steroids and lasix. No significant improvement since that
time, so he came into the ED. Found to be in afib or MFPAC.
Recieved 20mg dilt and 1 combivent neb PTA by EMS. Triggered for
HR on arrival at 145, no chest pain but SOB. Neb and BIPAP for
RR40 now 15 . HR 110, 02 sats have been 96% throughout. Chest
x-ray bilateral pna lower lobes, bedside ultrasound, no
pericardial effusion, troponin negative.
In the ED, initial VS were:
HR 145 BP 120/98 RR 40 POx 98% on RA
Past Medical History:
- COPD, predominantly emphysema with 80-pack year smoking
history and current tobacco use
- diagnosed with pericarditis [**1-/2193**] at [**Hospital1 112**]. He had multiple
episodes of paroxysmal atrial fibrillation around that time. He
reports these did not return after his pericarditis resolved and
he has been off anticoagulation since [**2193**]
- osteoperosis: s/p vertebral fracture in [**2196-8-20**], and
subsequent rib fracture after that. Was in rehab for several
months, discharged in [**Month (only) **]/[**2197-1-19**].
- Depression
- Restless leg syndrome
- Chronic venous insufficiency
- Diverticulosis
- Previous subarachnoid hemorrhage with clipping of cerebral
aneurysm in [**2178**]
- Melanoma removed from his back
- Basal cell carcinoma
- Hyperlipidemia
- Inguinal hernia repair [**2193**]
Social History:
He lives alone in [**Location (un) 3146**]. He is currently trying to quit
smoking, is down 5 cigarrettes per week now. A couple years ago
he was smoking 2 packs per day. Occasional alcohol. No illicit
drugs.
Family History:
No family history of COPD.
Physical Exam:
On admission [**2197-5-17**]
General: Alert, oriented, on BIPAP mask, able to talk but coughs
frequently (dry cough).
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, JVP elevated to 15 cm
CV: irreguarly irregular rate, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffusely wheezy, B/l basilar crackles, R > L
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: no foley
Ext: Warm, well perfused, 2+ pulses, 2+ edema in legs
Neuro: CNII-XII intact.
.
Discharge Exam:
Afebrile. HR 60-90s at rest, low 100s with exertion. 16 98%2L
Occasional pursed lips otherwise NAD, short sentences no
accessory muscle use
Lungs: Much improved airmovement with very scant wheezes, no
rales or rhonchi.
Ext: 1+ pedal edema.
Pertinent Results:
ADMISSION LABS
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2197-5-24**] 07:15 11.4* 4.05* 11.8* 37.0* 92 29.1 31.8 14.3
424
[**2197-5-23**] 07:20 11.9* 3.96* 11.5* 36.6* 93 29.1 31.4 14.3
420
[**2197-5-22**] 00:00 12.6* 3.85* 11.3* 35.2* 91 29.4 32.1 14.9
412
[**2197-5-20**] 07:58 12.9* 4.13* 12.0* 38.3* 93 29.0 31.3 14.1
427
[**2197-5-19**] 05:11 9.4 3.49* 10.5* 32.1* 92 30.1 32.7 14.2 318
[**2197-5-17**] 23:47 8.5 4.19* 12.3* 38.1* 91 29.3 32.2 14.8 331
[**2197-5-17**] 16:25 7.4 3.90* 11.8* 36.0* 92 30.3 32.8 14.4 306
.
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2197-5-24**] 07:15 424
[**2197-5-24**] 07:15 18.0* 1.7*
[**2197-5-23**] 07:20 420
[**2197-5-23**] 07:20 20.9* 2.0*
[**2197-5-22**] 00:00 412
[**2197-5-20**] 07:58 427
[**2197-5-20**] 07:58 46.2* 44.9* 4.6*
[**2197-5-19**] 16:55 45.5* 41.6* 4.5*
[**2197-5-19**] 05:11 318
[**2197-5-18**] 12:49 41.2* 41.6* 4.0*
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2197-5-24**] 07:15 851 29* 0.9 139 4.6 101 29 14
[**2197-5-23**] 07:20 881 29* 0.9 141 4.1 101 32 12
[**2197-5-22**] 00:00 941 26* 0.8 141 4.3 103 30 12
[**2197-5-20**] 07:58 981 25* 0.8 141 4.8 104 26 16
[**2197-5-19**] 05:11 128*1 26* 0.8 139 4.2 105 26 12
[**2197-5-18**] 12:49 140 4.0 106
[**2197-5-17**] 23:47 135*1 22* 1.0 143 3.6 105 24 18
ADDED
[**2197-5-17**] 16:25 147*1 20 0.8 140 4.0 105 22 17
.
CPK ISOENZYMES CK-MB cTropnT proBNP
[**2197-5-17**] 23:47 3 <0.011
ADDED
[**2197-5-17**] 16:25 <0.011
LIGHT GREEN TUBE
[**2197-5-17**] 16:25 3580*2
.
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2197-5-20**] 07:58 8.5 2.6* 2.3
[**2197-5-19**] 05:11 7.6* 2.2* 2.4
[**2197-5-17**] 23:47 3.7 7.6* 2.2* 1.9
.
HISTORY: Rib deformities, assess possible fracture.
TECHNIQUE: Multidetector helical scanning of the chest was
performed without intravenous contrast [**Doctor Last Name 360**], reconstructed as
contiguous 5- and 1.25-mm thick axial and 5-mm thick coronal and
parasagittal images compared to chest CTA, [**2195-10-23**],
read in conjunction with conventional chest radiograph earlier
on [**5-17**].
FINDINGS:
Several right rib fractures are chronic, generally healed, aside
from what may be a solitary pseudoarthrosis, which is sometimes
a source of pain. There is no suggestion that these are
pathologic fractures and there is no associated abnormality in
either the chest wall or adjacent pleura. The patient has had an
interim vertebral body cementoplasty in the lower thoracic
spine.
Emphysema is mild-to-moderate in the lung apices, less severe
elsewhere.
Bronchiolar nodulation is widespread, sparing only the lung
apices. A small discrete region of consolidation in the
lingula, 3:31, a second region in the right middle lobe, 3:43,
and a paraspinal component low in the rightr hemithorax are
probably pneumonia, but should be followed, using conventional
radiographs, until substantially cleared. Subcentimeter lung
nodules, slightly larger than what one would expect for
bronchiolar inflammation should be monitored with repeat chest
CT in six months, for example, in the right middle lobe, 4:124,
and a nearly 6-mm wide nodule in the left lower lobe, 4:161.
Bronchial wall thickening is extensive, mild ectasia of
peripheral small bronchioles is scattered. Numerous central
lymph nodes are top normal mildly enlarged, have grown, for
example, an 7 x 17 mm left upper paratracheal node was 8 x 11 mm
in [**2195-10-21**] and a 13 x 17 mm right hilar node, 2:25, was
previously 9 x 14 mm. Mild enlargement of the main and
intrapericardial right pulmonary arteries, 34 and 28 mm wide
respectively is stable. There is no pericardial or pleural
abnormality. Small hiatus hernia is stable. The esophagus is
air filled and not particularly dilated, throughout, also
unchanged.
IMPRESSION:
1. Widespread bronchiolitis and probable multifocal pneumonia
may be related to aspiration, given the presence of a hiatus
hernia and a patulous esophagus.
2. Worsened, mild central adenopathy, probably reactive.
3. At least two subcentimeter lung nodules should be evaluated
with repeat chest CT scanning in six months, but multifocal
pneumonia should be reevaluated with conventional chest
radiograph in six weeks in order to document substantial
clearing.
4. Multiple right rib fractures are chronic, and largely
healed.
CXR [**2197-5-17**]
CLINICAL HISTORY: COPD with short of breath. Assess for
pneumonia.
FINDINGS: AP upright portable chest radiograph is obtained.
There are right posterolateral rib deformities involving seven,
eight, and nine. Possible mild pulmonary edema. Underlying
emphysema is noted. Cardiomegaly is noted. No large effusions.
Please note the right rib cage deformities are new from the
prior radiograph from [**2196-10-5**].
IMPRESSION: Right seven through nine posterolateral rib
deformities, new from prior radiograph dated [**2196-10-5**].
Cardiomegaly with mild pulmonary edema uperimposed on background
emphysema.
Brief Hospital Course:
71 yo M with h/o COPD and afib, admitted to ICU and subsequently
to the floor with hypoxia secondary to acute COPD, acute on
chronic systolic CHF, bacterial PNA and afib with [**Month/Day/Year 5509**].
ACTIVE ISSUES:
# Hypoxemia: Multifactorial in etiology. The pt was admitted
with acute COPD exacerbation in the setting of multifocal
bacterial PNA (CAP) and pulmonary edema secondary to acute on
chronic systolic CHF. He was treated with BiPAP x1 day, broad
spectrum abx, prednisone, nebs, and diuresis (x1 dose) with
improvement. While in house he was treated with a week of
CTX/Azithromycin, Nebs, Steroids and IV lasix as needed. On
discharge his lung exam was much improved with minimial wheezing
with minimal 02 requirments.
- Continue prednisone steroid taper (see below)
- Cont neds
- Antitussives prn
- Discharge on PO lasix 40mg x1 week until pedal edema resolves
then consider adjustment.
.
# Afib with [**Name (NI) 5509**] - Pt with a history of afib with [**Name (NI) 5509**], usually on
diltiazem, and warfarin 2.5 mg/day. He was converted to 4x/day
diltiazem in the ICU and continued on the floor.
.
INACTICE ISSUES:
Depression - Continue citalopram
.
TRANSITIONAL ISSUES:
Direct verbal signout was provided to the patient PCP on the day
of discharge. In addition I have provided direct signout to her
regarding the incidental finding of subcentimeter pulmonary
nodules to follow-up in 6 months. The patient will be discharged
to rehab today.
Medications on Admission:
nr albuterol sulfate
90 mcg HFA Aerosol Inhaler as needed
nr fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose
Disk with Device 1 twice a day (pt not sure if still taking
this)
nr alclometasone 0.05 % Cream apply daily (Prescribed by Other
Provider) 09
nr clobetasol 0.05 % Solution daily
nr ipratropium-albuterol [Combivent]
18 mcg-103 mcg (90 mcg)/Actuation Aerosol
2 four times a day (Prescribed by Other Provider) [**2196-7-29**]
pramipexole 1.5 mg Tablet 1 Tablet(s) by mouth every evening
(Prescribed by Other Provider)
lovastatin 20 mg Tablet 1 Tablet(s) by mouth daily
diltiazem HCl 180 mg Capsule, Ext Release 24 hr 1 Capsule(s) by
mouth twice a day
citalopram [Celexa] 20 mg Tablet 1 Tablet(s) by mouth every
evening
lasix 3 pills/day for 3 days (started [**2197-5-15**])
warfarin 2.5 mg Tablet [**11-21**] Tablet(s) by mouth as directed by
[**Hospital 197**] clinic (Prescribed by Other Provider)
aspirin 81 mg Tablet, Chewable 1 Tablet(s) by mouth daily
(Prescribed by Other Provider)
Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
2. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
30mg x 3 days, then 20mg x 3 days, then 10mg x 3days then 5mg x
3days.
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
4. Advair Diskus 250-50 mcg/dose Disk with Device Sig: [**11-21**]
Inhalation once a day.
5. citalopram 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAYS
([**Doctor First Name **],MO,TU,WE,TH,FR,SA).
9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
10. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [**3-30**]
MLs PO Q6H (every 6 hours) as needed for cough.
11. pramipexole 0.5 mg Tablet Sig: Three (3) Tablet PO hs ().
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
14. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
Primary Diagnosis:
- Acute COPD Exacerbation
- Acute on Chronic CHF Exacerbation
- Community Acquired Bacterial Pneumonia
- Atrial Fibrillation with Rapid Ventricular Response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with difficulty breathing. You were
treated for an acute COPD exacebration, bacterial pnuemonia and
a mild congestive heart failure exacerbation. Please continue to
take all of your medications, a number of changes have been
made.
Followup Instructions:
Please follow-up with your PCP following your discharge from
acute rehabilitation
|
[
"4280",
"42731",
"4019",
"41401",
"311",
"2724"
] |
Admission Date: [**2163-11-21**] Discharge Date: [**2163-12-1**]
Date of Birth: [**2086-12-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
CHF, ARF, Mediastinal lymphadenopathy
Major Surgical or Invasive Procedure:
Bronchoscopy x 2
Mediastinoscopy with lymph node biopsy
History of Present Illness:
76M initially went to [**Hospital 1562**] hospital with L flank and sent
home with narcs. Represented with DOE, weight gain and L flank
pain. He reports that he has had intermittent DOE for year but
notice a sharp increase in his weight over a period of 10 days.
He gained 8-10lbs with associated LE swelling, but without
medication noncompliance, dietary changes, chest pain,
orthopnea, PND. This happened at the beginning of [**Month (only) 359**] and
his Lasix was increased from 40 to 60 daily. He also had a
holter revealing afib (rate 40-100), nuclear stress
([**2163-11-1**])without ischemia and normal ECHO on [**2163-11-3**] (mild AS,
mild MR). Upon arrival to the ED he was found to be hypotensive
with hyperkalemia and ARF (Cr ~4 from basline of 1.2) He was
sent to the floor, diuresed and then sent to the ICU after he
was hypotensive requiring dopamine and vasopressin. He had a
Swan-Ganz catheter placed on [**11-19**] and had renally dosed
dopamine. He was thought to be fluid overloaded and had a
transudative thoracentesis (amount removed unknown). He was
aggressively diuresed with Lasix and renally dosed Dopamine. His
renal function improved prior to transfer.
Swan numbers:
RA: 25
RV: 55/20/10
PA: 55/25
PCW: 26
His L flank pain was evaluated with a CT Abdomen and he was
found to have L nephrolithiasis and an exophytic cyst on the
lower pole of the L kidney. His pain has been controlled with
narcotics.
He had also been recieving Zyvox for presumed pneumonia and
solumedrol 60 mg q6h for presumed COPD.
He was transferred for evaluation of his mediatinal LAD. This
has been watched for seveal years and he has two non-FDG avid
PET CTs, most recently in [**2163-6-26**]. He denies any B symptoms.
He does have decreased appetite, but has been active with
outside hobbies including golf and curling. The thoracics
service was contact[**Name (NI) **] for this evaluation and it was suggested
that the patient be admitted to the MICU given his underlying
medical problems.
Past Medical History:
PAST MEDICAL HISTORY:
====================
AF, on coumadin at home
CRI Cr:1.6
Chronic Anemia
CHF EF
Bladder CIS s/p BCG washout in [**10/2163**]
Colonic dysplastic lesions on bx
OSA- unable to tolerate CPAP
low grade NHL with diffuse stable LAD
AS
R popliteal artery endarterectomy
uretral stent
Gout
PVD
L CEA [**2159**]
UGIB [**2161**]
LLL lobectomy in [**2135**]
Nephrolithiasis
Social History:
EtOH: 2 martinis daily
Tobacco: quit 1ppd 25 yrs ago
outside hobbies included golf and curling
Family History:
no history of malignancy
Physical Exam:
Tmax: 35.9 ??????C (96.6 ??????F)
Tcurrent: 35.9 ??????C (96.6 ??????F)
HR: 74 (67 - 75) bpm
BP: 113/46(60) {112/46(60) - 113/57(71)} mmHg
RR: 20 (20 - 24) insp/min
SpO2: 96%
Heart rhythm: AF (Atrial Fibrillation)
Physical Examination
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, MMM
Lymphatic: Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic),
III/VI holosystolic murmur @ apex, III/VI holosystolic murmur at
base
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : bilateral bases)
Abdominal: Soft, No(t) Non-tender, No(t) Bowel sounds present,
Distended, No(t) Tender: , No(t) Obese, hypoactive bowel sounds
Extremities: Right: Trace, Left: Absent, No(t) Cyanosis, No(t)
Clubbing
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
[**2163-11-22**] Echo: The left atrium is elongated. The right atrium is
markedly dilated. The right atrial pressure is indeterminate.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Left ventricular
systolic function is hyperdynamic (EF>75%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened.
There is mild to moderate aortic valve stenosis (area 1.2 cm2).
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Physiologic mitral regurgitation is seen
(within normal limits). [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
[**2163-11-23**] Pathology report
1. Lymph nodes, 4L, biopsy (A-C):
Metastatic neuroendocrine neoplasm, most consistent with
carcinoid tumor, in two of ten lymph nodes/lymph node fragments.
2. Lymph nodes, 7, biopsy (D):
Metastatic neuroendocrine neoplasm, most consistent with
carcinoid tumor, in three of four lymph nodes/lymph node
fragments. See note.
3. Lymph nodes, level 7, biopsy (E):
Metastatic neuroendocrine neoplasm, most consistent with
carcinoid tumor, in one of two lymph nodes/lymph node fragments.
Note:
Immunohistochemical stains show the tumor cells are diffusely
positive for synaptophysin and chromogranin and are negative for
CK 7 and TTF-1. Rare tumor cells are positive for CK20.
Despite the negative TTF-1, the tumor is compatible with a lung
primary. Clinical correlation recommended.
FLOW CYTOMETRY [**11-23**]:
FLOW CYTOMETRY IMMUNOPHENOTYPING:
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda and CD antigens: 2,3,5,7,19,20,23, and 45.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield. B cells comprise 34% of
lymphoid-gated events, are polyclonal, and do not express
aberrant antigens. T cells comprise 50% of lymphoid gated
events, and express mature lineage antigens.
INTERPRETATION:
Non-specific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by lymphoma are not
seen in specimen. Correlation with clinical findings and
morphology (see S08-[**Numeric Identifier 66053**]) is recommended. Flow cytometry
immunophenotyping may not detect all lymphomas due to
topography, sampling or artifacts of sample preparation.
[**11-23**] Bronchial Washings:
Bronchial washing, left upper lobe:
NEGATIVE FOR MALIGNANT CELLS.
Reactive bronchial epithelial cells and alveolar
macrophages.
ADDENDUM: Hematology slide 0559R of bronchoalveolar lavage (BAL)
was
reviewed and shows alveolar macrophages. No evidence of
malignancy.
[**11-23**] CXR:
FINDINGS: No pneumothorax. There is complete opacification of
the left lung, which is indicating collapse in the left upper
lung, likely due to mucus plug. There is overlapping
opacification, which was seen on the previous film, in the left
lower lung which might be postoperative, inflammatory, or
malignant and further evaluation is needed.
There is a small right pleural effusion, unchanged. There is no
consolidation in the right lung. The right jugular line was
removed.
[**2163-11-23**] CXR Post-Bronch:
FINDINGS: As compared to the previous examination, the left lung
is slightly better aerated. There is no evidence of left-sided
pneumothorax. In the right lung, in the middle lobe, some subtle
areas of atelectasis are seen. No evidence of larger pleural
effusions.
[**2163-11-24**] CXR:
PORTABLE CHEST RADIOGRAPH: Compared to recent studies of
[**2163-11-23**], there is improved aeration of the left upper lung,
without evidence of new
pneumothorax. There persists opacification of the left perihilar
and left
lower lung, likely representing combination of pleural effusion
and
atelectasis, although underlying consolidation cannot be
excluded. There is also improved aeration of the right lung
although small right pleural effusion persists.
[**2163-11-25**] CXR:
REASON FOR EXAM: Status post mediastinoscopy and bronchoscopy.
Since yesterday, diffuse opacification of the left lung is
overall unchanged, mostly in the perihilar and left lower lung
region, likely a combination of left pleural effusion and
atelectasis, possibly consolidation. Small right pleural
effusion is unchanged. The right lung is otherwise normal. There
is no other change.
[**2163-11-25**] CT Scan Chest:
IMPRESSIONS:
1. Subcutaneous gas consistent with recent mediastinoscopy. A
small left
lower paratracheal collection containing fluid and gas could
represent post- procedural changes. Correlation with recent
procedure and clinical symptoms recommended. Multiple
mediastinal lymph nodes are noted. Larger soft tissue density in
the subcarinal region could represent lymphadenopathy or in the
right clinical context could also represent a hematoma.
Comparison with prior study if available could help
differentiate between the two.
2. Status post left lower lobectomy with fibrotic changes and
atelectasis
noted in the left lung. Fluid collection with thick enhancing
rind in the
left posterior sulcus is chronic and organized.
3. Nodule in the anterior left lung could represent rounded
atelectasis,
though in atypical location. Recurrent tumor cannot be excluded.
4. Moderate right dependent pleural effusion with associated
dependent
atelectasis of the left lower lobe.
5. Left adrenal mass. Dedicated imaging of the adrenal glands
recommended
for further evaluation. There is also suggestion of
lymphadenopathy in the
retroperitoneum that is incompletely imaged. Small ascites noted
along the
dome of the liver.
EKG [**2163-11-27**]:
Normal sinus rhythm. Poor R wave progression, possibly related
to lead
placement. No other abnormality. No previous tracing available
for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 0 88 [**Telephone/Fax (2) 66054**]1
OCTREOTIDE SCAN (SOMATOSTATIN) Study Date of [**2163-11-29**]
Reason: NHL AND LUNG CA BX SHOWED MALIGNANT NEUROENDOCRINE
NEOPLASM
Prelim findings c/w metastatic carcinoid, full report pending.
[**2163-11-21**] 07:32PM GLUCOSE-130* UREA N-119* CREAT-2.2*
SODIUM-141 POTASSIUM-3.8 CHLORIDE-100 TOTAL CO2-29 ANION GAP-16
[**2163-11-21**] 07:32PM estGFR-Using this
[**2163-11-21**] 07:32PM CALCIUM-9.0 PHOSPHATE-5.3* MAGNESIUM-2.4
[**2163-11-21**] 07:32PM URINE HOURS-RANDOM UREA N-828 CREAT-45
SODIUM-LESS THAN
[**2163-11-21**] 07:32PM URINE OSMOLAL-427
[**2163-11-21**] 07:32PM WBC-11.5* RBC-4.11* HGB-11.7* HCT-36.4*
MCV-88 MCH-28.4 MCHC-32.1 RDW-15.1
[**2163-11-21**] 07:32PM NEUTS-96* BANDS-0 LYMPHS-2.0* MONOS-2 EOS-0
BASOS-0
[**2163-11-21**] 07:32PM PLT COUNT-389
[**2163-11-21**] 07:32PM PT-33.9* PTT-43.6* INR(PT)-3.6*
[**2163-11-21**] 07:32PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2163-11-21**] 07:32PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-TR
Other labs:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2163-12-1**] 05:45AM 5.1 3.50* 10.0* 32.4* 93 28.7 31.0 14.6
288
[**2163-11-30**] 08:05AM 5.3 3.41* 9.9* 31.5* 92 29.0 31.3 14.7
277
[**2163-11-29**] 06:45AM 5.5 3.52* 10.3* 32.3* 92 29.3 31.9 15.1
280
[**2163-11-28**] 07:00AM 6.2 3.41* 9.9* 30.7* 90 28.9 32.1 15.4
242
[**2163-11-27**] 07:25AM 9.3 3.49* 10.1* 32.4* 93 29.1 31.3 14.5
247
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2163-12-1**] 05:45AM 96 18 1.0 147* 4.0 105 37* 9
[**2163-11-30**] 08:05AM 81 20 0.9 145 4.0 108 34* 7*
[**2163-11-29**] 06:45AM 77 22* 0.9 1441 4.0 106 36* 6*
[**2163-11-28**] 07:00AM 79 27* 1.0 144 4.1 105 32 11
[**2163-11-27**] 07:25AM 95 30* 1.0 143 4.0 106 33* 8
[**2163-11-26**] 07:00AM 103 37* 0.9 143 4.2 107 33* 7*
[**2163-11-25**] 03:37PM 104 43* 1.0 147* 4.4 110* 33* 8
[**2163-11-25**] 02:07AM 168* 60* 1.0 146* 4.3 110* 31 9
[**2163-11-24**] 04:25AM 92 87* 1.2 150* 4.2 113* 31 10
[**2163-11-23**] 07:05AM 97 115* 1.7* 147* 4.5 108 31 13
[**2163-11-22**] 02:52PM 126* 2.0*
[**2163-11-22**] 05:34AM 122* 125* 2.1* 143 4.5 104 28 16
DIG ADDED 9:08AM
[**2163-11-21**] 07:32PM 130* 119* 2.2* 141 3.8 100 29 16
[**2163-11-27**] 07:25AM BNP 7554*1
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2163-12-1**] 05:45AM 8.9 3.2 2.2
[**2163-11-30**] 08:05AM 9.0 3.4 2.3
[**2163-11-29**] 06:45AM 9.0 2.8 2.3
[**2163-11-28**] 07:00AM 8.6 2.7 2.2
HEMATOLOGIC calTIBC Ferritn TRF
[**2163-11-22**] 05:34AM 153* 270 118*
DIG ADDED 9:08AM
PROTEIN AND IMMUNOELECTROPHORESIS PEP IgG IgA IgM IFE
[**2163-11-22**] 05:34AM NO SPECIFI1 1[**Telephone/Fax (3) 66055**] NO MONOCLO2
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
[**2163-11-22**] 01:50PM NEG NEG NEG NEG NEG NEG NEG 5.0 NEG
Source: Catheter
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2163-11-22**] 01:50PM 3* 2 FEW NONE <1 <1
Source: Catheter
URINE CASTS CastHy
[**2163-11-22**] 01:50PM 9*
Source: Catheter
OTHER BODY FLUID ANALYSIS WBC RBC Polys Lymphs Monos Macro Other
[**2163-11-24**] 08:13AM 01 01 71* 8* 6* 15* 02
BRONCHIAL LAVAGE
[**2163-11-25**] 3:37 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2163-11-27**]**
GRAM STAIN (Final [**2163-11-27**]):
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
[**2163-11-24**] 8:13 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
**FINAL REPORT [**2163-11-26**]**
GRAM STAIN (Final [**2163-11-24**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2163-11-26**]): NO GROWTH, <1000
CFU/ml.
[**2163-11-23**] 7:10 pm TISSUE Site: LYMPH NODE
GRAM STAIN (Final [**2163-11-23**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2163-11-26**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2163-11-29**]): NO GROWTH.
ACID FAST SMEAR (Final [**2163-11-24**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2163-11-24**]):
NO FUNGAL ELEMENTS SEEN.
LEGIONELLA CULTURE (Final [**2163-11-30**]): NO LEGIONELLA
ISOLATED.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2163-11-24**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
Brief Hospital Course:
76M initially admitted to [**Hospital 1562**] hospital for CHF
exacerbation, and then transferred ICU-to-ICU for workup of
chronic mediastinal LAD. Thoracic Surgery had been contact[**Name (NI) **]
and was interested in seeing the patient and deemed that he
would be most appropriate for MICU given his ongoing ARF. While
in the ICU his renal function improved with gentle intravascular
hydration. Echo was performed which revealed severe diastolic
dysfunction with ejection fraction of >70%. His digoxin was
therefore discontinued. He was discharged to the floor after
~24 hours of observation.
While on the medical service, the patient was brought to the OR
on [**2163-11-23**] for Flexible bronchoscopy with bronchoalveolar
lavage of the left upper lobe, cervical mediastinoscopy and
bronchoscopy. On post-op CXR there was noticeable whiteout of
the left lung field and the patient was kept in the PACU for
observation. He was treated with Chest PT, IS and suctioning
for the thought of possible mucus plugging. As per
documentation, the patient was doing well until the morning when
he had increasing oxygen requirements and more labored
breathing. At 8am on [**2163-11-24**] the patient underwent
unremarkable bronchoscopy by IP. Patient continued to have a
significant oxygen requirement, satting 93% on 40% facemask,
thus was transferred to the ICU for monitoring.
In ICU on [**11-25**], patient underwent upper airway suctioning,
along with albuterol, ipratropium, and mucinex treatment. He
utilized incentive spirometry as well. Serial chest x-rays
showed eventual clearing of his left lung. His oxygen saturation
improved to 100% on 4L. He underwent a chest CT which showed a
large right pleural effusion and left airspace disease possibly
consistent with pneumonia. he continued to produce increasing
amounts of airway mucous. Though he did not spike a fever or
develop a leukocytosis, he was started on empiric coverage for
hospital acquired pneumonia with vancomycin and zosyn. This was
continued for a total of 4 days, and then discontinued. His
respiratory status continued to improve, and he was weaned down
to 2L NC O2, and often maintained O2 sats > 94% on room air at
rest.
He was transferred from the ICU to the medicine floor on [**11-25**],
where the below issues were addressed:
Hypoxia: Thought to be due to mucus plugging in setting of
procedure. Given the acuity of both the change and the reversal
it is likely that he experienced lung collapse and then
reaeration of expectorating mucus. Received 4 days of vanc/zosyn
for presumed HAP coverage in setting of hypoxia and increased
sputum production, this was d/c'd [**11-28**] with no additional fevers
and decreasing sputum. He was continued on ipratropium nebs,
mucomyst nebs, guaifenesin, incentive spirometry. During his
stay, his oxygen requirement was weaned, now requiring 2L NC
only intermittently. Will continue albuterol and ipratropium
nebs on a prn basis.
.
Hypernatremia: Na as high as 150, did decrease with IVF but
still mildly elevated on transfer to floor. Improved to 147
with D5W. IV hydration stopped at this time and POs encouraged
given risk of CHF. Free water deficit estimated at 2.3L on
transfer to floor. Na remained stable in range of 143-147 when
taking more PO fluid. Recommend continued intermittent
monitoring.
LAD: s/p mediastinoscopy.
His mediastinal lymph node biopsy results were consistent with
carcinoid. The hematology/oncology service was consulted, and
they recommended getting an octreotide scan, the preliminary
read showed metastatic carcinoid. These results were discussed
with the patient and his outpatient oncologist. The patient
requested to be followed by his oncologist in [**Hospital1 1562**].
.
diastolic Congestive Heart Failure: ECHO with EF of 75%, has
severe dCHF. Cards consulted while in ICU. Digoxin was
discontinued in setting of diastolic CHF. Cardiology
recommended using either BB or verapamil to control HR, goal to
have <80. HR was well controlled without meds on transfer from
ICU. Added Metoprolol 12.5 mg [**Hospital1 **] on [**11-26**], though this was
d/c'd [**11-27**] for episodes of bradycardia to 30s. Added 12.5
Metoprolol SR [**11-28**], which he has tolerated well. Also added
Candesartan at low-dose (4mg, home dose 16 mg) given h/o
diastolic CHF and goal of reducing afterload. This can be
titrated up as his blood pressure allows. He did have some
increased edema during his stay on the medical floor, and was
given TEDs stockings and encouraged to ambulate. He also
received 40 mg IV lasix x 1 [**2163-11-28**], and an additional dose of
40 mg po on [**11-30**] and 40mg IV on [**12-1**]. The long-term goal
remains to minimize diuretics, but use extreme caution with
fluids as pt is exquisitely volume sensitive due to severity of
dCHF. Discharged with instructions to continue home lasix (40
mg) for 3 days with monitoring of daily weights and chemistries,
this may need to be reassessed and monitored.
.
RHYTHM: He has chronic afib. His heparin was held after
surgery. He was restarted on coumadin 1.25 mg daily on [**11-26**].
His INR rose to the therapeutic range, and was 2.5 on discharge.
Recommend intermittent monitoring to tritrate necessary dosing
regimen.
.
ARF: Improved with hydration. Renal signed off prior to transfer
to floor. Diuresis minimized on the floor, received 40 mg IV
lasix and 40mg PO lasix on two occasions with good diuresis, pt
maintained blood pressures. The goal continues to be to
minimize diuresis to prevent excessive preload reduction.
.
CAD: He was continued on his statin, held ASA due to h/o GI
bleed
Medications on Admission:
PPI
Lipitor 10
Atacand 16 (confirmed with spouse)
Digoxin 0.125 mg qd
Aldactone 25 qd
Lasix 40 qd
Allopurinol 100 mg qd
Verapamil 180 qd
Coumadin 2.5 (MWF); 1.25 (TTSS)
Flomax 0.5
Discharge Medications:
1. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Warfarin 1 mg Tablet Sig: 1.25 Tablets PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Candesartan 4 mg Tablet Sig: One (1) Tablet PO daily ().
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2857**] - [**Location (un) 9188**]
Discharge Diagnosis:
Primary:
Mediastinal Lymphadenopathy
Metastatic Carcinoid
Acute renal failure
Secondary:
chronic diastolic congestive heart failure
anemia
atrial fibrillation
chronic renal insufficiency
Discharge Condition:
fair, tolerating PO, afebrile, VS wnl, O2 95-100% on
supplemental O2 2L [**Hospital **] transfer to chair with assist
Discharge Instructions:
You were admitted to the hospital with mediastinal
lymphadenopathy. You had a mediastinoscopy and bronchcoscopy.
The pathology reports showed this was consistent with carcinoid.
You were seen by the oncologists, who recommended an Octreotide
scan; you indicated you would like to follow up with your
outpatient oncologist.
You were also noted to have an exacerbation of your heart
failure. You were seen by the cardiologists, who recommended
you stop your digoxin. You were given diuretics to remove
fluid. You also had acute renal failure, which resolved during
your stay.
.
A CT scan showed a mass on your left adrenal gland, this should
be worked up as an outpatient, you should talk with your primary
care doctor about further evaluation.
.
The following changes were made to your medications:
Your digoxin, verapamil and aldactone were stopped
Your atacand dose was decreased to 4 mg
You were started on metoprolol
You were started on docusate, senna, and bisacodyl as needed for
constipation and albuterol and ipratropium nebs as needed for
SOB/wheezing
Your allopurinol and flomax were held, these can be restarted
during your rehab stay
Your coumadin was decreased to 1.25 mg daily, this can be
adjusted based on your INR
.
Please call your doctor or return to the ED for:
- fevers/chills
- shortness or breath or chest pain
- increasing sputum production
- weight gain > 3 lbs
- any other new or concerning symptoms
Followup Instructions:
Follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25237**]
([**Telephone/Fax (1) 66056**], within 1 week of leaving rehab. On a CT scan,
you were noted to have a mass on your left adrenal gland, and
they recommended dedicated CT or MRI for better
characterization. Dr. [**Last Name (STitle) 25237**] should help you this setting this
up.
Follow up with your cardiologist Dr. [**Last Name (STitle) 41632**] [**Name (STitle) **] [**Telephone/Fax (1) 19666**],
fax [**Telephone/Fax (1) 66057**] within the next 2-3 weeks for reevaluation and
adjustment of heart failure meds as needed.
Oncology Dr. [**Last Name (STitle) 27009**] [**Telephone/Fax (1) 66058**]. You have an appointment on
[**12-13**] at 1:20 PM, call if you need to reschedule or be
seen sooner.
|
[
"5849",
"486",
"5180",
"2760",
"4280",
"42731",
"5859",
"4241",
"32723",
"V5861"
] |
Admission Date: [**2156-6-29**] Discharge Date: [**2156-7-4**]
Date of Birth: [**2089-7-5**] Sex: M
Service: Cardiac Surgery
CHIEF COMPLAINT: Dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 11196**] is a 66 year-old
diabetic who reports dyspnea on exertion since the past two
years. He becomes short of breath when he carries his 22
month old daughter for more than three or four block. He
also gets short of breath when climbing one flight of stairs
or walking 15 minutes on a treadmill. He had a stress test
that demonstrated inferolateral ischemic changes and on
nuclear images had a moderate to severe reversible defect in
the inferior wall. His ejection fraction was estimated at
64 percent. Cardiac catheterization revealed a right
dominant system with three vessel coronary disease. He was
referred for cardiac surgery.
PAST MEDICAL HISTORY: Is notable for the following: 1)
Hypertension. 2) Hypercholesterolemia. 3) Insulin dependent
diabetes mellitus. 4) Ulcerative colitis. 5) history of
bleeding gums. 6) Heavy cigar use, quit three years ago.
PAST SURGICAL HISTORY: 1) Vocal cord papilloma, status post
32 throat surgeries.
Patient is not allergic to any medicines. He takes the
following medications: 1) aspirin 325 mg q.d., 2) Humolog
insulin 12 units in the A.M., 10 units in the P.M. at dinner.
3) NPH 30 units in the A.M., 40 units at bedtime, 4) Lipitor
10 mg p.o. q.h.s., 5) Asacol 800 mg p.o. b.i.d., 6) Atenolol
50 mg p.o. q.d., 7) doxycycline 100 mg p.o.q.d. 8) Xanax
0.25 q.j.s. p.r.n., 9) vitamin D 400 international units q.d.
ADMISSION LABORATORY DATA: White [**Known lastname **] cell count is 6.9,
hematocrit is 44, platelets are 244, BUN/creatinine 22/1.2.
HOSPITAL COURSE: The patient was admitted as a Same Day
surgery patient to the Cardiac Surgery Service. He was taken
to the operating room where he had coronary artery bypass
grafting time four. His grafts are LIMA to LAD, saphenous
vein graft to LAD/diagonal, saphenous vein graft to OM and
saphenous vein graft to right PDA. Patient's procedure
itself was unremarkable. Postoperative he was taken
intubated to the Intensive Care Unit on Neosynephrine and
insulin drips. Overnight he was extubated. His Lopessors
were weaned off on the first postoperative day and his
insulin drip was converted to his home insulin regimen after
his [**Known lastname **] sugars normalized. He did have problems with [**Name2 (NI) **]
sugars as high as 400 but these subsequently corrected. By
the evening of the first postoperative day he was on the
hospital floor. The remainder of the hospitalization was
unremarkable. His Foley catheter, chest tube and pacing
wires were all discontinued in normal fashion. His primary
care physician was involved in managing his [**Name2 (NI) **] sugars. He
was restarted on his appropriate home medications. By his
fifth postoperative day he was eating, ambulating, voiding
and was cleared by physical therapy to be safely discharged
home. He did have some lability of his [**Name2 (NI) **] sugars and that
extended his hospitalization for one day. He also had no
changes in his insulin regimen as it was felt that his eating
habits would normalize once he arrived home.
On [**2156-7-4**] patient was discharged home in stable
condition under the care of his family. He will have a
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) 11197**] his wound status and ensure that he
is managing adequately at home. He is discharged on the
following medications: 1) Lopressor 50 mg p.o. b.i.d., 2)
aspirin 325 mg p.o. q.d., 3) Asacol 800 mg b.i.d., 4) Lipitor
10 mg q.d., 5) Zantac 150 mg b.i.d., 6) Colace 100 mg b.i.d.,
6) Xanax 0.25 mg q.h.s. p.r.n., 7) Lasix 20 mg q.d. times
seven days, 8) potassium chloride 10 mEq q.d. times seven
days, 9) NPH 30 units q. A.M., 40 units q.h.s., 10) Humolog
12 units q.A.M., 10 units q. P.M. at dinner, 11) Percocet 325
1 to 2 p.o. q 4 to6 hours p.r.n.
Patient is to follow up with his primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11198**] within the next two to three weeks. In
addition, he is to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in six weeks.
DISCHARGE DIAGNOSIS:
Three vessel coronary artery disease, now status post
coronary artery bypass graft times four.
Insulin dependent diabetes mellitus, partially controlled.
Hypercholesterolemia.
Hypertension.
Ulcerative colitis.
Vocal cord papillomas.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 9638**]
MEDQUIST36
D: [**2156-7-4**] 11:43
T: [**2156-7-4**] 12:29
JOB#: [**Job Number 11199**]
|
[
"41401",
"2720",
"4019"
] |
Admission Date: [**2166-1-4**] Discharge Date: [**2166-1-15**]
Date of Birth: [**2113-2-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Atorvastatin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Shortness of Breath, Chest Pressure
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4, with the left
internal mammary artery to the left anterior descending
artery and reversed saphenous vein grafts to the posterior
descending artery, obtuse marginal artery, and diagonal
artery.
History of Present Illness:
52M with prior MI [**70**] years ago sp angioplasty, DM, [**Hospital 33210**]
transferred from [**Location (un) **] with concern for NSTEMI Trop 2.26) and
heart failure. Patient notes SOB for one month, cough productive
of dark green sputum, recently started on Zpak and prednisone as
outpatient without significant improvement in symptoms. Denies
fever, chills. Notes increased lower extremity edema over last
few weeks and orthopnea.
.
two days prior to admission noted acute increase in his symptoms
of shortness of breath. Also noted chest pressure, no pain, that
did not radiate. Pt states that this chest pressure is very
different from his MI [**70**] years ago - that pain presented with
neck, jaw, and back pain rather than vague chest pressure for 2
days. Presented to [**Location (un) **]. Trop found to be 2.26 and BNP 889.
Patient was started on heparin gtt, nitro gtt, and BiPAP.
Transferred to [**Hospital1 18**] for further managment.
Treated for CHF and acute coronary syndrome and evaluated for
cardaic surgery.
Past Medical History:
- Myocardial Infarction 16 years ago, no stents, one vessel
angioplasty
- Diabetes non insulin dependent diagnosed 2.5 years ago
- Chronic Low Back Pain/Sciatica
- Surgery on testicles due to injury several years ago
Social History:
- Tobacco history: smoke 1 ppd for 30 years, cut back last
month, now [**12-26**] cigarettes per day, none for past couple of days
- ETOH: occasional drinking on the weekend
- Illicit drugs: None
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: healthy
- Father: 86 sees a cardiologist for unknown reason
- Uncle had heart problems
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Afebrile BP=101/64 HR= 101 RR=22 O2 sat= 97%
GENERAL: WDWN male, sitting up in bed, 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.
Mucous membranes dry.
NECK: Supple with JVP 2cm above clavicle
CARDIAC: distant heart sounds, RRR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Diminished BS at bilateral bases with crackles, dullness
to percussion bilateral bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
EXTREMITIES: warm, dry, no hair on lower extremities, 2+ PT
pulses
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
.
STUDIES:
CXR [**2166-1-4**]:
IMPRESSION: Moderate pulmonary congestion. Underlying
consolidation can not be excluded.
.
TTE [**2166-1-4**]:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. There is moderate regional left ventricular systolic
dysfunction with severe hypo/akinesis of the inferior,
inferolateral and anterolateral and apical walls. There is mild
hypokinesis of the remaining segments (LVEF = 30 %). The
estimated cardiac index is borderline low (2.0-2.5L/min/m2).
Right ventricular cavity size is mildly increased. The diameters
of aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
Mitral regurgitation is present but cannot be quantified. There
is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
enlargement with regional and global systolic dysfunction
suggestive of multivessel CAD or other diffuse process.
.
CARDIAC CATH [**2166-1-7**]:
COMMENTS:
1. Coronary angiography in this right-dominant system
demonstrated
three-vessel disease. The LMCA had no angiographically apparent
disease.
The LAD had a proximal 70% stenosis, diffuse mid disease up to
90%, and
an apical subtotal occlusion. The LCx had a large OM branch with
a 70%
stenosis. The RCA was occluded distally and filled via
left-right
collaterals.
2. Limited resting hemodynamics revealed severely elevated
left-sided
filling pressures with LVEDP 33mmHg. The systemic arterial blood
pressure was normal with SBP 105 mmHg and DBP 70mmHg.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Sevre LV diastolic dysfunction.
.
CXR [**2166-1-4**]:
IMPRESSION: Moderate pulmonary congestion. Underlying
consolidation can not be excluded.
.
[**2166-1-4**] 09:49PM %HbA1c-13.2* eAG-332*
[**2166-1-4**] 07:12PM GLUCOSE-243* UREA N-24* CREAT-0.7 SODIUM-135
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-16
[**2166-1-4**] 07:12PM CK-MB-7 cTropnT-0.82*
Brief Hospital Course:
HOSPITAL COURSE:
52 yo male with history of cornary artery disease, MI [**70**] years
ago. Transfered from OSH with concern for given conern for
congestive heart failure, ? NSTEMI. Pt found to have flat
cardiac enzymes and in DKA. He was only on metformin and
glyburide at home. Ketones in urine here with anion gap elevated
suggested DKA. He was placed on an insulin drip. His A1c was
checked and was 13.2. [**Last Name (un) **] was consulted and he was
transitioned to lantus and a sliding scale. Nutrition was
consulted for diabetic education.
Mr. [**Known lastname 1968**] had no known prior history of CHF, and presented with
symptoms concerning for new onset CHF given orthopnea, worsening
dyspnea on exertion, elevated BNP, crackles on exam, and CXR
consistent with volume overload. Unclear precipitating event of
myocarditis vs. MI a month prior when symptoms began. TTE as
above demonstrated EF 30% and global hypokinesis. Cardiac cath
showed LVEDP 33. Pt was diuresed with IV lasix, and symptoms
improved.
He was started on beta blockade and Ace-I.
He presented with vague pressure in setting of worsening dyspnea
of several weeks, and did not appear to be ACS. Heparin was
initially started and discontinued as enzymes remained flat. He
was continued on ASA 325mg daily. As above, beta blockade was
started once BP's could tolerate. ACEI and crestor started. He
went for cardiac cath, which showed diffuse disease of RCA and
LAD. Cardiac surgery was consulted, and recommended CABG.
Mr. [**Known lastname 1968**] is a smoker placed Nicotine patch and SW consulted for
counseling. Pt was strongly encouraged to discontinue smoking.
.
On [**2166-1-9**] he was taken to the operating room and underwent
Coronary artery bypass grafting x4, with the left internal
mammary artery to the left anterior descending
artery and reversed saphenous vein grafts to the posterior
descending artery, obtuse marginal artery, and diagonal artery.
Immediately postopertively he was admitted to the ICU for
cardiopulmonary monitoring and management. On POD#1 he was
weaned from the ventialtor and extubated. Once gylemic control
was achieved he was transferred fromt he ICU to the step down
unit. His chest tubes and temporary pacing wires were removed
per protocol. He was diuresed toward his baseline weigth and his
betablocker, ace-I were titrated to optimize heart function.
Statin therapy was maintained. He was evaluated by physical
therapy for strength and conditioning and claered for discharge
on POD#6. All appointments and instructions were advised.
Medications on Admission:
- Metformin 1000mg [**Hospital1 **]
- Glyburide 2.5mg daily
- Prilosec OTC
- ASA 200mg Daily
- MVT
- Prednisone 4mg dose pack filled in beginning of [**Month (only) **]
- Nitro prn
- Proair MDI prn
Discharge Medications:
1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
8. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
10. Wellbutrin SR 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO twice a day.
Disp:*60 Tablet Extended Release(s)* Refills:*2*
11. insulin regular human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
Disp:*1 bottle* Refills:*2*
12. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous QAM.
Disp:*1 bottle* Refills:*2*
13. insulin syringes (disposable) 1 mL Syringe Sig: Thirty
(30) syringes Miscellaneous once a day: 30 day supply.
Disp:*30 syringes* Refills:*2*
14. glucomter
glucometer and test stripts(30 day supply)
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Diabetes Dyslipidemia, MI, Chronic Low Back Pain/Sciatica,
mitral regurgitation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema : 3+ bilateral lower extremity edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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 Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2166-2-5**]
1:30
Cardiologist:Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] to schedule an appointment in [**2-25**]
weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2166-1-15**]
|
[
"41071",
"41401",
"412",
"V4582",
"2724",
"3051",
"4280",
"V5867",
"53081",
"4240"
] |
Admission Date: [**2161-1-19**] Discharge Date: [**2161-1-25**]
Date of Birth: [**2115-6-28**] Sex: F
Service: NEUROLOGY
Allergies:
Codeine / Metronidazole
Attending:[**First Name3 (LF) 7567**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Lumbar Puncture
Bilateral trigger point injections without steroids.
History of Present Illness:
Ms. [**First Name4 (NamePattern1) **] [**Known lastname **] is a 45 yo W with h/o seizure disorder who
presented on [**2161-1-19**] in status epilepticus. The patient is
transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] intubated and sedated, and no
family is available for collateral. History was obtained from
OSH
records. Patient presented to [**Hospital **] Hospital 1 day PTA for
headache, the details of the ED visit are unknown. On the day of
admission, the patient had [**4-3**] generalized tonic clonic seizures
at home, witnessed by her father-in-law. She was brought to [**First Name8 (NamePattern2) **]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], where she had additional seizures refractory to
medications, without regaining consciousness in between. She
received a total of 10 mg IV Ativan, 1 g Dilantin and was
intubted/sedated and bolused with propofol. She was reportedly
moving all extremities and following commands before intubation.
On arrival to [**Hospital1 18**] ED, patient was on propofol drip.
Toxic/metabolic workup at OSH was negative, as was NCHCT.
Patient
had been afebrile, VSS.
Past Medical History:
PAST MEDICAL HISTORY: Notable for chronic headaches, including
migraine headaches for which she takes a triptan and Fioricet.
She has a history of occipital neuralgia after a neck injury in
[**2134**] with multiple cervical fractures. She required multiple
surgeries, including the removal of a bony spur in [**2147**] and a C7
discectomy and fusion in [**2154**]. She has had hysterectomy and
endometriosis. Osgood-Schlatter disease in the right knee.
Finally, the patient suffers from depression.
Social History:
SOCIAL HISTORY: She lives alone in [**Location (un) 13011**] and works at
[**Company 23944**] Farms. She smoked a pack daily for the past 35 years.
She admits to smoking marijuana (reportedly for "medicinal"
purposes) several times a month.
Family History:
There is no family history of seizures reported
Physical Exam:
GEN: Sitting in bed in c-collar holding sides of head and
appearing nauseated
HEENT: sclera anicteric
CV: RRR, no m/r/g
PULM: CTAB
AB: soft, ND, NT
EXT: right hand edematous (per patient this is a side effect of
her prior spine surgeries and occurs intermittently)
SKIN: no rash
NEURO:
Mental Status: Awake, alert, Ox3. +DOW backwards, fluency
intact, no paraphasic errors
CN: EOMI, no nystagmus, PERRL (2-1.5mm),
Motor: No drift, [**4-2**] strnegth b/l deltoids, biceps, triceps,
finger extensors, hip flexors, knee flexors/extensors, tib ant
[**Last Name (un) 938**]
Coordination: No dysmetria
INITIAL LABS:
Urine Benzos Pos
Urine Barbs Pos
Urine Opiates, Cocaine, Amphet, Mthdne Negative
UCG: Negative
UA negative
Pertinent Results:
[**2161-1-19**] 04:00PM URINE HOURS-RANDOM
[**2161-1-19**] 04:00PM URINE UCG-NEGATIVE
[**2161-1-19**] 04:00PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2161-1-19**] 04:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2161-1-19**] 04:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2161-1-19**] 04:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2161-1-19**] 03:00PM WBC-8.8 RBC-3.38* HGB-12.1 HCT-34.2* MCV-101*
MCH-35.7* MCHC-35.3* RDW-13.8
[**2161-1-19**] 03:00PM NEUTS-65.9 LYMPHS-26.9 MONOS-4.9 EOS-1.8
BASOS-0.5
[**2161-1-19**] 03:00PM PLT COUNT-368
[**2161-1-19**] 02:55PM CEREBROSPINAL FLUID (CSF) PROTEIN-36
GLUCOSE-65
[**2161-1-19**] 02:55PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 POLYS-0
LYMPHS-60 MONOS-40
[**2161-1-19**] 02:37PM LACTATE-1.4
[**2161-1-19**] 02:31PM GLUCOSE-125* UREA N-9 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-18* ANION GAP-14
[**2161-1-19**] 02:31PM estGFR-Using this
[**2161-1-19**] 02:31PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-POS tricyclic-NEG
[**2161-1-19**] 02:31PM WBC-UNABLE TO RBC-UNABLE TO HGB-UNABLE TO
HCT-UNABLE TO MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO
[**2161-1-19**] 02:31PM NEUTS-UNABLE TO LYMPHS-UNABLE TO
MONOS-UNABLE TO EOS-UNABLE TO BASOS-UNABLE TO [**Doctor Last Name **]-UNABLE TO
[**2161-1-19**] 02:31PM PLT COUNT-UNABLE TO
Brief Hospital Course:
Ms. [**Known lastname **] was transferred to our Neuro ICUintubated and on
propofol, after [**4-3**] GTC's. She was soon extubated and sent to
the epilepsy floor, where she admitted to only taking her Keppra
500mg daily, instead of [**Hospital1 **] as prescribed. She explained this
was due to monetary reasons. While admitted she complained of
significant migrainous symptoms and frequently asked for "2mg IV
Dilaudid" to control her pain. She had a history of migraines
treated with Zomig and Fioricet. She was also, as an
outpatient, treated with significant doses of flexeril and
valium for neck spasm after a fall from a ladder in '[**58**]. Pain
service was consulted and they recommended trigger point
injections, which were performed..
She was kept on LTM EEG and her Keppra was stopped, with the
hope of capturing an event. She had previously been labeled as
having "non-epileptic seizures" previously, but to our
understanding her typical events had never been captured on EEG.
The night prior to dischage she had several typical events,
with another one the morning of discharge. Clinically, these
were characterized by arching of the back and neck, irregular
stiffening and tremor of all 4 limbs, and unresponsiveness,
lasting several minutes. Although full EEG was not recorded for
the first 2 events due to the left hemisphere leads falling off,
the last event was captured and there was no EEG correlate. She
was discharged with the diagnosis of non-epileptic psychogenic
seizures.
Medications on Admission:
Keppra 500 mg [**Hospital1 **] (admits to only 500mg daily)
diazepam 5 mg TID
seroquel 300 mg QHS
celexa 60 mg daily
oxycontin 20 mg [**Hospital1 **]
Vicodin prn
compazine prn
phenergan prn
Nexium
estrogen supplement
Fiorecet prn
Discharge Medications:
1. quetiapine 300 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for neck spasm.
4. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q12H (every 12 hours).
5. promethazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for nausea.
6. estradiol 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Nexium 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Nonepileptic psychogenic events, 780.39.
Neck pain.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms [**Known lastname **],
It was a pleasure taking care of you. You presented after being
intubated in generalized convulsions. After monitoring it
appears that these events are likely stress related and did not
have seizure activity on EEG. A lumbar puncture was done in the
emergency room that was normal. Head CT was normal. You were
seen by the pain service and given an injection.
Followup Instructions:
You should follow up with your Neurologist Dr. [**First Name (STitle) **] in [**Location (un) 12021**]
port. Please call in AM.
You could call your primary care physician and make an
appointment in the next 7 to 10 days
You were seen by the pain service and may continue to follow
with the pain service as an outpatient as needed for your pain
control.
You should continue to follow with your therapist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3236**]
weekly
|
[
"311",
"3051"
] |
Admission Date: [**2110-3-27**] Discharge Date: [**2110-5-15**]
Date of Birth: [**2080-7-13**] Sex: M
Service: SURGERY
Allergies:
Pertussis Vaccine,Fluid
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
abdominal distension and bilious vomiting
Major Surgical or Invasive Procedure:
1) Exploratory laparotomy, small bowel
resection, removal of jejunal feeding tube and
jejunojejunostomy. [**2110-3-27**]
2) Exploratory laparotomy; repair of small bowel
perforation x2. [**2110-3-31**]
Placement of VAC dressing.
3) Split-thickness skin graft from right thigh to
abdominal wound [**2110-5-8**]
History of Present Illness:
The patient is a 29 year old male with a complicated past
medical history including SMA syndrome and several abdominal
operations by Dr. [**Last Name (STitle) **] (please see previous discharge summary
for further details), presented to [**Hospital1 18**] on [**2110-3-26**] with new
onset abdominal distension and bilious emesis at his rehab
center.
Past Medical History:
1) Cerebral palsy with mental retardation
2) Seizure disorder
3) History of H. pylori gastritis
4) Recent right clavicular fracture on [**2109-9-14**]
5) History of multiple surgeries to the lower extremities for
flexion contractures
6) Recurrent Klebsiella UTI, treated with Bactrim, Rocephin and
Tequin.
7) SMA Syndrome: Followed by Dr. [**Last Name (STitle) **] (surgery) SBO initially
felt secondary to obstipation brought about by codeine use for
pain managment secondary to clavicular fracture. A barrium
swallow on [**2109-9-21**] was suggestive of partial obstruction at the
second portion of the duodenum. However, he continued to have
high NG residuals and radiographic features c/w partial SBO
despite clearance of stools, which led to a consideration of SMA
syndrome. A CT on [**2109-10-2**] showed stable distension of the
stomach and duodenum, with proximal duodenal distension without
apparent dilatation of the distal duodenum. A repeat EGD on
[**2109-10-17**] was performed, at which time duodenal narrowing was not
appreciated. A subsequent gastrograffin study, however, showed
high grade partial obstruction of the duodenum. Suspected
gastric outlet obstruction/partial SBO due to SMA syndrome
suggested on radiographic studies, although duodenal narrowing
not appreciated on repeat EGD. The patient had had minimal
improvement with conservative management, with continued weight
loss and inability to tolerate POs. NG tube was maintained, and
TPN was continued per nutrition recs. GI consulted, CT angio of
abdomen was done. The patient underwent EUS on [**11-11**], duodenal
biopsies taken, unable to visualize pancreas, decision made for
pancreatic MRI to be done. Surgery consulted, thought clinical
picture c/w SMA, plan to have patient undergo surgical
decompression in the near future once his nutritional status has
improved (goal weight of 105 pounds). The patient was continued
on a PPI [**Hospital1 **] for GI protection given his history of fundus
ulcers. The patient had a G/J tube placed under IR on [**11-13**],
and tube feeds were started 24 hours after placement. Biopsies
from duodenum showed mild inactive duodenitis.
8) ARDS [**9-/2109**] at [**Hospital **] Hospital; admitted with abdominal
pain, ? hematemesis and suspected SBO. A CT chest and abdomen
was performed and reportedly showed multifocal pneumonia with
bilateral pleural effusions, no abdominal mass. His clinical
picture evolved into an ARDS picture requiring intubation on
[**2109-9-22**]. He was treated with Zosyn for presumed aspiration
pneumonia; sputum cultures grew [**Female First Name (un) 564**] Albicans. He
self-extubated on [**2109-10-6**], and has been stable from a
respiratory standpoint since that point.
9) Left LE DVT, diagnosed on [**2109-12-5**], initially treated with
lovenox, then switched to coumadin.
10) Pancreatic Head Cystic Lesion, followed q1 year
Social History:
Mr. [**Known lastname 6164**] is a resident of [**Hospital1 **] Meadows in [**Location (un) **].
Patient reportedly ambulates with assist and wears a helmet for
safety in the nursing home.
Family History:
Not available.
Physical Exam:
VS- 98.3, 117, 130/72, 20, 100%
Gen: nonverbal, uncomfortable
Lungs: coarse bilaterally
Heart: sinus tachycardia
Abdomen: firm and distended, normal rectal tone, guiac +,
disimpacted with a large amount of stool in the ED
Pertinent Results:
[**2110-3-26**] 06:20PM BLOOD WBC-31.0*# RBC-3.74* Hgb-11.2* Hct-33.1*
MCV-89 MCH-30.0 MCHC-33.8 RDW-19.5* Plt Ct-768*
[**2110-3-27**] 06:17PM BLOOD WBC-4.4# RBC-4.58*# Hgb-14.0# Hct-39.9*#
MCV-87 MCH-30.6 MCHC-35.1* RDW-18.0* Plt Ct-328#
[**2110-3-28**] 04:21AM BLOOD WBC-19.0* RBC-3.69* Hgb-11.3* Hct-32.0*
MCV-87 MCH-30.6 MCHC-35.3* RDW-18.5* Plt Ct-342
[**2110-3-28**] 02:00PM BLOOD WBC-27.1* RBC-3.00* Hgb-9.0* Hct-26.2*
MCV-87 MCH-30.1 MCHC-34.5 RDW-18.6* Plt Ct-308
[**2110-3-29**] 03:23AM BLOOD WBC-26.6* RBC-2.77* Hgb-9.0* Hct-24.1*
MCV-87 MCH-32.5* MCHC-37.3* RDW-18.7* Plt Ct-288
[**2110-3-30**] 03:01AM BLOOD WBC-32.3* RBC-2.56* Hgb-7.7* Hct-22.8*
MCV-89 MCH-30.3 MCHC-34.0 RDW-18.5* Plt Ct-265
[**2110-4-11**] 03:11AM BLOOD WBC-16.0* RBC-2.26* Hgb-6.8* Hct-20.4*
MCV-90 MCH-29.9 MCHC-33.1 RDW-17.8* Plt Ct-503*
[**2110-4-16**] 02:28AM BLOOD WBC-14.4* RBC-2.66* Hgb-7.9* Hct-23.7*
MCV-89 MCH-29.6 MCHC-33.2 RDW-18.1* Plt Ct-723*
[**2110-4-17**] 02:06AM BLOOD WBC-20.4* RBC-2.55* Hgb-7.6* Hct-22.9*
MCV-90 MCH-29.8 MCHC-33.3 RDW-18.2* Plt Ct-772*
[**2110-5-2**] 02:36AM BLOOD WBC-59.8*# RBC-2.81* Hgb-8.5* Hct-25.8*
MCV-92 MCH-30.2 MCHC-33.0 RDW-18.4* Plt Ct-690*
[**2110-5-2**] 04:55PM BLOOD WBC-42.1* RBC-2.60* Hgb-7.7* Hct-23.7*
MCV-91 MCH-29.8 MCHC-32.7 RDW-18.5* Plt Ct-615*
[**2110-5-4**] 02:26AM BLOOD WBC-18.4* RBC-2.20* Hgb-6.5* Hct-20.4*
MCV-92 MCH-29.3 MCHC-31.7 RDW-19.1* Plt Ct-633*
[**2110-5-5**] 02:58AM BLOOD WBC-14.2* RBC-3.03* Hgb-9.3* Hct-27.6*
MCV-91 MCH-30.8 MCHC-33.7 RDW-18.9* Plt Ct-492*
[**2110-5-14**] 04:03AM BLOOD WBC-13.1* RBC-2.89* Hgb-8.5* Hct-26.6*
MCV-92 MCH-29.5 MCHC-32.0 RDW-17.7* Plt Ct-762*
[**2110-3-26**] 06:20PM BLOOD PT-12.1 PTT-21.8* INR(PT)-1.0
[**2110-3-26**] 06:20PM BLOOD Glucose-157* UreaN-18 Creat-0.4* Na-135
K-3.3 Cl-88* HCO3-33* AnGap-17
[**2110-3-26**] 06:20PM BLOOD ALT-35 AST-21 AlkPhos-404* Amylase-21
TotBili-0.4
[**2110-3-26**] 06:20PM BLOOD Lipase-12
[**2110-3-26**] 06:20PM BLOOD Albumin-3.6
[**2110-3-27**] 02:57AM BLOOD calTIBC-169* TRF-130*
[**2110-5-12**] 03:45AM BLOOD calTIBC-124* Ferritn-1153* TRF-95*
Brief Hospital Course:
The patient was admitted to [**Hospital1 18**] on [**2110-3-26**] for abdominal
distension and bilious emesis. His WBC was 31. He was
afebrile. He was hypokalemic and hypochloremic. A CT scan
showed distended loops of fecalized small bowel with jejunostomy
tube in place and collapse of the transverse colon, descending
colon, sigmoid colon. These findings were concerning for
small-bowel obstruction. He was admitted to the ICU. He was
kept NPO on IV fluids. He was started on Ativan for agitation
and morphine for pain. He was started on Lopressor for
tachycardia. He was empirically started on Linezolid (history
of VRE), Levaquin, and Flagyl. On HD 2, a left sided central
venous line was placed and his PICC was removed. Later that day
he had an exploratory laparotomy, small bowel resection, removal
of jejunal feeding tube and
jejunojejunostomy by Dr. [**Last Name (STitle) **] (please see operative note for
details). The jejunal feeding tube had a perforation near it
with barium and tube feedings. There was
a significant amount of barium spillage in the abdomen during
the procedure. The cause of the obstruction appeared to be an
omental band across the Roux-Y loop just as it entered the
distal jejunal anastomosis. The Roux-Y loop appeared to be
intact with the duodenum but this could not be assessed
completely. He recieved 6 L of IV fluids and albumin boluses
post-operatively for oliguria and he eventually responded.
Fluconazole was added. An A-line was placed. He was
transferred back to the ICU intubated and sedated. He had a JP
drain. He was maintained on drips of Fentanyl, Midazolam, and
Pitressin. He had an NG tube. His abdomen was left open.
On POD 1, he had low grade fevers. His WBC was 19 and hit Hct
was stable. On POD 2 he was started on TPN. His hematocrit
dropped to 22. He did not recieve blood for this as it was
assumed to be dilutional. He was weaned off of pressors later
that day. On POD 4, he went to the OR for closure of his open
abdomen. He wound up having an exploratory laparotomy; repair
of small bowel perforation x2, and placement of VAC dressing
(please see operative note for details). He was transferred
back to the ICU after his surgery. He was again intubated and
sedated. His antibiotics were continued. TNP was continued.
On POD [**4-14**], he was afebrile with stable vitals except for
tachycardia. His WBC was 37. HIs Hct was stable at 26. He was
maintained on Fentanyl and Midazolam drips. His abdomen was
soft. He was stable off pressors. On POD [**5-16**], his HG tube was
removed. His VAC was changed at the bedside. On POD [**6-16**], his
WBC was 23. He ran low grade temperatures. On POD [**7-18**], a right
subclavian line was placed. He was febrile to 102. His WBC was
26. His antibiotics were Linezloid, Meropenem, and Fluconazole.
VRE was cultured from his peritoneal fluid. He had Klebsiella
in his blood. He was also growing Pseudomonas from his urine
and sputum. Cefipime was added. His line was changed to a
right IJ line. On POD [**8-19**], he continued to be febrile to 102.
On POD [**9-19**] his VAC was changed. On POD [**10-21**], he continued to
be febrile to 102. His WBC was 25. An echo was done to rule
out endocarditis and was negative. A CT was done to rule out an
asbcess and showed extensive postoperative change and fluid,
with widespread airspace consolidation consistent with pneumonia
throughout the lung fields. There was no evidence of
anastamotic leak. His A-line tip culture was growing out gram
negative rods. This may have been the source of his bacteremia.
He was maintained on Meropenem, Cefipime, Linezolid, and
Fluconazole. On POD [**11-21**], his WBC was 19 and he continued to be
febrile. On POD 14/10, his Tmax was 101. His WBC was 17. HIs
VAC was changed. His was started on trials of CPAP with PS
ventillation. On POD 15/11, his Hct was 20 and he recieved 1
unit RBCs for blood loss anemia (? source). His WBC was 16. On
POD 15/11, lower extremity ultra sounds ruled out DVTs. On POD
17/13, his Tmax was 100 and his WBC was 15. His sedation was
weaned (he was still on Fentanyla nd Midazolam drips) and his
dilantin level had to be adjusted up. On POD 18/14 his VAC was
changed. He was doing well on CPAP/PS. Midazolam was
discontinued. On POD 19/15, his WBC was 12 and his Tmax was
100. On POD 20/16, he underwent trach collar trials. His
Fentanyl was weaned. He had a breakthrough seizure (30 seconds,
GTC), possibly due to a supratheraputic Dilantin level, so his
Dilantin was held. He was maintained on 150mg [**Hospital1 **] with a goal
of an adjusted Dilantin level of the mid 20s (given his low
albumin of 2.4). On POD 21/17, he spiked a fever to 101 and his
WBC increased to 20. A CT was done to look for a source of
infection and this showed extensive worsening bilateral
pneumonia with near total opacification of both lungs, and a new
rim enchancement of a large fluid collection along the left
abdomen extending into left pericolic gutter that measures 13 x
6 cm. His right IJ line was removed and the tip was cultured.
He required increased FiO2 and PEEP. As his PEEP was increased
to 15, his FiO2 was weaned to 70%. There was concern for a
serious nosocomial pneumonia vs ARDS. A right femoral A-line
was placed. On POD 22/18, he was transfused 2 units of RBCs for
blood loss anemia (Hct 22, ? source). On POD 23/19, he had
successful CT-guided aspiration of left upper quadrant
intraabdominal collection, with 200 cc of serous fluid removed.
Samples were sent for Gram stain and culture. He was started on
Flagyl empirically for C. Difficile, although his toxin levels
were negative. On POD 24/20, he was started on Amikacin and
Ceftazidime for pneumonia. His other antibiotics were
discontinued. On POD 27/23, he had an upper GI series with
small bowel follow through, which did not show any stricture or
leak. He was started on tube feeds (impact with fiber, full
strength through the G-tube, goal 60 cc/hour). On POD 34/30,
his TPN was discontinued. His pressure support was weaned to
10. His tube feeds were at 60cc/hour (goal). His WBC was 19
and his Tmax was 98. He did not tolerate a trial of trach
collar. His tube feeds had to be held for high residuals. On
POD 35/31, his WBC was 24 and he had a low grade fever. A left
subclavian TLC was placed and his right IJ was removed and the
tip cultured. Later that night, he spiked to 104 and his
respiratory status declined. His lungs had bilateral rhonchi an
ascultation. Vancomycin was started empirically. On POD 36/32,
his G-tube was put to gravity and TPN was re-started due to high
residuals. A CT was done to look for an abscess and we found
diffuse severe pulmonary opacities and consolidations consistent
with ARDS or pneumonia. There were moderate bilateral pleural
effusions. There were no acute intraabdominal abnormalities
identified. Meropenem was started to broaden his coverage given
his history of resistant organisms. His A-line was changed over
a wire. His WBC was 59. Propofol was used for sedation. On
POD 37/33, his temperature was down to 100 and his WBC was 27.
He was started on a Neosynepherine drip for BP control. His
tube feeds were restarted. Vancomycin was discontinued. On POD
38/34, he was weaned off pressors. He was afebrile. His WBC
was 18. The source of his decompensation was unclear. [**Name2 (NI) **] was
on Linezolid in case his blood grew out VRE. His On POD 39/35,
he recieved 1 unit of red blood cells for a Hct of 20 due to
blood loss anemia. Linezolid was discontinued because his blood
was free of VRE. Amikacin and Ceftazidime were continued for
Pseudomonas pneumonia and Meropenem for Klebsiella pneumonia.
Flagyl was discontinued. His tube feeds were slowly increased.
His WBC was 14 and he was afebrile. On POD 40/36, he tolerated
a CPAP/PS trial. On POD 41/37, his WBC was up to 19. He was
afebrile. Cultures were sent which were subsequently negative.
Tube feeds were advanced to goal. His CVL was discontinued and
a PICC was placed. On POD 42/38, he went to the OR for a STSG
from his right thigh to cover his abdominal wound. The
operation went well with no complications (please see operative
note for details). Afterwards, he was tramsferred back to the
ICU in good condition.
On POD 43/39/1, he was afebrile and his WBC was 17. On POD
44/40/2, his A-line was discontinued. On POD 46/42/4, his
phenytoin was increased to 200mg Q 12 because of a low level.
His dressing was changed on his donor site. On POD 47/43/5, his
skin graft dressing was changed-- the graft took well. His
ventillator continued to be weaned and he was screened for
rehab. He completed his course of Meropenem on [**2110-5-15**] and was
discharged to rehab.
Medications on Admission:
nystatin s/s, metoprolol 25'''', ASA 325, heparin sc, albuterol
2puff q4 prn, ipratropium bromide 2puff qid, RISS, lansoprazole
30', roxicet prn, iron liquid', phenytoin 100mg iv bid,
lorazepam 2mg iv prn, levothyroxine 100', reglan 10''''
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
2. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-16**]
Drops Ophthalmic PRN (as needed).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: 6-8 Puffs
Inhalation Q4H (every 4 hours).
6. Albuterol 90 mcg/Actuation Aerosol Sig: 6-10 Puffs Inhalation
Q4H (every 4 hours).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
8. Methadone 5 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
9. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day: hold for SBP < 100, HR < 60.
11. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4
hours) as needed for agitation.
12. Metoclopramide 5 mg/mL Solution Sig: Ten (10) mg Injection
Q6H (every 6 hours).
13. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
14. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 1 days: finish coursewith
last dose PM [**2110-5-15**] then discontinue.
15. Heparin Lock Flush 100 unit/mL Solution Sig: Two (2) ML
Intravenous DAILY (Daily) as needed.
16. Phenytoin Sodium 50 mg/mL Solution Sig: Four (4) mL
Intravenous Q12H (every 12 hours). Goal level [**10-3**].
17. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection as directed Injection ASDIR (AS DIRECTED): Insulin SC
Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-65 mg/dL [**12-16**] amp D50
66-120 mg/dL 0 Units
121-140 mg/dL 3 Units
141-160 mg/dL 5 Units
161-180 mg/dL 7 Units
181-200 mg/dL 9 Units
201-220 mg/dL 11 Units
221-240 mg/dL 13 Units
241-260 mg/dL 15 Units
261-280 mg/dL 17 Units
281-300 mg/dL 19 Units
301-320 mg/dL 21 Units
> 321 mg/dL Notify M.D.
.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
small bowel obstruction with perforation, new small bowel
perforations, non-healing abdominal wound, ARDS, pneumonia,
sepsis, breakthrough seizures, blood loss anemia
Discharge Condition:
stable, on mechanical ventilation (CPAP w/ pressure support of
10, PEEP 5), no drips.
Discharge Instructions:
Please call or come to the ED with any fevers > 101, nausea,
vomiting, increasing pain, shortness of breath, yellow drainage
or redness spreading around the abdominal wound, or any other
worrisome issues that may arise.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to schedule a follow-up in
[**12-16**] weeks at ([**Telephone/Fax (1) 6449**].
Completed by:[**2110-5-15**]
|
[
"5849",
"5990",
"99592"
] |
Admission Date: [**2139-7-13**] Discharge Date:
Date of Birth: [**2139-7-13**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname **] was born at 41 and
4/7 weeks gestation and admitted to the NICU for monitoring
following neonatal cardiorespiratory depression.
MATERNAL HISTORY: Mom is a 25-year-old G1, P0, now 1 woman
with prenatal screens: Blood type O positive, DAT negative,
HBsAg negative, RPR nonreactive, rubella nonimmune, GBS
positive. Antenatal history: [**Last Name (un) **] was [**2139-7-2**] for an
estimated gestational age of 41 and 4/7 weeks at delivery.
This pregnancy was uncomplicated. It was spontaneous vaginal
delivery under epidural anesthesia. Rupture of membranes
occurred 15 hours prior to delivery and yielded clear
amniotic fluid. There was no interpartum fever or other
clinical evidence of chorioamnionitis. Interpartum
antibacterial prophylaxis was administered beginning 19 hours
prior to delivery. The neonatal course: The NICU team was not
requested prior to delivery. The infant emerged apneic and
hypotonic. He received tactile stimulation and bag mask
manual ventilation. Heart rate was initially less than 100 by
report but responded to ventilation. The NICU team arrived at
approximately 4 to 5 minutes of age. The infant had onset of
spontaneous respirations at 5 minutes of age followed by
gradual resolution of hypotonia. Apgar scores were 3 at 1
minute, 5 at 5 minutes and 7 at 10 minutes. The infant was
noted to have moderate subcostal retractions at 10 minutes
and was transferred to the NICU for monitoring of neonatal
transition.
PHYSICAL EXAMINATION: Birth weight of 4210 grams which is
greater than 90th percentile; length 53.5 cm which is greater
than 90th percentile; head circumference 37 cm which is
greater than 90th percentile. HEENT: Anterior fontanel soft
and flat, nondysmorphic, occipital caput. Red reflex was
deferred. No nasal flaring. CHEST: Mild to moderate
intercostal retractions, resolving over the first 30 minutes
of age. Good bilateral breath sounds. No adventitious sounds.
CARDIOVASCULAR: Well perfused. Normal rate and rhythm.
Femoral pulses normal. Normal S1 and S2. No murmurs. ABDOMEN:
Soft, nondistended. No organomegaly. No masses. Bowel sounds
active. Anus appears patent. Three-vessel umbilical cord.
GENITOURINARY: Normal penis. Testes descended bilaterally.
CNS: Active, alert, responds to stimuli. Tone was normal to
low, and symmetric. Moves all extremities well. Suck, root,
gag were intact. No facial asymmetry. SKIN: Normal.
MUSCULOSKELETAL: Normal spine, limbs, hips and clavicles.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: The
infant required nasal cannula oxygen initially in the NICU at
100 cc flow of 100% nasal cannula. The infant weaned to room
air on day 2 of life and has remained stable on room air
since 6 p.m. on [**2139-7-15**]. He has had no spells and
required no methylxanthine therapy.Occasionally he had mild
desaturation of feeding but did not require intervention.
CARDIOVASCULAR: The infant had a hemodynamically stable
status throughout the hospitalization in the NICU with no
murmurs and stable blood pressures and heart rate.
FLUIDS, ELECTROLYTES AND NUTRITION: The infant never required
IV fluids, ad lib PO feedings were initiated on the newborn
day. The infant has been ad lib PO feeding and really has
started taking off with feeds on [**2139-7-15**]. He is PO
feeding very well at this time voiding and stooling normally.
He has had no electrolytes measured.
GASTROINTESTINAL: There had been no GI issues. Bilirubin was
sent on day 3 of life and the result is 1.2
HEMATOLOGY: No blood typing has been done on this infant.
Initial CBC was done on admission and hematocrit was 47.4
with a platelet count of 356. There had been no further blood
sampling done.
INFECTIOUS DISEASE: Due to the delayed transition and
depression at birth, CBC and blood culture were done on
admission to the NICU. The blood culture remained negative.
CBC was benign and not left shifted. Antibiotics were never
given.
NEUROLOGIC: The infant has maintained a normal neurologic
examination for gestational age.
SENSORY: Audiology - hearing screen was performed automated
auditory brain stem responses and the results are .....
PSYCHOSOCIAL: [**Hospital1 18**] social worker has been involved with the
family. There are no active ongoing psychosocial issues at
this time. If the social worker needs to be reached, she can
be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home to the parents. Parents are
Spanish speaking only.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from
[**Location (un) 1468**]. Telephone No.: [**Telephone/Fax (1) 50457**].
CARE RECOMMENDATIONS:
1. Feedings: Ad lib PO feedings of breast feeding or Similac
20 with iron.
2. Medications: None.
3. No car seat position screening was done on this infant.
4. State newborn screen was done on day of life 3 and
results are pending.
5. Immunizations received:
6. Immunizations Recommended:
7. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following three criteria.
1. Born at less than 32 weeks gestation.
2. Born between 32 and 35 weeks gestation with two of
the following:
8. daycare during the RSV season.
9. a smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings.
10. with chronic lung disease.
1. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
Follow up appointment is recommended with the pediatrician
within 48 hours of discharge from the NICU.
DISCHARGE DIAGNOSES:
1. Delayed transition to extrauterine life.
2. Sepsis ruled out.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2139-7-16**] 22:04:37
T: [**2139-7-16**] 23:40:33
Job#: [**Job Number 69607**]
|
[
"V290",
"V053"
] |
Admission Date: [**2172-9-22**] Discharge Date: [**2172-9-28**]
Date of Birth: [**2106-9-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ceftriaxone / Clozaril / Loxitane / Lamotrigine /
Shellfish
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
ecchymoses in hands, supratheurapeutic INR
Major Surgical or Invasive Procedure:
NA
History of Present Illness:
Pt is a 66M with A-fib on Coumadin and schizophrenia who
presented with 1 day history of bilateral hand brusing and
dizziness. No falls or trauma. Pt also noted left sided
abdominal pain with no changes in bowel habits (constipated at
baseline). Pt has continued to tolerate po intake however has
taken less in over the past few days by report of his caretaker.
Dizziness resolved by arrival. No f/c. Patient presented to ED
with the hand bruising, and INR found to be 22 adn HCt was found
to be in the low 20s. In ED, received 4 units of FFP and factor
9 to reverse coagulopathy in setting of RP bleed. Pt was also
transfused PRBc. He was transferred to the ICU for close
monitoring.
Past Medical History:
1. Schizophrenia
2. Kleinfelters syndrome
3. Atrial fibrillation
4. GERD
5. Hypertension?
6. Seizure disorder; no seizure in "years"
Social History:
Lives in a group residence on Beacon street. No tobacco or ETOH;
denies illicit drugs.
Family History:
Mother with breast cancer. Father with heart disease.
Physical Exam:
VS: T 98, HR 100, BP 140/80 RR 18 Sat 100 RA
Gen: NAD pleasant
HEENT: PERRL, anicteric
Neck: No JVD
Lungs: CTAB no C/W
Heart: RRR S1 S2 no g/m/r
Abd: +BS, soft, mild TTP periumbilical no rebound or guarding;
Ext: +2 RP no edema
Neuro: A&Ox 3, speech fluent, CN 2-12 intact strength +5
throughout
Pertinent Results:
[**2172-9-22**] 12:00PM BLOOD WBC-14.9*# RBC-4.25* Hgb-12.1* Hct-35.8*
MCV-84 MCH-28.4 MCHC-33.7 RDW-13.8 Plt Ct-371
[**2172-9-28**] 07:25AM BLOOD WBC-11.0 RBC-4.01* Hgb-11.8* Hct-33.9*
MCV-85 MCH-29.4 MCHC-34.7 RDW-14.1 Plt Ct-382
[**2172-9-22**] 12:00PM BLOOD Neuts-83.7* Lymphs-9.8* Monos-5.5 Eos-0.8
Baso-0.3
[**2172-9-27**] 01:13PM BLOOD Neuts-72.1* Lymphs-16.3* Monos-9.1
Eos-2.3 Baso-0.2
[**2172-9-22**] 12:00PM BLOOD PT->150* PTT-107.1* INR(PT)->22.8*
[**2172-9-23**] 04:43AM BLOOD PT-15.4* PTT-41.1* INR(PT)-1.4*
[**2172-9-24**] 11:03AM BLOOD PT-15.6* PTT-42.9* INR(PT)-1.4*
[**2172-9-28**] 07:25AM BLOOD PT-14.5* INR(PT)-1.3*
[**2172-9-22**] 12:00PM BLOOD Glucose-179* UreaN-27* Creat-1.6* Na-133
K-5.1 Cl-95* HCO3-18* AnGap-25*
[**2172-9-28**] 07:25AM BLOOD Glucose-99 UreaN-17 Creat-0.9 Na-134
K-3.6 Cl-101 HCO3-24 AnGap-13
[**2172-9-22**] 12:00PM BLOOD ALT-17 AST-21 LD(LDH)-247 AlkPhos-99
TotBili-0.4
[**2172-9-22**] 12:00PM BLOOD Albumin-4.1 Calcium-9.0 Phos-2.9 Mg-2.3
[**2172-9-25**] 07:55AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
CT Abd/pel no C
1. Interval development of moderate-sized retroperitoneal
hematoma, likely
due to the patient's coagulopathy.
2. Interval development of mild-to-moderate left-sided
hydronephrosis, which may be due to hemorrhage within the
proximal ureter, or related to
inflammation/stranding within the retroperitoneum from
underlying hemorrhage. An underlying proximal ureteral stricture
cannot be completely excluded, as no IV contrast was
administered. A followup CT or MRI examination is recommended
after resolution of the hematoma to exclude an underlying
lesion.
3. Unchanged mesenteric and retroperitoneal lymphadenopathy
dating back to
[**2170**], of unclear etiology.
4. Stable mild calcification involving the gallbladder wall.
CT head no C
No acute intracranial process. Probable chronic opacification
involving the right maxillary and ethmoid air cells.
CXR
As compared to the previous radiograph, there is no relevant
change. Minimal left suprabasal atelectasis. Otherwise,
unremarkable, no
evidence of pneumonia. Normal size of the cardiac silhouette.
Brief Hospital Course:
In brief the patient presented with echymoses in his hands and
noted to have elevated INR. A CT scan was positive for
retroperitoneal hematoma. Surgery was consulted in the ED and
did not think a surgical intervention was necessary at the time.
Initially the patient was admitted to the ICU (2 day stay) and
then transfered to the wards.
1. Retroperitoneal hematoma: this was attributed to the elevated
INR. The etiology of the patient's elevated INR is umclear. The
patient was not given any new medications recently. His group
home dispenses his medications. The trigering event for the
hematoma might have been the minor fall that the patient
experienced. The echymoses in his hand may have been explained
by the fall/coagulopathy. The patient received FFP and his INR
normalized to less than 1.4 (4 units, last unit [**2172-9-22**]). The
patient was advised to have his INR checked in three days. The
patient's HCT stablized after trasfusion of pRBCs (x4 units,
last unit [**2172-9-23**]). On D/C HCT was 39. A repeat CT showed
resolving hematoma. Warfarin will be restarted as an outpatient
by his PCP when [**Name9 (PRE) 94630**] safe. The PCP was [**Name (NI) 653**] and [**Name2 (NI) 10815**]
to hold warfarin for one month
2. Fever: the patient developed intermittent fever throughout
the stay. Blood and urine cultures were negative, throughout
his stay. A CXR was positive only for atelectasis and a repeat
CT was read as a resolving RP hematoma without acute changes.
The fever was felt to be secondary to the hematoma and no
antibiotics were indicated.
3. Atrial fibrillation: This was stable during this admission.
Rate controlled with metoprolol. The patient will not receive
anticoagulation because of the retroperitoneal bleed.
4. Schizophrenia remained stable during admission on his
outpatient regimen.
5. Code: Full
Discharge Medications:
1. Olanzapine 10 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime).
2. Oxcarbazepine 600 mg Tablet Sig: 0.5 Tablet PO QHS (once a
day (at bedtime)).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Outpatient Lab Work
please have CBC and INR drawn 3 days from discharge. Please fax
results to [**Telephone/Fax (1) 6309**].
6. Seroquel 100 mg Tablet Sig: see below Tablet PO see below:
Take 300mg QHS
Take 100mg Qam.
7. Trileptal 300 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day.
9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Milk of Magnesia 400 mg/5 mL Suspension Sig: One (1) PO at
bedtime as needed for constipation.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
12. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: hold
for SBP <100, HR <55.
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Supratherapeutic INR/coagulopathy
Retroperitoneal bleed
Acute blood loss anemia
Secondary:
Schitzophrenia
Atrial fibrilation
Kleinfelter's disease
Discharge Condition:
Stable
Discharge Instructions:
You were admitted because your dosing of blood thinning
medication was high. Also you experienced bruising of your
hands. Although not exactly clear why this happened we believe
that it may be due to the decreased oral intake and diarrhea
that you experienced prior to the admission. We did a scan of
your abdomen and noted that you had some bleeding which has been
stable over the last several days.
.
We gave you medications to help restore your blood's ablity to
clot as well as blood trasfusions to help restore your blood
loss.
Please call your regular doctor or come to the ED if you
experience lightheadedness, bleeding, blood in your stool,
dark-tarry stool or any other symptom that is concerning for
you.
.
In addition, you will need to have your INR and hematocrit
checked 3 days after discharge. Please have this done at your
PCP's office.
.
Your coumadin was stopped. Please do not take this medication
until you discuss with your PCP when to resume this medication.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **] at your earliest convinience.
.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2172-10-12**] 10:00
.
Provider: [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. Date/Time:[**2172-10-16**] 10:50
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2172-9-29**]
|
[
"2851",
"5990",
"42731",
"53081",
"4019"
] |
Admission Date: [**2192-1-9**] Discharge Date: [**2192-1-11**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Intracerebral hemorrhage
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 72539**] is an 85 year old right-handed man with a history of
hypertension (per his wife it is not severe) and cutaneous
T-cell lymphoma (stable for 17 years), who is transferred from
[**Hospital **] Hospital with the diagnosis of left intraparenchymal
hemorrhage. Per his wife he had not recently been ill and was
feeling quite well this morning, without complaint of headache,
visual changes, or new trouble with his balance. He has chronic
low back pain and had an appointment with his chiropractor this
morning. He told his wife he was going to work out after that,
and left the house at about 11 a.m. The chiropractor then
called his wife, saying that he looked rather shaky. Mr.
[**Known lastname 72539**] then apparently left the office and sat in the driver's
seat of his car, with the door open. Someone noticed that he
did not look well and called EMS.
They found him with right face/arm/leg weakness and slurred
speech. His blood glucose was 91 and BP was 168/98. He was
brought to [**Hospital **] Hospital where his initial BP was 151/72 and
his HR was 57. He was afebrile. There he was described as
having no speech output but he was following commands. He was
not coagulopathic, with an INR of 0.95, PTT of 29.9, and
platelets of 322. He had a head CT which revealed a small
(about 3 x 2.5 cm) hemorrhage in the left external capsule, with
no midline shift and no intraventricular blood. He was then
transferred to [**Hospital1 18**] for further workup.
Upon arrival here his blood pressure was elevated at 188/77 and
he was given hydralazine. He was taken for head CT, and per
recommendation of Neurosurgery, CTA (presumably to look for
dissection, although per his wife he gets no neck manipulation).
Review of systems: No recent fever, weight loss, cough,
rhinorrhea, shortness of breath, chest pain, palpitations,
vomiting, diarrhea, or rash. No complaints of headache,
diplopia, dysarthria, tinnitus, vertigo, dysphagia, weakness,
numbness, or paresthesias prior to this event.
Past Medical History:
- Cutaneous T-cell Lymphoma - followed by Dr. [**Last Name (STitle) 72540**] at BU;
diagnosed in [**2174**], s/p treatment with "photopheresis" and
currently maintained on a medication called "Targretin"
- Hypertension - per his wife they have never been told that it
is severe
- S/p "tongue cancer" ?leukoplakia
- Chronic back pain
Social History:
Lives with his wife.
Family History:
Father deceased from MI in his late 70's. No stroke that his
wife knows of.
Physical Exam:
(initially examined while lying flat awaiting CT, then later
seen while sitting up, when much more awake)
T Afebrile HR 54 BP 140/63 RR 18 Pulse Ox 98% on 2L NC
General appearance: Sleepy 85 year old man in NAD
HEENT: NC/AT, neck supple
CV: Regular rate and rhythm without murmurs, rubs or gallops. No
carotid or vertebral bruits.
Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended
Extremities: no clubbing, cyanosis or edema
Mental Status: (when lying flat) Somnolent. No spontaneous eye
opening, briefly opens eyes to sternal rub but requires repeated
stimulation. Mute. Does not repeat, does not follow commands.
Does not mimic movements. Decreased attention to the right side
of space.
(when sitting up about 30 minutes later) Awake, eyes
spontaneously open and looking around the room (prefers left),
still mute, does not repeat or follow commands, does not mimic,
but seems to recognize wife and son-in-law, and they thinks he
understands a little bit of what they say.
Cranial Nerves: Pupils are pinpoint and non-reactive. Does not
blink to threat with either eye (but based on visual attention
likely has right homonymous hemianopia). Optic disc margins
could not be visualized. Gaze is midline and conjugate, when
sleepy could doll to either direction. There is no nystagmus. +
corneals, +grimace to nasal tickle bilaterally. Right UMN facial
weakness. Tongue is midline. Weak gag.
Motor System: Exam somewhat limited due to global aphasia and
initially, somnolence. Normal muscle bulk. Flaccid on right
side. Spontaneously moves left arm and leg antigravity.
Extensor postures right arm to noxious stimuli, and makes no
movement with right leg, which is held externally rotated.
Reflexes: Deep tendon reflexes are trace on the left, absent on
the right. Plantar responses are flexor on the left, extensor
on the right. No [**Doctor Last Name 937**].
Sensory: Withdraws to noxious stimuli with left arm and leg,
grimaces and extends right arm, does not respond to noxious in
right leg.
Coordination, Gait: Could not assess.
Pertinent Results:
At [**Hospital **] Hospital:
2.5>11.1/33.2<322
PT 11.6 INR 0.95 PTT 29.9
UA: SG 1011, negative
129 96 21 100 AGap=17
4.5 21 1.0
Comments: K: Hemolysis Falsely Elevates K
estGFR: 71 / >75 (click for details)
MCV 92
3.3 > 11.4 < 322
32.5
N:62.6 L:22.9 M:11.5 E:2.9 Bas:0.2
PT: 13.1 PTT: 27.2 INR: 1.1
Imaging:
CXR: negative for CHF or PNA
Head CT/CTA [**1-9**]: FINDINGS: There is a large 4.1 x 7.8 cm
intraparenchymal hematoma in the left basal ganglia,frontal and
temporal lobes with intraventricular extension. There is midline
shift of approximately 8.8 mm with effacement of the ipsilateral
ventricle. There is mild trapping of the contralateral
ventricle. There are confluent hypodensities in the
periventricular and subcortical white matter compatible with
small vessel ischemia in a patient of this age group. There is a
prominent right frontal extra-axial space. There are secretions
in the right maxillary sinus.
Evaluation of the CTA of the brain demonstrates no aneurysm or
hemodynamically significant stenosis. There is calcification of
the cavernous carotid arteries bilaterally. There is mild
stenosis of the left PCA.
Evaluation of the CTA of the neck demonstrates calcified
atheromatous plaquing at the origin of the right distal common
carotid artery and bulb extending to the proximal ICA. There is
approximately 50% stenosis of the distal common carotid
artery/carotid bulb and mild stenosis of the proximal ICA which
does not appear to be hemodynamically significant.
There is a focal calcific plaque at the origin of the right
vertebral artery which is occluded.
IMPRESSION:
1. Large left intraparenchymal hematoma in the left basal
ganglia and frontal and temporal lobes.
2. No underlying lesion noted on the CTA.
3. Approximately 50% stenosis of the right carotid bulb
extending to the proximal ICA with a calcified plaque.
4. Occlusion of the right vertebral artery with a calcific
plaque at the origin.
EKG: Sinus bradycardia
First degree A-V delay
Consider left atrial abnormality although baseline artifact
makes assessment difficult
No previous tracing available for comparison
Intervals Axes
Rate PR QRS QT/QTc P QRS T
54 [**Telephone/Fax (2) 72541**] 31 54
Head CT [**1-10**]: FINDINGS: Again seen is a large evolving 7.4 x 3.8
cm left intraparenchymal hematoma centered in the left basal
ganglia. There is surrounding edema which causes moderate mass
effect. There is compression of the left lateral ventricle and
entrapping of the right lateral ventricle. Ventricular size has
not changed compared to the prior study. A small amount of blood
is seen layering the right atrium and a moderate amount of blood
is seen layering the left atrium. Again seen is 9 mm rightward
subfalcine shift. The osseous structures are unchanged. There is
mild mucosal thickening of the right maxillary sinus.
IMPRESSION:
1. Evolving left intraparenchymal hematoma centered at the left
basal ganglia with surrounding edema resulting in a 9-mm of
rightward subfalcine herniation and mass effect on the left
lateral ventricle.
2. Moderate amount of intraventricular hemorrhage. The size of
the ventricles has not changed compared to prior study.
Brief Hospital Course:
85 year old man with history of hypertension, now with left
external capsule hemorrhage, which had more than doubled in size
in the past 4 hours, although he had no evidence of
coagulopathy. He had significant involvement of most of the
left hemisphere, blood in the left lateral ventricle, midline
shift and right subfalcine herniation. The etiology of the
hemorrhage was most likely hypertensive, although the location
was a bit unusual (would expect basal ganglia or thalamus), but
another spike in his blood pressure may have been responsible
for the expansion of the bleed. The subcortical location would
not be typical for amyloid angiopathy. Clinically, on initial
exam, he was fairly awake, although he was globally aphasic and
had a dense right hemiparesis. He was at significant risk for
deterioration of his mental status, especially given the
subfalcine herniation. His prognosis for meaningful recovery,
i.e. without major disability, was poor.
We discussed this at length with Mr. [**Known lastname 72542**] wife and
son-in-law. [**Name (NI) **] had expressed to his family quite clearly that
he did not wish to be kept alive on a long-term basis by
artificial means, did not want any heroic measures, and would
not want to live with major disability. Neurosurgery had spoken
with the family about the possibility of an EVD, but Mrs.
[**Known lastname 72539**] felt that he would not want to have any surgical
intervention. She expressed that initially he could be
intubated if his mental status were to decline, but if the
intubation were to become prolonged, they would reconsider
whether they wanted to keep the tube in. They did not want him
to be resuscitated (i.e. no CPR, shocks, meds) if his heart were
to stop beating.
Neuro: Patient was admitted to Neurology ICU where serial
neurochecks were performed. Mannitol 50g IV was given initially
in the ED and then continued 25mg every 6 hours thereafter with
parameters to hold subsequent doses for Na >150 or Osm >320. He
was loaded with 1g Dilantin which was subsequently discontinued
upon re-evaluation in the am since his bleed was subcortical and
risk of seizure was low. Head of bed elevated greater than 30
degrees and kept euthermic and euglycemic. Repeat head CT the
following morning showed an evolving left intraparenchymal
hematoma centered at the left basal ganglia with surrounding
edema resulting in a 9-mm of rightward subfalcine herniation and
mass effect on the left lateral ventricle. There was also a
moderate amount of intraventricular hemorrhage. The size of the
ventricles had not changed compared to prior study. Clinically,
patient was more somnolent with less spontaneous movement.
Meeting was again held with the family regarding his clinical
status and family made decision to make patient do not
resuscitate and do not reintubate. The following morning the
patient's family made him comfort measures only and he was
called out of the surgical intensive care unit to the floor. He
was subsequently discharged to hospice care.
CV: Ruled out myocardial infarction. EKG notable for first
degree AV block and sinus bradycardia without priors for
comparison. Continued cardiac telemetry while in ICU. Goal SBP
< 160, MAP < 130 and gave metoprolol standing and hydralazine as
needed. Continued lipitor 10mg QD.
PULM: Patient did not require intubation.
FEN: Patient was kept nothing per mouth as aspiration precaution
and family declined nasogastric tube feedings. His serum sodium
downtrended to 127 and he was fluid restrict and treated with
hypertonic 3% saline at a slow rate with good result.
PPX: PPI, Insulin SS, maintain euthermia, boots, bowel regimen
Medications on Admission:
Aspirin 81 mg daily
Beta blocker
Lipitor
Targretin
Discharge Medications:
1. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for fever, pain.
Disp:*60 Suppository(s)* Refills:*0*
2. Scopolamine Base 1.5 mg Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours) as needed for secretions.
Disp:*10 Patch 72HR(s)* Refills:*0*
3. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
secretions.
Disp:*60 Tablet, Sublingual(s)* Refills:*0*
4. Lorazepam 2 mg/mL Concentrate Sig: 0.5-2 mg PO Q1H (every
hour) as needed for agitation.
Disp:*30 mg* Refills:*0*
5. Morphine Concentrate 20 mg/mL Solution Sig: 0.5-1 mL PO Q2-3H
as needed for pain.
Disp:*25 mL* Refills:*0*
6. Bisacodyl 10 mg Suppository Sig: One (1) suppository Rectal
once a day as needed for constipation.
Disp:*30 suppositories* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1121**] VNA
Discharge Diagnosis:
Left external capsular bleed
Intraventricular hemorrhage
Discharge Condition:
Responsive with movement to noxious stimuli, some spontaneous
left sided movement, no speech or eye opening, follows no
commands.
Discharge Instructions:
Takes medications as needed.
Call your PCP with any concerns.
Followup Instructions:
With PCP as needed.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2192-1-11**]
|
[
"4019"
] |
Admission Date: [**2148-7-22**] Discharge Date: [**2148-7-30**]
Date of Birth: [**2089-6-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Difficulty ambulating, fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 59yoM with multiple medical problems including CAD
s/p stent, CVA x2, DM2, OSA, HTN, HLD, and advanced renal
disease who is presenting for evaluation of difficulty walking
and fatigue. He repeatedly falls asleep during our interview and
requires redirection on every question. He fully alerts and
answers questions appropriately, though his somnolence limited
the history-taking substantially.
.
He describes a chronic decline in function over the past few
months, noting that it has been more difficult to rise out of
chairs and ambulate. He at times attributed this to right hip
pain as the limiting factor, though later suggested the hip is
not painful. He feel fatigued throughout the daytime and has a
general lack of energy. He does carry a diagnosis of OSA and has
not been compliant with CPAP recently. He was unfortunately also
inconsistent with symptoms of lightheadedness during these
episodes of difficulty walking- He has been nauseated and has
not been drinking as much recently. He denies any trauma.
.
On arrival to the ED, his initial vitals were 98.8 56 117/52 20
95% 2L Nasal Cannula. He complained of severe back pain. There
was no concerning EKG findings, and a CXR revealed no acute
cardiopulmonary process. There was no fracture on a left hip
plain film as well.
.
On arrival to the floor, his initial vitals were T100 BP196/77
P72 RR20 Sat95RA. He recalled having told the ED about a bout of
tachypnea last night that was self limiting, but he has no
further chest symptoms. He mentions that he thinks he has been
sleeping poorly. He mentions right hip pain, though the left hip
was examined and radiographed downstairs. A broad review of
systems yields no focal weakness, no fevers/chills, no nausea or
vomiting, no chest pain or pressure, no abdominal pain, dysuria,
hematuria, no hematochezia or melena, no coughing or wheezing,
no weight gain or loss.
Past Medical History:
-diastolic CHF-weight [**2148-6-27**] 295 lbs, up from 286 lbs [**2148-5-9**]
-CAD s/p LAD stent x2 (unclear date)
-CVA x 2 15ya and 2 [**Last Name (un) **]
-Back pain
-Obstructive sleep apnea on CPAP
-Retinopathy, diabetic, bilateral
-Obesity, morbid
-DM (diabetes mellitus), type 2 with renal complications, last
A1c 7.3
-CKD (chronic kidney disease), stage IV s/p L AVF not on
dialysis
-h/o C. difficile diarrhea
-Vitreous hemorrhage
-Pseudophakia
-Cataract
-Hyperkalemia
-Gout
-Hyperlipidemia LDL goal < 70
-Proteinuria
Social History:
Lives in [**Location (un) 90795**] with a roommate, he apparently has 24hr
home care. No smoking or ETOH.
Family History:
mom died of MI, father died of old age.
Physical Exam:
Admission:
VITALS: T100 BP196/77 P72 RR20 Sat95RA
GENERAL: somnolent, falls asleep between questions though easily
arousable
HEENT: PERRL, EOMI
NECK: no carotid bruits, JVD
LUNGS: CTAB on limited anterior exam, could not comply with
posterior
HEART: RRR, normal S1 S2, 3/6 SEM at the R 2nd ICS with carotid
radation, apical murmur also radiating to the axilla.
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: 2+ edema to midleg. Full ROM without pain in the R
and L hip.
NEUROLOGIC: A+OX3 strength full in UE and LE bilaterally
Discharge: VS T98.2-98.5 HR55-72 BP 157-159/76-79 RR18 O2Sat 98%
RA
General: Morbidly obese, A&Ox3, Denies current VH/AH.
CV: Regular rate and rhythm, II/VI systolic murmur.
Lungs: CTAB, no wheezing, crackles; moderate air movement
Abdomen: soft, obese, non-distended; slightly tender is
epigastrum.
Ext: warm, well perfused, 2+ pulses, 1+ bilateral pitting edema
to the shin, LUE fistula
Pertinent Results:
[**2148-7-22**] 06:35PM BLOOD WBC-7.9 RBC-3.82* Hgb-12.0* Hct-36.0*
MCV-94 MCH-31.3 MCHC-33.2 RDW-13.4 Plt Ct-208
[**2148-7-22**] 06:35PM BLOOD Neuts-61.8 Lymphs-24.9 Monos-9.5 Eos-3.1
Baso-0.7
[**2148-7-22**] 06:35PM BLOOD PT-10.8 PTT-43.6* INR(PT)-1.0
[**2148-7-22**] 06:35PM BLOOD Glucose-132* UreaN-88* Creat-4.2*# Na-141
K-5.3* Cl-110* HCO3-22 AnGap-14
[**2148-7-22**] 06:35PM BLOOD ALT-18 AST-19 AlkPhos-90 TotBili-0.3
[**2148-7-23**] 05:50AM BLOOD CK-MB-7 cTropnT-0.04*
[**2148-7-23**] 10:27AM BLOOD CK-MB-7 cTropnT-0.14*
[**2148-7-23**] 04:55PM BLOOD CK-MB-8 cTropnT-0.24*
[**2148-7-24**] 03:56AM BLOOD CK-MB-5 cTropnT-0.23*
[**2148-7-23**] 05:50AM BLOOD Calcium-8.5 Phos-7.1* Mg-2.1
[**2148-7-22**] 06:35PM BLOOD TSH-5.9*
[**2148-7-23**] 10:27AM BLOOD T3-93 Free T4-1.1
[**2148-7-23**] 07:38AM BLOOD Type-ART Temp-38.3 FiO2-91 O2 Flow-6
pO2-75* pCO2-50* pH-7.16* calTCO2-19* Base XS--10 AADO2-532 REQ
O2-88 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2148-7-23**] 10:42AM BLOOD Type-[**Last Name (un) **] pO2-170* pCO2-39 pH-7.22*
calTCO2-17* Base XS--11 Comment-GREEN TOP
[**2148-7-22**] 08:37PM BLOOD Lactate-1.4
[**2148-7-23**] 10:38AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.011
[**2148-7-23**] 10:38AM URINE Blood-MOD Nitrite-NEG Protein-300
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2148-7-23**] 10:38AM URINE Eos-NEGATIVE
[**2148-7-23**] 10:38AM URINE Hours-RANDOM UreaN-490 Creat-151 Na-24
K-36 Cl-28
[**7-22**] CXR: Patchy opacity in the lingula, which is not specific
as to etiology; pneumonia is not excluded, but the area is not
well evaluated and opacity may be due to atelectasis. Noting
the technical limitations of the film followup PA and lateral
radiographs may be helpful if pulmonary symptoms
were to persist.
7/16 L Hip film: No acute abnormality. If there is concern for
an occult fracture, recommend MRI.
[**7-23**] CXR: As compared to the previous radiograph, there is
unchanged evidence of lower lung volumes and moderate
cardiomegaly with signs of minimal fluid overload. No
pneumonia, no larger pleural effusions. No lung nodules or
masses.
Renal U/S: No hydronephrosis.
[**2148-7-26**] 07:20AM BLOOD WBC-5.9 RBC-3.59* Hgb-11.1* Hct-32.8*
MCV-92 MCH-30.9 MCHC-33.8 RDW-13.2 Plt Ct-194
[**2148-7-26**] 07:20AM BLOOD Glucose-109* UreaN-108* Creat-5.0* Na-141
K-4.0 Cl-109* HCO3-23 AnGap-13
[**2148-7-25**] 08:12AM BLOOD Glucose-99 UreaN-110* Creat-5.5* Na-141
K-4.3 Cl-109* HCO3-21* AnGap-15
[**2148-7-24**] 03:56AM BLOOD Glucose-86 UreaN-95* Creat-4.9* Na-143
K-4.8 Cl-114* HCO3-15* AnGap-19
[**2148-7-23**] 04:55PM BLOOD Glucose-113* UreaN-96* Creat-4.6* Na-142
K-4.9 Cl-114* HCO3-14* AnGap-19
[**2148-7-23**] 04:55PM BLOOD Glucose-113* UreaN-96* Creat-4.6* Na-142
K-4.9 Cl-114* HCO3-14* AnGap-19
[**2148-7-29**] 06:00AM BLOOD Glucose-118* UreaN-80* Creat-3.5* Na-142
K-3.8 Cl-108 HCO3-25 AnGap-13
[**2148-7-28**] 07:00AM BLOOD Glucose-127* UreaN-86* Creat-3.7* Na-144
K-3.9 Cl-112* HCO3-21* AnGap-15
[**2148-7-27**] 08:48AM BLOOD Glucose-113* UreaN-97* Creat-4.2* Na-141
K-4.2 Cl-109* HCO3-20* AnGap-16
Brief Hospital Course:
59M with dCHF, stage IV CKD, HTN, DM who presented with subacute
weakness and fatigue, found to have [**Hospital 90796**] transferred to ICU
for hypoxia and AMS, most likely from flash pulmonary edema and
uremia.
.
.
# Hypoxia: Was oxygenating well on room air/2L NC at
presentation and now requiring 6L NC with pO2 75. A-a gradient
approx. 150. CXR with equivocal findings for PNA, also febrile
with increasing WBC though no left shift or leukocytosis at
admission. Some evidence of volume overload on exam with
elevated JVP and bibasilar crackles, also with evidence on CXR,
and SBP almost 200 at admission so may have had flash pulmonary
edema. ACS also on differential, EKG unchanged. PE also a
possibility though no evidence of significant hypoventilation
given pCO2 of 50 in patient with OSA and likely elevated pCO2 at
baseline. Uncontrolled OSA may also have been contributing.
Mr. [**Known lastname **] was transferred to ICU and received BiPAP for four
hours and his respiratory and mental status improved. After
BiPAP, he was able to maintain oxygenation on 3L NC. He received
course of levofloxacin for possible PNA and was diuresed to
relieve pulmonary edema. At time of discharge, he was satting
well on RA and his respiratory exam was normal.
# Altered Mental Status: Oriented to person, place, ?time at
admission, was only oriented to person in context of changing
clinical status next morning. After receiving BiPAP,
antibiotics, and diuresis, patient was A&Ox3 and remained so for
the remained of his stay. Differential diagnosis of altered
mental status includes hypercarbia, uremia, sepsis. PCO2 only
mildly elevated, so hypercarbia unlikely to cause this degree of
altered mental status. Chest x-ray questionable for pneumonia.
Urinalysis not convincing for infection. It is likely that all
of these conditions combined to produce altered mental status.
Patient had persistent hallucinations admission. Patient had
excellent insight into his hallucinations. Per his roommate and
sister, he hallucinates at baseline.
# Acid/Base Status: ABG 7.16/50/75/19, AG 13 on day of
admission. Most likely represents respiratory acidosis with
superimposed AG and non-AG metabolic acidosis vs primary
metabolic acidosis with respiratory compensation in the setting
of chronically elevated pCO2 >50, though serum HCO3 22 in
2/[**2148**]. Per Winter's formula, expected pCO2 would be 30 with
HCO3 15. Delta delta=8. AG acidosis could be due to
hyperlactatemia. Non-AG acidosis most likely due to AoCRF. PH
returned to [**Location 213**] during stay in the ICU with treatment of
pneumonia and acute kidney injury.
# Acute on chronic renal failure: Worsening Cr most likely due
to obstruction or prerenal in setting of poor PO intake. FeNa
15%. Renal service was consulted and recommended holding ACE
inhibitor. Hemodialysis was not initiated. Patient was fluid
resuscitated and subsequently diuresed. Creatinine improved and
was nearing baseline at time of discharge.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Furosemide 40 mg PO DAILY
hold for SBP<100
2. Carvedilol 12.5 mg PO BID
hold for SBP<100, HR<60
3. NIFEdipine CR 60 mg PO DAILY
hold for SBP<100
4. Lisinopril 5 mg PO DAILY
hold for SBP<100
5. Acetaminophen-Caff-Butalbital [**1-8**] TAB PO Q6H:PRN HA
6. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Isosorbide Dinitrate 60 mg PO DAILY
hold for SBP<100
8. Gabapentin 600 mg PO DAILY
9. Gabapentin 300 mg PO BID
in afternoon and evening
10. Allopurinol 100 mg PO DAILY
11. Simvastatin 20 mg PO DAILY
12. LaMOTrigine 100 mg PO BID
13. Aspirin 325 mg PO DAILY
14. Amitriptyline 20 mg PO HS
15. Clonazepam 1 mg PO DAILY
16. Ranitidine 150 mg PO BID
17. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Allopurinol 100 mg PO DAILY
2. Glargine 25 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. LaMOTrigine 100 mg PO BID
4. Ranitidine 150 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Aspirin 325 mg PO DAILY
8. Furosemide 40 mg PO DAILY
hold for SBP<100
9. Isosorbide Dinitrate 60 mg PO DAILY
hold for SBP<100
10. NIFEdipine CR 60 mg PO DAILY
hold for SBP<100
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4542**] Rehabilitation and Nursing of [**Location (un) 38**]
Discharge Diagnosis:
Pneumonia
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent. Visual hallucinations with
insight
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital for difficulty breathing and
confusion. Your chest x-ray showed a possible pneumonia, so you
were treated with antibiotics. Your lab tests showed that your
kidneys suffered some damage, so you were given IV fluids and
diuretics and your kidney function improved. Your trouble
breathing improved with oxygen and CPAP.
The following medications were changed:
1. Lisinopril - do not take this medication until instructed to
do so by your nephrologist.
2. gabapentin - please discuss when to restart this medication
with your primary physician.
3. clonazepam - please discuss when to restart this medication
with your primary physician
4. Lasix - your dose of this medication was changed
5. Amitriptyline - this medication was stopped
6. Acetaminophen-Caff-Butalbital - this medication was stopped
Please be sure to schedule and keep all of your follow-up
appointments. And please take your medications as directed.
It was a pleasure taking part in your care. We wish you a quick
recovery.
Followup Instructions:
Please follow-up with your primary care doctor.
Please call your nephrologist to make a followup appointment:
- Dr. [**Last Name (STitle) **]
- [**Location (un) 2274**] [**Hospital1 392**]
- Call [**Doctor First Name **] to schedule appointment at [**Telephone/Fax (1) 90797**]
|
[
"51881",
"5849",
"4280",
"40390",
"2767",
"41401",
"V4582",
"2724",
"32723"
] |
Admission Date: [**2146-9-14**] Discharge Date: [**2146-10-28**]
Date of Birth: [**2076-11-26**] Sex: M
Service: SURGERY
Allergies:
Percodan / Codeine / Atorvastatin / Tramadol / Readi-Cat /
Flagyl
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Pancreatitis and pseudocyst
Major Surgical or Invasive Procedure:
[**2146-9-14**]:
1. ERCP
[**2146-9-20**]:
1. Open pancreatic necrosectomy and peripancreatic abscess
drainage.
2. Open cholecystectomy with fluoroscopic intraoperative
cholangiography.
3. An 18-French Malecot gastrostomy tube.
4. Feeding jejunostomy tube - 12-French whistle-tip.
[**2146-10-4**]:
1. PTC placement
[**2146-10-17**]:
1. PTC exchange
[**2146-10-19**]:
1. PTC exchange and upsizing
[**2146-10-21**]:
1. Aborted thoracentesis of the right side.
2. Right video-assisted thoracic surgery decortication of
loculated right pleural effusion.
History of Present Illness:
69year old male with complaint of 6 weeks of abdominal pain with
multiple admissions to [**Hospital3 13313**] for pancreatitis.
Has experienced a 37 pound weight loss over this time. Over
this course, amylase has returned to [**Location 213**] following an initial
amylase of 2640. The patient reports doing well when kept NPO,
but the recurrence of sharp abdominal pain with PO intake. Pain
is described as diffusely epigastric, sharp, constant at a [**5-22**],
made worse with PO intake, relieved with narcotic pain meds,
non-radiating. Patient also reports moderate nausea relieved
with Zofran.
Past Medical History:
1. HTN
2. COPD (PFTs in [**6-21**]: FEV1 75% predicted, moderate restrictive
disease, significant response to bronchodilatator)
3. "silent" MI years ago (negative stress test in [**2137**])
4. hypertriglyceridemia
5. legally blind secondary to degenerative visual condition
6. chronic back pain
Social History:
Married. Retired carpenter. Smoked 1 PPD x 45 years; quit in the
[**2127**]. Rare alcohol. No illicits.
Family History:
Father died in his 70s from an MI. Mother lived to her 90s and
died from unclear causes.
Physical Exam:
On Admission:
AVSS/afebrile.
Gen: In NAD.
HEENT: Legally blind. Sclerae anicteric. O-P clear.
CV: RRR; s1s2+
Chest: CTA(B).
Abd: BSx4. Obese, soft, NT, non-rigid. G-J tube in place.
Ext: 1+ ankle edema
NEURO: A+Ox3.
.
At Discharge:
AVSS/afebrile
GEN: Well appearing in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple. No [**Doctor First Name **]. No JVD.
LUNGS: Posterior apical and basal chest tubes to [**Doctor First Name 84856**].
Prior CT site at anterior apical with occlussive dressing.
Slightly decreased BS (R) base, otherwise CTA.
COR: RRR; nl S1/S2 w/o m/c/r.
ABD: (L)UQ G-Tube clamped. (L)LQ J-Tube clamped for transport.
Both patent/intact. (R)[**Name (NI) **] PTC drain capped. Tube insertion sites
c/d/i. Abdominal incision well approximated, healing well OTA.
BSx4. Soft/NT/ND.
EXTREM: Mild ankle edema w/o pitting. No cyanosis, pallor.
NEURO: A+Ox3. Legally blind. Otherwise non-focal/grossly intact.
SKIN: WWP.
Pertinent Results:
On Admission:
[**2146-9-14**] 09:38PM GLUCOSE-105 UREA N-8 CREAT-0.5 SODIUM-134
POTASSIUM-3.5 CHLORIDE-98 TOTAL CO2-26 ANION GAP-14
[**2146-9-14**] 09:38PM ALT(SGPT)-170* AST(SGOT)-187* ALK PHOS-363*
AMYLASE-37 TOT BILI-2.8*
[**2146-9-14**] 09:38PM LIPASE-33
[**2146-9-14**] 09:38PM CALCIUM-8.9 PHOSPHATE-4.2 MAGNESIUM-1.6
[**2146-9-14**] 09:38PM WBC-10.8 RBC-3.66* HGB-9.5* HCT-29.5* MCV-81*
MCH-26.1* MCHC-32.4 RDW-14.9
[**2146-9-14**] 09:38PM PLT COUNT-398
.
IMAGING:
[**2146-9-17**] CT Abd/Pelvis: pancreatitis, pseudocysts, SMV
thrombosis
[**2146-9-17**] CTA Pancr Abd/Pelvis: confirmed SMV thrombosis on
venous phase
[**2146-9-27**] Upper GI no oral contrast is seen beyond the duodenal
bulb .
[**2146-10-22**] CXR patchy consolidation of the RUL, bigger R pleural
effusion
[**2146-10-22**] CXR: large R pleural effusion, additional loculated
pleural fluid
[**2146-10-23**] CXR: large focal consolidation in the right lower lobe
with loculated pleural effusion and multiple chest tubes on the
right, no appreciable change since prior study.Small L pleural
effusion
[**2146-10-23**] CXR: Dense opacification of the right hemithorax with
three chest tubes on the right. The loculated right-sided
pleural effusion appears to be somewhat less dense at the right
periphery and there appears to be mildly improved opacification
of the right lung. Dense effusion at the right lung apex and at
the right lung base. Left lung is relatively clear
[**2146-10-24**] CXR: Right loculated pleural effusion is associated
with small amount of air component, difficult to assess in this
single frontal semi-upright view. This is unchanged from prior.
Right chest tubes remain in place. Cardiomediastinal contour is
unchanged. The left lung is grossly clear besides linear
atelectasis in the base.
[**2146-10-25**] CXR: Substantial right pleural effusion, particularly
basal, persist despite presence of three right pleural tubes,
one at the apex, one along the mediastinum and one coiled at the
right base. Attendant atelectasis is persistent, most severe in
the middle and lower lobes. Left lung clear. Heart size normal.
No endotracheal tube is seen below C7, theupper margin of this
film.
[**2146-10-26**] CXR: The examination is compared to [**2146-10-25**].
The three right-sided chest tubes show an unchanged course and
position. The extent of the lateral pleural opacities have
minimally decreased, the extent of the more medial pleural
opacities are without relevant change. There is no evidence of
pneumothorax. Unchanged blunting of the right costophrenic sinus
suggesting a small pleural effusion. Unchanged opacities along
one of the three chest tubes. The left lung is unremarkable.
[**2146-10-27**] AM CXR: As compared to the previous radiograph, the
position of the right-sided chest tube is unchanged. In the
interval, a minimal decrease of the right pleural fluid has
occurred. The transparency of the right-sided lung parenchyma is
minimally improved. In the left lung, no relevant changes are
seen. No evidence of interval recurrence of focal parenchymal
opacity suggesting pneumonia. No left pleural effusion.
[**2146-10-27**] PM CXR: P....
.
MICROBIOLOGY:
.
[**2146-9-20**] 12:45 pm SWAB PANCREATIC ABSCESS.
**FINAL REPORT [**2146-9-24**]**
GRAM STAIN (Final [**2146-9-20**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2146-9-23**]):
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. SECOND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 2 S 16 I
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2146-9-24**]):
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
.
[**2146-10-21**] 9:29 pm TISSUE PLEURA RIGHT SIDE.
GRAM STAIN (Final [**2146-10-22**]): 2+ (1-5 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
TISSUE (Preliminary): KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
CITROBACTER FREUNDII COMPLEX. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| CITROBACTER FREUNDII
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S 2 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2146-10-26**]): NO ANAEROBES ISOLATED.
[**2146-9-20**] 12:45 pm SWAB PANCREATIC ABSCESS.
GRAM STAIN (Final [**2146-9-20**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2146-9-23**]):
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH.
KLEBSIELLA PNEUMONIAE. MODERATE GROWTH. SECOND MORPHOLOGY.
SENSITIVITIES: MIC expressed in MCG/ML
______________________________________________________
KLEBSIELLA PNEUMONIAE
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S 8 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 2 S 16 I
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final [**2146-9-24**]): BACTEROIDES FRAGILIS GROUP.
SPARSE GROWTH. BETA LACTAMASE POSITIVE.
.
MRSA SCREEN (Final [**2146-10-24**]): No MRSA isolated.
Brief Hospital Course:
The patient was admitted to the General Surgical Service [**2146-9-14**]
for further evaluation of pancreatitis and a pseudocyst after
undergoing a failed ERCP. The ERCP demonstrated severe edema of
the distal stomach and bulb causing narrowing with a spontaneous
drainage of pruluent material from the bulb, most likely due to
a large pseudocyst or fluid collection. Unable to pass the ERCP
scope beyond the bulb. He was made NPO, an NG Tube was placed,
started on IV fluid, a foley catheter was placed, and he was
started on IV Unasyn. Routine labwork, CXR, and ECG were
performed. Admission Abdominal/pelvic CT demonstrated findings
consistent with pancreatitis with note a pseudocyst. The study
also showed mild intrahepatic biliary dilation, inflammation of
the duodenum and CBD, as well as raised suspicion for SMV
thrombosis. A PICC line was placed, and TPN was started. A CTA
pancreas protocol was perfomed on [**2146-9-17**], which redemonstrated
pancreatitis with numerous adjacent air and fluid filled
pseudocysts, as well as a filling defect of the upper portion
of the SMV, consistent with SMV thrombosis. There was no
evidence of reactive pseudo-aneurysm formation. The patient was
started on a Heparin infusion, titrated until therapeutic.
.
On On [**2146-9-20**], the patient underwent open pancreatic necrosectomy
and peripancreatic abscess drainage, open cholecystectomy with
fluoroscopic intraoperative cholangiography, and placement of
both a gastrostomy and feeding jejunostomy tubes, which went
well without complication (reader referred to the Operative Note
for details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO with an NG tube, on IV fluids
and antibiotics, with a foley catheter, J-Tube and G-Tube to
gravity, a JP drain in place, and a Dilaudid PCA for pain
control. He was continued on IV Unasyn. The patient was
hemodynamically stable. On POD#1, he required multiple IV fluid
boluses totalling 1.5 Liter as well as Metoprolol IV for
tachycardia and low urine output with good response. He
accidentally self-discontinued his NG tube the as well, but did
not require replacement. Otherwise, his initial post-operative
course was unremarkable. Heparin infusion was restarted
post-operatively. He was started on trophic tubefeeds via the
J-tube on POD#6, which were advanced to goal. TPN was continued
until POD#7, then discontinued. He got out of bed with Physical
Therapy. His recovery progressed as expected.
.
On [**2146-10-1**], however, the patient experienced tachycardia,
dyspnea, and BRBPR. A hematocrit was 15.7 down from 28.6 four
days prior. Heparin was stopped. The patient was transferred to
the SICU. He received a total of 5 units of PRBCs, and was
stabilized. Gastroenterology was consulted, recommending holding
heparin, transfuse, continue PPI, and holding off on colonoscopy
as inpatient unless bleeding re-occurs. While in the SICU, the
patient developed parotiditis, which resolved later on the floor
with sucking on [**Doctor Last Name **] drops and [**Last Name (un) **] [**Doctor Last Name 84857**]. Tubefeeds were
restarted toward goal.
.
When hemodynamically stable, the patient was returned to the
floor on [**2146-10-3**]. He experienced increased abdominal pain and
distension, despite venting the G-Tube. Abdominal/pelvic CT
revealed an overall stable appearance of the abdomen and pelvis
with persistent small fluid collection tracking lateral to the
duodenum/posterior to the pancreatic head and small probable
hepatic subcapsular fluid collection. On [**2146-10-4**], the patient
underwent PTC drainage of the perihepatic fluid collection with
drainage catheter placed to gravity. Given history of GIB on
Heparin infusion, it was determined to start subcutaneous
heparin prophylaxis only. At this point, his recovery again
progressed. Foley catheter was discontinued. Staples were
removed with steri-strips placed. G-tube was clamped. Tubefeeds
continued via the J-Tube at goal. The patient continued to work
with Physical Therapy. On [**2146-10-7**], the PTC was capped, but then
later uncapped and G-Tube vented for abdominal pain, nausea and
dyspnea. Tubefeeds were held overnight. By [**2146-10-13**], he was able
to tolerate a clamped G-tube, capped PTC, J-tube feeds, and
sips. The PICC was discontinued on [**2146-10-9**] and the tip sent for
culture for a temperature spike. IV Vancomycin was added to
Unasyn. PICC tip culture was negative.
.
On [**2146-10-17**], the patient underwent IR cholangiogram demonstrating
a stricture of the distal common bile duct, but no signs of bile
leak. The pigtail drain was replaced with a new drain of the
same size for better bile drainage, as the patient did not
tolerate upsizing of the drain at that time. The day after the
procedure, he was restarted on tubefeeds, clear liquids, and the
PTC was capped, which he tolerated. He was also started on IV
Reglan to improve his GI motility. On [**2146-10-19**], he underwent PTC
evaluation in IR, which demonstrated no evidence of ductal
dilatation, again with long area of narrowing in the lower CBD
likely related to mass effect from edema. The PTC this time was
successfully upsized to a 10 French drain. Tubefeedings and diet
were restarted, and the PTC subsequently capped. IV Vancomycin
and Unasyn were discontinued, and discharge planning underway.
.
On [**2146-10-20**], the patient again experienced abdominal pain and
nausea, as well as dyspnea and increased oxygen demand. CXR
revealed a marked increase in the extent of the pre-existing
right pleural effusion, with the effusion occupying about
one-half of the right hemithorax. Also, signs of fluid overload.
Chest CT demonstrated a large multiloculated right pleural
effusion, compressive atelectasis and patchy ground-glass
opacities. On [**2146-10-21**], the patient initially underwent an
unsuccessful thoracentesis attempt of the right side, followed
by a successful right video-assisted thoracic surgery (VATS)
decortication of loculated right pleural effusion (See Operative
Notes for full details). Three chest tubes were placed; anterior
apical, posterior apical, and basilar chest tubes to suction.
The patient was subsequently admitted to the SICU.
.
SICU Course:
Tranferred to SICU for increased WOB. A-line placed. Lasix x2
given with good diuresis. Self-resolved V-tach Approx. 5sec x2,
asymptomatic. Rate controlled.
[**2146-10-23**]: Restarted tubefeeds via J-tube, PCA for pain with good
effect, CXR for this afternoon. Tachycardia responsive to extra
doses of metoprolol. Increased dosing to Q4 hrs. Antibiotic
discontinued. PTC drain clamped. PVC's, repleting electrolytes.
Pleural effusion growing GPR per initial report; Infectious
Disease consulted. Most likely a contaminate. Suggest Flagyl to
cover clostridium if he gets worse or spikes a temperature.
[**2146-10-24**]: Pleural effusions growing GNR (correction from GPR
stated previously), started on Ciprofloxacin. Tachypneic
overnight, ABG 7.41/51/107, CXR stable.
.
On [**2146-10-25**], the patient was transferred back to the inpatient
floor. He was tolerating a full liquid diet PO and tubefeeds at
goal via the J-tube, the G-tube was clamped, PTC drain was
capped, and he had three chest tubes in place 10 15cm suction,
an anterior apical, posterior apical, and basal. He was voiding
without assistance, and ambulating well with assistance due to
legal blind status, and not weakness. He was continued on
Ciprofloxacin. Also, he continued to receive Lasix approximately
every other day for gentle diuresis. On [**2146-10-26**], the culture of
the pleural tissue returned with pan-sensitive Klebsiella
pneumoniae and Citrobacter freundii complex; Flagyl was added to
Cipro for more comprehensive gram negative coverage. All three
chest tubes were placed to water seal, which he tolerated. On
[**2146-10-27**], a CXR revealed a minimal decrease of the right pleural
fluid with minimally improved transparency of the right-sided
lung parenchyma. In the left lung, no relevant changes are seen.
No evidence of interval recurrence of focal parenchymal opacity
suggesting pneumonia. No left pleural effusion. The anterior
apical chest tube was discontinued, and pneumostats were placed
on the remaining chest tubes (posterior apical and basal).
.
The patient had experienced some mild, non-specific pruritus
starting [**2146-10-26**], which developed into a rash and hand
angioedema early overnight into [**2146-10-28**]. Flagyl, intitiated on
[**10-26**], was suspected and stopped. The patient was given
Benadryl, Fexofenadine, and Singulair with symptomatic
improvement. Otherwise, he remained stable. He will continue on
Fexofenadine and Singulair for one week to prevent recurrent
delayed hypersensitivity reaction.
.
At the time of discharge on [**2146-10-28**], the patient was doing
well, afebrile with stable vital signs. The patient was
tolerating a regular diet, albeit not with completely adequate
intake, and tubefeeds at goal via the J-tube, G-Tube was
clamped, PTC was capped, and posterior apical and basal chest
tubes had pneumostats in place. He was ambulating with
assistance due to visual impairment, voiding without assistance,
moving his bowels, and pain was well controlled. Infectious
Disease has recommended that he continue on Ciprofloxacin for at
least 3 weeks, preferably for 2 weeks AFTER all his drains have
been removed. He was discharged home with VNA services. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
Atenolol 50mg PO daily.
Prilosec 20mg PO daily.
ASA 81mg PO daily.
Fenofibrate 200mg PO daily.
Spiriva 18mcg 1 tab via inhalation daily.
MVI 1 tab PO daily.
Glucosamine
Calcium+D
Fish Oil
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation: Over-the-counter.
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching, redness.
Disp:*1 large bottle* Refills:*2*
9. Fenofibrate Micronized 200 mg Capsule Sig: One (1) Capsule PO
once a day.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Calcium 500 with Vitamin D Oral
12. Fish Oil Oral
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 17 days.
Disp:*34 Tablet(s)* Refills:*0*
14. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*7 Tablet(s)* Refills:*0*
15. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for pruritus for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
16. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for itching.
Disp:*30 Capsule(s)* Refills:*0*
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day
for 10 days.
Disp:*5 Tablet(s)* Refills:*0*
18. Nebulizer & Compressor For Neb Device Sig: One (1)
device Miscellaneous As directed.
Disp:*1 unit* Refills:*0*
19. Nebulizer Accessories Kit Sig: One (1) kit with
hand-held nebulizer and tubing Miscellaneous As directed.
Disp:*1 unit* Refills:*2*
20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation four times a day as
needed for shortness of breath or wheezing.
Disp:*25 pre-filled nebs* Refills:*4*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] Homecare
Discharge Diagnosis:
1. Complicated gallstone pancreatitis.
2. SMV thrombosis
3. Moderate intrahepatic ductal dilatation and severe common
bile duct dilatation
4. Loculated right pleural effusion.
Discharge Condition:
Good
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-22**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
General Drain Care:
.
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water, pat dry, and place
a drain sponge if needed daily and PRN.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
Chest Tube with [**Month/Year (2) **] Information
You are ready to go home, but still need your chest tube. A
small device, called an Atrium [**Month/Year (2) **], has been placed on
the end of your chest tube to help you get better.
About The Atrium [**Month/Year (2) **]:
The Atrium [**Month/Year (2) **] is made to allow air and a little fluid to
escape from your chest until your lung heals. The device will
hold 30ml of fluid. Empty the device as often as needed (see
directions below) and keep track of how much you empty each day.
Items Needed for Home Use:
?????? Atrium [**Month/Year (2) **] Chest Drain Valve (provided by hospital)
?????? [**Last Name (un) **]-lock syringes to empty drainage, if needed (provided by
hospital or VNA Nurse)
?????? Wound dressings (provided by hospital or VNA Nurse)
Securing the [**Last Name (un) **]:
Utilize the pre-attached garment clip to secure the [**Last Name (un) **]
to your clothes. It is small and light enough that you won't
even feel it hanging at your side. Make sure to keep the
[**Last Name (un) **] in an upright position as much as possible. Before
lying down to sleep or rest, empty the [**Last Name (un) **] so there will
be no fluid to potentially leak out.
Wound Dressing:
You have a dressing around your chest tube. This should be
changed at least every other day or as prescribed by your
doctor.
Showering/Bathing:
Showering with a chest tube is all right as long as you don't
submerge the tube or device in water. No baths, swimming, or hot
tubs.
Note:
This device is very important and the tubing must stay attached
to the end of your chest tube.
?????? If it falls off, reconnect it immediately and tape it
securely.
?????? If it falls off and you can't get it back together, go to the
closest hospital emergency room.
Warnings:
1. Do not obstruct the air leak well.
2. Do not clamp the patient tube during use.
3. Do not use or puncture the needleless [**Last Name (un) 30342**] port with a
needle.
4. Do not leave a syringe attached to the needleless [**Last Name (un) 30342**] port.
5. Do not connect [**First Name8 (NamePattern2) 691**] [**Last Name (un) 30342**]-lock connector to the needleless
[**Last Name (un) 30342**] port located on the bottom of the chest drain valve.
6. If at any time you have concerns or questions, contact your
nurse [**First Name (Titles) **] [**Last Name (Titles) **].
[**Name10 (NameIs) 84858**] the [**Name10 (NameIs) **]
?????? Keep the [**Name10 (NameIs) **] in an upright position and make sure the
tubing stays firmly attached to the end of your chest tube. Make
sure the [**Name10 (NameIs) **] stays clean and dry. Do not allow the
[**Name10 (NameIs) **] to completely fill with fluid or it may start to leak
out. If fluid does leak out, clean off the [**Name10 (NameIs) **] and use a
Q-tip to dry out the valve.
?????? If the [**Name10 (NameIs) **] becomes full with fluid, empty it using a
[**Last Name (un) 30342**]-lock syringe. Firmly screw the [**Last Name (un) 30342**]-lock onto the port
located on the bottom of the [**Last Name (un) **].
?????? Pull the plunger back on the syringe to empty the fluid. When
the syringe is full, unscrew the syringe and empty the fluid
into the nearest suitable receptacle. Repeat as necessary. If it
becomes difficult to empty the fluid using a syringe, squirt
water through the port to flush out the blockage or consult your
nurse [**First Name (Titles) **] [**Last Name (Titles) **]. [**Name10 (NameIs) **] [**Name11 (NameIs) **] may need to be changed out.
.
Right abdominal PTC drain is capped. If you experiences fever,
uncap the PTC and place to collection bag. Call Interventional
Radiology Fellow for further instructions. Weekdays:
([**Telephone/Fax (1) 84859**] [**Hospital Ward Name 517**]. Nights/Weekends: Interventional
Radiology Fellow/Resident - call page operator ([**Telephone/Fax (1) 84860**] and
ask for pager# [**Serial Number 5603**]. Call the VNA nurse or Dr.[**Name (NI) 9886**] Office
if unsure with carrying out the above procedure, or proceed to
the Emergency Room.
Followup Instructions:
Please call ([**Telephone/Fax (1) 84861**] to arrange a follow-up appointment
with Dr. [**First Name (STitle) **] (PCP) in 2 weeks.
.
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7542**], MD (Surgery). Phone: ([**Telephone/Fax (1) 471**].
Date/Time: [**2146-11-14**] at 9:45am. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].
.
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2146-11-8**] 9:00. Location: Chest Disease Center, [**Hospital Ward Name 121**]
Bldg., [**Hospital1 **] I
.
The patient will be contact[**Name (NI) **] [**Name2 (NI) 84862**] by Interventional
Radiology to arrange post-discharge follow-up.
Completed by:[**2146-10-28**]
|
[
"51881",
"2761",
"9971",
"2851",
"4019",
"496",
"V1582"
] |
Admission Date: [**2102-9-27**] Discharge Date: [**2102-10-27**]
Date of Birth: [**2039-6-1**] Sex: M
Service: MEDICINE
Allergies:
Ativan / Ibuprofen
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Progressive Right-Sided Weakness
Major Surgical or Invasive Procedure:
PEG tube placement
Tracheostomy
Endotracheal intubation
PICC line placement x 2
Bronchoscopy
History of Present Illness:
PER ADMITTING RESIDENT:
The history was obtained from Mr [**Known lastname 84568**] son [**Name (NI) **], as the
patient was confused and agitated. Mr [**Known lastname **] is an ambidextrous
man who writes with his left hand with a hitherto unremarkable
medical history, who presents with progressive right sided
weakness. It started off 5 weeks ago with a right facial palsy,
which his PCP, [**Name10 (NameIs) **] [**Last Name (STitle) 10851**] in NH thought was a Bells palsy.
However, the symptoms did not improve, and he started to
complain
of severe back pain, so much so that he resorted to sleeping in
a
Jacuzzi for 20 mins at a time. He went back to his PCP, [**Name10 (NameIs) **]
according to [**Doctor First Name **], he was given analgesia and sent home. On [**8-23**], his PCP ordered an MRI of the brain which showed a
1.5
cm soft tissue mass in the midbrain and a question of a small
acute infarct in the right posterior part of the pons. Mr [**Known lastname **]
then started to develop right sided arm weakness accompanied by
numbness two weeks ago, which has become progressively worse.
Last week, his right leg started to become involved in a similar
manner. In addition to these symptoms, [**Doctor First Name **] mentioned that his
father weighed ~220 lb 5 weeks ago, and then a few days ago he
was weighed at ~185 lb in an OSH. Last week on [**Last Name (LF) 2974**], [**First Name3 (LF) **]
took
his father to CMC [**Location (un) 5450**] [**Name (NI) **], and he had a CT scan of his
brain which he was told showed nothing, and the MRI of his
entire
spine w/o contrast showed a questionable lesion (probable
hemangioma) at T7, otherwise there was a minor disc protrusion
at
T9/10. He was discharged home, however, he got worse over the
weekend, and his son took him into [**Hospital6 204**]
yesterday, and they transferred him to the [**Hospital1 **] ER for a stroke
evaluation. At [**Hospital1 189**] he had a CXR which showed atelectasis of
the R middle lobe which could be due to a lesion or infection,
and his CT head scan had a lot of movement artifact.
ROS: no fevers or chills according to his son, no other
neurological or systemic symptoms obtainable from Mr [**Known lastname **] due
to his mental status.
Past Medical History:
- Alcohol Dependence
- Nicotine/Tobacco dependence
- Esophageal Strictures requiring regular dilatations
- HTN
- ITP treated with steroids in the past
Social History:
HABITS
- Tobacco: smokes 1 PPD x 35 years
- ETOH" drinks 6-12 beers/night or 1 liter vodka/night (for "all
life")
- Recreational Drug Use: remote marijuana use
Family History:
- negative for autoimmune d/o
- negative for neurological d/o
- negative for muscle d/o
Physical Exam:
On ADMISSION:
T-98.2 BP-154/109 HR-86 RR-18 O2Sat-96%
Gen: Trying to crawl out of bed. There is marked asymmetry from
the back between the right and left side. At one point he had
almost a pill rolling movement in his left hand.
HEENT: NC/AT, wearing an eye patch over the right eye, the right
side of his face almost looks as if it has "caved in", moist
oral
mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Rhonchi heard in the right mid zone
aBd: +BS soft, has two subcutaneous lipomas in the right upper
quadrant, nontender
ext: no edema
Neurologic examination:
Mental status:Confused, agitated, thinks that he is in [**Country 480**],
then states that he knows that he is in America, somewhere.
Knows
who he is, and can identify his son.
Cranial Nerves:
Right eye looks ecchymotic, cornea looks cloudy, pupil
unreactive, in fundoscopy, question of debris in the anterior
chamber. Left eye 3-->2 mm. Blinks to threat. EOMS appear full.
Corneals in tact bilaterally. Right lower motor facial nerve
palsy with a positive Bell's phenomenon. Hearing intact to
finger rub bilaterally. Palate elevation symmetrical. Shoulder
shrug looks asymmetric. Tongue deviates to the left.
Motor:
Evidence of weight loss. Tone increased in the right arm and
right leg. No observed myoclonus or tremor
right pronator drift
Left side appears strong, can keep his left arm and leg up for
30
s, will not comply with formal testing
Right side arm can stay antigravity for 5 s, and the right leg
for 10 s.
Sensation: Moves all 4 limbs symmetrically away from noxious
stimuli
Reflexes:
1 and symmetric throughout, apart from absent ankle jerks.
Right - Babinski
Left - downgoing
Coordination: he would not attempt this, he could grab my neuro
tools to try and prevent me from his left hand, but could not do
this easily on the right side.
Gait: when he stands, he keels over to the right
Pertinent Results:
Admission Lab Data:
.
WBC-8.4 RBC-4.14* HGB-14.0 HCT-40.2 MCV-97 MCH-33.8* MCHC-34.9
RDW-13.6
GLUCOSE-95 UREA N-17 CREAT-0.7 SODIUM-135 POTASSIUM-4.7
CHLORIDE-97 TOTAL CO2-29 ANION GAP-14
CK-MB-4 cTropnT-<0.01
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
.
URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-40
BILIRUBIN-SM UROBILNGN-1 PH-5.5 LEUK-NEG
UPEP: Neg
.
CSF ([**2102-9-27**]):
Tube 1: WBC-45 RBC-1450* POLYS-1 LYMPHS-91 MONOS-5 OTHER-3
Tube 4: WBC-200 RBC-3* POLYS-0 LYMPHS-87 MONOS-9 OTHER-4
PROTEIN-246* GLUCOSE-42
Cytology: Hypercellular specimen with many lymphocytes and
monocytes.
Gram Stain: No PMNs, No microorganisms
Fluid Cx: Neg
AFB: Negative
HSV PCR: Negative
EBV: Negative
HHV-6: Negative
Enterovirus: Negative
Listeria: P
Lyme: Equivocal
VDRL: P
West Nile Virus: P
.
CSF ([**2102-10-4**]):
Tube 1: WBC-10 RBC-7 POLYS-0 LYMPHS-88 MONOS-5 OTHER (plasma) -2
Tube 4: WBC-195 RBC-55 POLYS-0 LYMPHS-90 MONOS-6 OTHER (plasma)
-4
PROTEIN-73 GLUCOSE-63
Cytology:
Gram Stain: No PMNs, No microorganisms
Fluid Cx: Neg
Lyme:
.
SERUM:
Lyme IgM: POSITIVE; IgG: Negative
Listeria: Negative
HIV: Negative
[**Doctor First Name **]: Negative
ANCA: Negative
ESR: 21
CRP: ([**2102-9-28**]) 43.3, ([**2102-10-3**]): 65.9
SPEP: Neg
CEA: 5.1
Ca [**11**]-9: 14
.
BAL
AFB: Negative
Cx: No growth
Gram Stain: 4+ PMN, no microorganisms
.
Resp Viral Cx: Negative
.
Discharge Lab Data:
.
IMAGING:
.
CT Head ([**2102-9-27**]):
IMPRESSION: No acute intracranial process.
.
CT C-spine, Chest, Abdomen, Pelvis ([**2102-9-27**]):
IMPRESSION:
1. Large left lower lobe atelectasis. An obstructive
endobronchial lesion
cannot be excluded. Other etiologies would include mucous
plugging.
2. Gastric, cardiac and fundus mural thickening of unclear
etiology.
Differential considerations include inflammatory/neoplastic
infiltration.
Further evaluation with endoscopy may be considered.
3. Hepatic steatosis.
4. Splenic low attenuation lesions, not seen before. These could
represent
splenic infarcts. In the current clinical setting can not
exclude an
infectious component.
5. Moderate hiatal hernia.
.
MRI Brain ([**2102-9-27**]:
IMPRESSION:
1. Abnormal cranial nerve enhancement most likely secondary to
the patient's diagnosis of Lyme Disease.
2. Abnormal signal surrounding the obex at the cervicomedullary
junction may also relate to the patient's Lyme disease but is of
unclear etiology.
.
Right Shoulder X-ray ([**2102-10-1**]):
No fracture, dislocation, or gross degenerative change is
identified. Mild
degenerative changes of the AC joint are noted.
.
CXR ([**2102-9-28**]):
ET tube tip is 3.2 cm above the carina. NG tube tip is out of
view below the diaphragm. There is no pneumothorax or enlarging
pleural effusions. There are low lung volumes. Bibasilar
opacities consistent with atelectasis have improved on the right
and probably increased on the left. Cardiac size is top normal.
.
CXR ([**2102-9-28**]):
FINDINGS: The patient is post extubation. New left lower lobe
collapse and
volume loss in the left hemithorax in a short time interval is
most likely due to mucus plugging. The right lung is grossly
clear.
.
CXR ([**2102-10-1**]):
FINDINGS: In comparison with the study of [**9-30**], there is some
decrease in
the degree of left lower lobe atelectasis. The mediastinal
contours are
substantially less shifted to the left. Right lung is clear.
.
Transthoracic Echocardiogram ([**2102-9-29**]):
The left atrium is mildly dilated. 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%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). 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 ascending aorta is moderately dilated.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion. No obvious vegetations or
masses seen.
Brief Hospital Course:
Mr. [**Known lastname **] 63 year old male smoker with a past medical history
significant for alcohol dependence, esophageal stricture,
hypertension and ITP who was admitted on [**9-27**] with a 5-wk
history of progressive right-sided weakness (face --> wrist drop
--> leg) in the setting of 35# unintentional weight loss in 5
weeks and was found to have a positive serum LYME titer.
.
1. Lyme encephalitis: Diagnosed based MRI, CSF lymphocytic
pleocytosis, positive serum serology with equivocal CSF
serology. He was initially admited to the neurology service. In
brief, per the patient's son, the patient developed right facial
palsy 5 weeks prior to admission and was diagnosed as Bell's
palsy. He also developed back pain and was given analgesia.
MRI brain was ordered with demonstated a possible pontine acute
infarct and midbrain mass. He then developed R sided
progressive arm and leg numbness and weakness as well as
confusion at home. There is also report of previous bulls eye
rash. The patient was admitted to the SICU/Neuro ICU. He was
diagnosed with probable Lyme encephalitis and started on
ceftriaxone. Patient recieved a full 4 week course of
ceftriaxone (28 days). He was followed by the neurology service
throughout his admission. Patient did have improvement in his
neurologic status, but it is unclear which of his deficits are
permanent.
.
2. Agitation/altered mental status. Patient had multifactorial
delerium thought to be secondary to encephalitis as well as
electrolyte abnormalities and med related. Patient had had some
chronic narcotic use, and methadone was started by the SICU team
for pain control. When patient was transfered to MICU he was no
longer experiencing pain, so methadone was slowly tapered down
with some improvement noted in his confusion. He was also
started on Seroquel for agitation which was noted to help.
Patient had hypernatremia on transfer to MICU service and was
treated with free water boluses in his PEG feeds, which improved
his hypernatremia. It was noted that his mental status was much
improved with improvement of his hypernatremia, and therefore
his sodium was maintained as close to 140 as possible.
.
3. Respiratory failure. Patient had difficulty weaning off
ventilator so had trach and PEG placed [**10-10**]. There was concern
for pneumonia based on CXR, however the patient had a BAL and
sputum cultures which were both negative for any growth. The
patient was afebrile without elevation in WBC count without
treatment. Patient thought to have difficulty clearing
secretions, with significant suctioning of secretions. Also had
periods of apnea, thought to be related to sedating effects of
medications. Once his mental status cleared and he was able to
clear his secretions, he was placed on trach mask trial which he
did well with and tolerated for a full 5 days prior to
discharge. Patient was treated throughout his hospitalization
with inhaled medications for bronchospasm as there was thought
to be a COPD component to his respiratory failure as he had a
significant prior smoking history.
.
4. Fever: Patient had multiple low grade temperatures throughout
the hospitalization. He has been afebrile since [**10-15**] without any
treatment. All blood, sputum and urine cultures were negative.
He had a PICC line in place at the time of the fever, which was
discontinued, and nothing grew from the catheter tip. He had
negative C. diff cultures. The source was thought to be likely
Lyme, which was treated with Ceftriaxone.
.
5. Abdominal Pain: Patient had an episode of severe abdominal
pain on the morning of [**10-26**]. He had also had a bloody bowel
movement the evening of [**10-25**], which was attributed to
hemerhoids as the blood was surrounding the bowel movement
without mixing and was red. He was seen by surgery, who felt
that the patient did not have a surgical abdomen. He had a PEG
tube lavage which was negative for any upper GI bleeding source.
His hematocrit remained stable. He was also seen by
gastroenterology who did not perform either an EGD or
colonoscopy as his bleeding had resolved. His LFTs, amylase and
lipase were all normal. He had a right upper quadrant ultrasound
which was normal. He had a normal lactate, which ruled out
ischemia. His KUB showed a significant amount of stool, so
constipation was thought to be the major source of his pain. He
was maintained on a bowel regimen for stooling and his tube
feeds were restarted without evidence of pain.
7. Hypernatremia thought to be likely iatrogenic as patient was
not getting free water flushes with his tube feeds. This
corrected with free water flushes. Free water via PEG tube may
need to be adjusted at rehab based on regular sodium checks.
.
8. Corneal ulcer. Patient was noted to have a corneal ulcer,
seen by ophthalmology who performed eyelid suturing on [**10-13**].
Likely related to inability to protect eye with neurologic
deficits. Patient was given a 10 day course of Vigamox
antibiotic eye oitment. He was also given bacitracin ointment
and artificial tears per ophthalmology, which should be
continued until he is seen in 1 week by an outpatient
ophthalmologist.
.
9. Accelerated idioventricular rhythm. Patient had an episode
of an accelerated idioventricular rhythm, and was seen by
cardiology. They felt that this was likely benign and not
related to Lyme disease. He was started on Metoprolol and there
was no reoccurance of the accelerated idioventricular rhythm.
.
10. Hypotension: Patient had periods of hypotension, thought to
be likely iatrogenic as patient had clonidine given for
aggitation. The clonidine was tapered off and this improved his
hypotension. His medications were also spaced out so that his
lopressor was not given with his seroquel, which also resolved
his hypotension. He has had no periods of hypotension in the
past 4 days since these medication changes were made.
.
11. Nutrition: Patient is recieving tube feeding via PEG tube
for nutrition as well as free water flushes with 300 mL every 4
hours for free water repletion.
.
12: DVT prophylaxis was given for the course of his hospital
stay with subcutaneous heparin.
.
13. Patient was full code throughout his hospital stay
HCP: son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 84569**]
Medications on Admission:
- oxycodone 5/325 mg po q 4-6h prn pain
- hydromorphone 2 mg po q4h prn pain
- cyclobenzaprine 10 mg po TID prn pain
- lorazepam 0.5 mg po q 12h
- neurontin 300 mg po tid
- hctz 25 mg po daily
- theratears
- mvi po daily
ALLERGIES:
- motrin - GI distress
- ativan - paradoxical reaction
Discharge Medications:
1. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q6H (every 6 hours).
2. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic Q2H (every 2 hours).
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): HOLD for SBP <100, Hr <60.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
5. Methadone 5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day)
for 1 days: patient will complete methadone taper on [**2102-10-28**].
6. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS;PRN () as
needed for agitation .
9. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) inhalation Inhalation [**Hospital1 **] ().
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for sob, wheezing.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Lyme encephalitis
.
Respiratory failure
Delerium
Corneal ulcer
Accelerated idioventricular rhythm
Hypotension
Hypernatremia
Atelectasis
Lower Gi bleed
Fever
Discharge Condition:
Stable, off ventilator on trach mask oxygen, ongoing delerium
with some delusional and paranoid features. Persistent R sided
facial droop and R sided weakness that has been gradually
improving.
Discharge Instructions:
You were admitted after having neurologic changes due to a
severe Lyme disease infection. You have completed a course of
antibiotics and are improving. You also had difficulties
getting off the ventilator, but this has also improved. You
will need to go to rehab following your hospitalization to
improve your physical strength and allow time for your thinking
to improve.
.
Please return to the hospital or call your doctor if you have
weakness or other changes in your neurologic function,
increasing confusion, headache, fever greater than 101, chest
pain, abdominal pain, or any new symptoms that you are concerned
about.
.
You had a number of medication changes during your hospital stay
here. Please take all medications as prescribed.
Followup Instructions:
Followup with your primary care physician will be arranged after
your discharge from rehab.
.
Please followup with ophthalmology available at your rehab
facility within one week. Please continue your eyedrops as
prescribed until that followup appointment.
.
In the future you should followup with gastroenterology due to a
single episode of bloody stool that occurred on [**2102-10-25**].
.
You should see a speech therapist for swallowing evaluation
while at rehab. Until that time, we do not feel it is safe for
you to take food or drink by mouth.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2102-10-27**]
|
[
"51881",
"2760",
"5180",
"3051",
"4019",
"42789"
] |
Admission Date: [**2153-11-18**] Discharge Date: [**2153-11-20**]
Date of Birth: [**2077-7-1**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Coumadin
Attending:[**First Name3 (LF) 7881**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr [**Known lastname 24110**] is a 76 y/o M with a history of multiple sclerosis,
paroxysmal atrial fibrillation on aspirin and [**Known lastname 4532**],
hypertension, hyperlipidemia, previously diagnosed "vasovagal
syncope," prostate cancer, neurogenic bladder with chronic
suprapubic cath, history of ESBL UTI, chronic constipation, and
left parietal AVM, presenting from home after a syncopal
episode. Patient apparently woke up this morning feeling
extremely weak and tired. Per his wife, he was also difficult
to arouse with multiple episodes of somnolence. EMS was called
in the morning, but patient refused to be taken to the hospital
as he felt well by their arrival. Patient was then eating a
bowl of fruit this afternoon, and his wife found him slumped in
a chair. He regained conciousness several minutes later. EMS
was subsequently called again. Patient has no recollection of
passing out, nor did he feel any prodrome of chest pain, nausea,
diaphoresis, SOB, dizziness. On EMS arrival, HR 30s BP 70s, and
patient was asymptomatic.
.
On arrival to the ED, HR was in the 30s-40s, BPs labile
80s-120s. Patient had no symptoms during low BPs. He was given
IV cipro for history of UTI, 2L NS and sent to the unit. His
Hct was 26 and was guiac negative in the ED. On transfer to the
unit, patient was afebrile HR 44, 114/49 18 100% on 2L NC.
.
Of note, patient had been admitted in [**Month (only) **] for a similar
episode of unresponsiveness with a negative workup, as well as
prior synopal workups in the past. He reports that todays
episode was similar in nature in that he did not feel any
prodrome and did not remember passing out. He also has had
several episodes of diagnosed "vasovagal syncope," prior to
which he sometimes feels weak and nauseous. On review of prior
notes, patient is also chronically bradycardic with HRs in 40s
at [**Month (only) 5348**], with transient episodes of hypotension. He has a
Holter monitor in our system from [**2141**], which showed no ectopy,
HRs 49-70, with prolonged PR intervals .24.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. Of note, he had a EGD/colonoscopy on [**11-11**] for workup of
Fe deficiency anemia, which showed a non-bleeding adenoma. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. His last bowel movement was 1.5 weeks ago,
whichg he states is roughly his [**Month/Year (2) 5348**]. 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.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
1. Multiple sclerosis - followed by Dr.[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 45435**] at [**Hospital1 2025**].
2. Neurogenic bladder - suprapubic catheter in place; followed
by Dr. [**Last Name (STitle) 9125**].
3. Hypertension
4. Severe constipation - followed by Dr. [**Last Name (STitle) 10689**].
5. Glaucoma
6. Prostate cancer - s/p hormonal therapy and radiation. He has
been pursuing watchful waiting since the Spring [**2149**]. He is
followed at the [**Hospital3 328**] Cancer Institute.
7. Pneumonia
8. Cellulitis
9. Osteoarthritis
10. Hyperlipidemia
11. Depression
12. History of AVM in the left parietal lobe
13. Obstructive sleep apnea utilizing CPAP at night
14. Peripheral neuropathy
15. Thoracic outlet syndrome
16. PE - [**3-21**]
17. Gastroesophageal reflux disease
18. History of MRSA
19. History of left foot fracture
21. Osteopenia
22. Atrial Fibrillation on [**Month/Year (2) **]
22. Shingles - [**2151**]
Social History:
Lives with wife in [**Name (NI) **]. Former etoh, sober since [**2123**] via
AA. Quit cigars a few years ago. Retired judge (at age 68 due to
fatigue).
Family History:
Per notes, daughter and cousin with MS, mother with AD, father
with leukemia, brother with arrhythmia.
Physical Exam:
VS: T= 97 BP= 108/57 HR= 44 RR= 12 O2 sat= 100% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Distended, firm. Hypoactive bowel sounds. Nontender,
no guarding or rebound.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
1. Labs on admission:
[**2153-11-18**] 05:40PM BLOOD WBC-7.8 RBC-3.31* Hgb-8.7* Hct-26.8*
MCV-81*# MCH-26.4* MCHC-32.6 RDW-15.3 Plt Ct-178
[**2153-11-18**] 05:40PM BLOOD PT-14.1* PTT-31.7 INR(PT)-1.2*
[**2153-11-19**] 05:00AM BLOOD Glucose-159* UreaN-16 Creat-0.9 Na-139
K-3.6 Cl-112* HCO3-23 AnGap-8
[**2153-11-19**] 05:00AM BLOOD CK(CPK)-40*
[**2153-11-18**] 05:40PM BLOOD cTropnT-<0.01
[**2153-11-19**] 05:00AM BLOOD CK-MB-3 cTropnT-<0.01
[**2153-11-19**] 05:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.0
[**2153-11-18**] 05:54PM BLOOD freeCa-1.08*
.
2. Labs on discharge;
[**2153-11-20**] 05:59AM BLOOD WBC-5.2# RBC-3.80*# Hgb-9.9*# Hct-30.7*#
MCV-81* MCH-26.0* MCHC-32.3 RDW-14.6 Plt Ct-161
[**2153-11-20**] 05:59AM BLOOD Glucose-110* UreaN-17 Creat-0.9 Na-140
K-3.9 Cl-111* HCO3-23 AnGap-10
[**2153-11-20**] 05:59AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0
.
3. Imaging/diagnostics:
- CXR ([**2153-11-18**]): No acute cardiopulmonary process.
- EKG ([**2153-11-19**]): Sinus bradycardia and A-V conduction delay with
slight shortening of the P-R interval as compared to the
previous tracing of [**2153-11-18**]. The Q-T interval remains prolonged.
No diagnostic interim change.
- Tilt-table test ([**2153-11-20**]): *preliminary finding*: delayed
neurally mediated syncope with orthostatic hypotension, systolic
blood pressure drop from 160s to 60s. Final report to follow.
Brief Hospital Course:
Mr [**Known lastname 24110**] is a 76 y/o M with a history of multiple sclerosis,
paroxysmal atrial fibrillation on aspirin and [**Known lastname 4532**],
hypertension, hyperlipidemia, previously diagnosed "vasovagal
syncope," neurogenic bladder with chronic suprapubic cath,
history of ESBL UTI, chronic constipation, and left parietal
AVM, presenting from home after a syncopal episode.
.
#. Syncope: EKG on admission showed first degree heart block.
Patient did not have any other arrythmia throughout the hospital
course. Symptoms similar to prior vaso-vagal episodes. Tilt
table test was done which showed delayed neurally mediated
syncope with orthostatic hypotension (sBP 160s-->60s). Patient
to follow-up with outpatient cardiologist.
.
#. Atrial Fibrillation: Remained in sinus bradycardia and was
kept on home regimen of aspirin/[**Known lastname 4532**] rather than coumadin in
the context of known AVM.
.
# HTN: Kept on home enalapril. New home [**Known lastname 4085**] amlodipine
was stopped.
.
# HLD: Continue one home simvastatin
.
# Chronic UTI: History of ESBL UTI with suprapubic catheter
site. Urinanalysis on admission was positive and urine culture
grew out E. coli. Speciation at the time of discharge was not
available. Per outpatient urologist, this is consistent with
chronic colonization and will be treated with outpatient
antibiotics regimen by urologist.
.
#. Multiple Sclerosis: Continue baclofen.
.
# Neurogenic bladder: Patient was on oxybutynin while in patient
and discharged with home darifenacin on discharge.
.
#. Constipation: Secondary to neuropathy from MS, chronic
problem. Aggressive bowel regimen administered with effect.
.
Medications on Admission:
- Amlodipine 7.5 mg daily
- Baclofen 20 mg qhs
- Brimonidine .1% drops TID
- [**Known lastname **] 75 mg daily
- Darifenacin 7.5 mg daily
- Dorzolamide-timolol 1 drop TID
- Enalapril 20 mg [**Hospital1 **]
- Latanoprost 1 drop qhs
- Macrobid 100 mg daily one out of 3 weeks
- Omeprazole 40 mg [**Hospital1 **]
- Peg-electrolyte solution 420 1 bottle daily
- Simvastatin 10 mg qhs
- Aspirin 325 mg daily
- Calcium 600 mg + D daily
- Cascara
- Colace
- Multivitamin
- Omega-3 fatty acids
Discharge Medications:
1. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO once a
day.
11. baclofen 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. darifenacin 7.5 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO QHS (once a day (at
bedtime)).
13. carbamide peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 4 days.
14. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
15. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Vasovagal syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid ([**Hospital1 **]
or cane).
Discharge Instructions:
You were seen in the hospital because a syncopal episode. This
episode was likely secondary due a vasovagal cause. You had a
tilt table test to explore possible causes for your syncopal
episode, which showed a drop in your blood pressure with
tilting. You will need to follow up with your cardiologist Dr.
[**Last Name (STitle) **] (appointment below) to discuss the final results.
.
We made the following changes to your medications:
STOPPED Amlodipine
.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
-You have an appointment scheduled with Dr. [**Last Name (STitle) **]:
Monday [**2153-11-26**] at 11:30 AM
-You should also make a follow up appointment with your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **]
Completed by:[**2153-11-20**]
|
[
"5990",
"42731",
"4019",
"2724",
"25000"
] |
Admission Date: [**2147-5-28**] Discharge Date: [**2147-6-5**]
Date of Birth: [**2074-8-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Fever.
Major Surgical or Invasive Procedure:
1. Central venous access insertion.
History of Present Illness:
Pt is a 72yo F with DM2, HTN, CAD, s/p CABG in [**2146-10-5**] with
MVR and AVR who presents with bladder pressure for 2 days and
fever and chills since this morning. Pt states that she saw her
OB/Gyn for vaginal spotting. She had a pelvic u/s down which she
states was normal & there was no evidence of bleeding seen.
Since Thursday, 3 days ago, she had bladder pressure sensation
with sensation that she was unable to void completely. She
denied any nausea, vomiting, back pain, dysuria, hematuria, or
odor to her urine. She felt cold over the weekend, and then
developed fever and chills this morning. She said she was
shaking a lot and her daughter decided to bring her to the [**Name (NI) **].
They did not take a temp prior to coming to the ED.
.
In the ED, initial vs were: T 101.7 P 116 BP 106/72 R 18 O2 sat
100% on RA. UA was positive. Patient was given 3L IV fluids,
tylenol 1000mg, Ceftriaxone 1g, 4g of IV Magnesium. The patient
was started on levophed gtt for persistent pressures in the
80's. Lactate went from 3.3-->2.3 after 3L IVF. Prior to
transfer to the floors, she was on Levophed 0.04.
.
.
On the floor, she feels like her mouth is dry, but has no other
complaints. She currently denies any abdominal pain or back
pain. BP apparently runs in 110s at home. Pt has not taken am BP
meds. Pt does not recall prior UTIs and has not taken any recent
abx.
.
Review of systems:
(+) Per HPI. Also with some itching from her CABG scar, but this
is unchanged.
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies arthralgias or myalgias. Denies rashes or
skin changes.
Past Medical History:
CAD s/p MI in [**2146-10-5**]. CABG and AVR and MVR in [**2146-10-5**].
DM2
HTN
Anemia
GERD
Proteinuria
Non-immune hemolytic anemia [**3-8**] AVR
HLD
Thyroid nodule
Social History:
She has over 40 years of smoking and stopped last year in the
fall of [**2146**]. She smoked approximately one or more pack per
day. She denies any alcohol abuse history or illicit drug use.
She currently lives with her son and daughter since her surgery
in [**Name (NI) **].
Family History:
Mother had heart disease. Her brother died at the age of 42
from heart disease.
Physical Exam:
ADMISSION PHYSICAL:
Vitals: T: 98.9 BP: 116/66 P: 86 R: 10 O2: 97%RA CVP 13
General: Alert, oriented, no acute distress, pleasant, sitting
up in bed
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, R IJ in place
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: well-healed midline vertical CABG scar, Regular rate and
rhythm, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema; scarring of left hand (from burn many years ago)
Neuro: A&Ox3, CN II-XII grossly intact, moving all extremities,
no gross deficits
Pertinent Results:
ADMISSION LABS:
[**2147-5-28**] 07:00AM BLOOD WBC-11.0 RBC-3.70* Hgb-11.2* Hct-32.8*
MCV-89 MCH-30.2 MCHC-34.1 RDW-15.3 Plt Ct-150
[**2147-5-28**] 07:00AM BLOOD Neuts-88.9* Lymphs-7.7* Monos-2.5 Eos-0.7
Baso-0.2
[**2147-5-28**] 07:00AM BLOOD Glucose-236* UreaN-34* Creat-1.4* Na-133
K-5.2* Cl-98 HCO3-20* AnGap-20
[**2147-5-28**] 07:00AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.0*
[**2147-5-28**] 07:15AM BLOOD Lactate-3.3*
[**2147-5-28**] 08:59AM BLOOD Lactate-2.3* K-4.2
[**2147-5-28**] 03:33PM BLOOD Lactate-1.5 K-3.3*
[**2147-5-28**] 12:19PM BLOOD O2 Sat-66
LABS PRIOR TO DISCHARGE:
[**2147-6-4**] 07:00AM BLOOD WBC-9.1 RBC-3.64* Hgb-11.0* Hct-32.8*
MCV-90 MCH-30.2 MCHC-33.6 RDW-16.1* Plt Ct-424
[**2147-6-2**] 11:00AM BLOOD Neuts-72* Bands-1 Lymphs-13* Monos-11
Eos-2 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2147-6-3**] 07:20AM BLOOD Neuts-50 Bands-3 Lymphs-38 Monos-6 Eos-1
Baso-1 Atyps-0 Metas-1* Myelos-0
[**2147-6-4**] 07:00AM BLOOD Neuts-68 Bands-2 Lymphs-24 Monos-4 Eos-0
Baso-0 Atyps-1* Metas-0 Myelos-1*
[**2147-6-4**] 07:00AM BLOOD Glucose-197* UreaN-12 Creat-1.1 Na-142
K-4.0 Cl-107 HCO3-23 AnGap-16
[**2147-6-4**] 07:25AM BLOOD Lactate-1.8
Micro:
[**2147-5-31**] blood cultures pending x2
[**2147-5-31**] blood cultures pending x2
[**2147-5-30**] blood cultures pending
[**2147-5-29**] urine culture negative
[**2147-5-29**] blood cultures pending
[**2147-5-28**] MRSA screen: negative
[**2147-5-28**] urine culture: pansensitive E.coli
[**2147-5-28**] blood cultures x2: pansensitive E.coli
Images:
[**2147-6-3**] RUQ ultrasound: Liver echotexture is normal. There are
no focal hepatic lesions. The previously demonstrated right
liver lobe abnormality on CT is not visualized on this
ultrasound study. The portal vein is patent with normal
hepatopetal flow. There is no ascites. There is no intra- or
extra-hepatic biliary duct dilatation with the common bile duct
measuring 4 mm. The spleen is normal measuring 9 cm.
IMPRESSION: No US finding that would be corresponding to the
previously seen lesion on CT.
[**2147-6-2**] CT abd/pelvis: 1. Bilateral patchy enhancement of the
renal parenchyma, consistent with the stated history of
pyelonephritis, without evidence of renal or perinephric
abscess. Additional areas of scarring suggest previous infection
or ischemic change. No hydronephrosis. 2. 12 mm focal hypodense
lesion within the right lobe of the liver, not fully
characterized, could be further assessed with ultrasound when
clinically appropriate. 3. Severe atherosclerotic change of the
abdominal aorta and iliac arteries. 4. Diverticulosis without
evidence of diverticulitis.
[**2147-5-29**] CXR: As compared to the previous radiograph, the
opacities indicative of pulmonary edema have minimally
decreased. No focal parenchymal opacities have newly appeared.
Presence of a minimal left pleural effusion cannot be excluded.
Unchanged alignment of the sternal wires, unchanged position of
the right internal jugular vein catheter. Unchanged size of the
cardiac silhouette.
[**2147-5-29**] TTE: Poor image quality.The left atrium is elongated.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is probably
mildly depressed (LVEF= 40 %) with global hypokinesis. There is
no ventricular septal defect. with depressed free wall
contractility. A bioprosthetic aortic valve prosthesis is
present. The aortic valve prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. No
aortic regurgitation is seen. A mitral valve annuloplasty ring
is present. The gradient across the mitral valve is increased
(mean = 10 mmHg). Trivial mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Tricuspid regurgitation is
present but cannot be quantified. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2147-1-26**], the degree of MR is less. If
indicated, a TEE would better assess the degree of MR due to
poor TTE quality and acoustic shadowing from the mitral ring.
[**2147-5-28**] CXR: One portable view. Comparison with the previous
study of [**2147-5-28**]. There is diffusely increased parenchymal
density bilaterally with increased interstitial markings most
suggestive of edema. The patient is status post median
sternotomy and MVR as before. Mediastinal structures are
unchanged. A right internal jugular catheter remains in place.
IMPRESSION: Diffusely increased pulmonary parenchymal density
most suggestive of edema.
[**2147-5-28**] CXR: IJ in place.
[**2147-5-28**] CXR: No acute cardiopulmonary process. Mild
cardiomegaly, stable. Mild fluid overload.
[**2147-5-28**] EKG: ST at 122, LVH, NA, NI, STE in V1 and V2 unchanged
from prior
Brief Hospital Course:
72 yo female with history of Type 2 Diabetes, HTN, and CAD s/p
CABG in [**2146-10-5**] with MVR and AVR who presents with fevers, UTI
and hypotension found to have pansensitive E.coli urosepsis.
# Septic shock secondary to E.coli Bacteremia from E.coli UTI:
Patient presented with symptoms of bladder pressure, incomplete
emptying, fevers, and rigors. Labs revealed a left shift with
[**Last Name (un) **]. Urinalysis was grossly positive with pansensitive E.coli
growing in urine and blood cultures from the day of admission.
She had criteria for sepsis on admission with fever,
tachycardia, hypotension, and a source. She went to the MICU
initially with a L-IJ, requiring IVF and Levophed for support.
She has been maintained on Ceftriaxone with white count and
fever curve trending down. She had another fever after one week
of Ceftriaxone, so a CT abdomen/pelvis was done which revealed
with pyelo. A RUQ was done to evaluate a liver hypodensity seen
on CT abd/pelvis, but this was not visualized. Blood cultures
are pending at the time of discharge. She was continued on oral
ciprofloxacin for a total antibiotic course of 14 days given
bacteremia ([**Date range (1) 111050**]).
# Acute kidney injury: Cr 1.4 upon admission with baseline of
0.8. Likely hypovolemic in the setting of fever, sepsis, and
poor PO intake. She received four liters of IVF in the MICU and
ED with partial resolution of her [**Last Name (un) **]. Her diuretics were held
initially so a component of poor forward flow. Her creatinine
has been stable on her home bumex regimen. She was euvolemic on
exam prior to discharge.
# Normocytic anemia: HCT 32 at baseline of 33. She has a history
of non-immune hemolytic anemia [**3-8**] AVR. She is followed as an
outpatient with heme. No history of iron deficiency, but is on
iron and vitamin C.
# CAD s/p CABG with AVR and MVR: EKG on admission stable from
prior, with exception of tachycardia which has resolved. She
was continued on ASA, atorvastatin and lisinopril. Metoprolol
was initially held in the setting of septic shock. She was
titrated to lower dose of 25 mg po BID instead of 37.5 mg po TID
prior to discharge. With LVEF of 40% she would benefit from
Metoprolol XL which we will defer to her PCP.
# Acute on chronic CHF exacerbation: Secondary to IVF received
during initial resuscitation efforts for urosepsis. Most recent
TTE with EF 40% from [**1-/2147**], confirmed on TTE and TEE during
this admission. Patient restarted on her home dose of bumex.
She was also continued on ASA, atorvastatin, metoprolol, and
lisinopril.
# CAD s/p CABG, AVR, MVR: Continued on ASA, atorvastatin. As
above, initially held
lisinopril, metoprolol, bumex given hypotension. ECG was
unchanged.
# DM2: Held metformin given acute renal failure. Placed on QID
fingersticks & ISS.
# GERD: Continued protonix 40mg [**Hospital1 **] per home dosing.
Follow up for PCP
1. With LVEF of 40% she would benefit from Metoprolol XL which
we will defer to her PCP.
Medications on Admission:
Medications: per OMR & confirmed with patient
Atorvastatin 40mg po daily
Bumex 1mg MWF
Lisinopril 10mg po daily
Metformin 1000mg po bid
Metoprolol 37.5mg po tid
Pantoprazole 40mg po bid
Potassium Chloride 40mEq daily
Ascorbic Acid 1000mg po daily
ASA 81mg po daily
Calcium Carbonate Vit D3
Cyanocobalamin 1000mcg po daily
Ferrous gluconate 240mg
Omega 3 Fatty acids daily
Magnesium oxide 500mg 2 caps MWF, 1 cap TuThSaSu
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. bumetanide 1 mg Tablet Sig: One (1) Tablet PO three times per
week.
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
10. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
11. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO once a day.
12. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. magnesium oxide 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
15. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 2 doses.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Gram Negative Rod Bacteremia with Septic
Shock secondary to UTI and Pyelonephritis
Secondary Diagnosis: CAD s/p CABG, AVR, MVR, Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted for fever and chills. You had a urinary tract
infection that spread to your kidneys and into your bloodstream.
You were given IV antibiotics until transitioning to oral
antibiotics.
The following changes were made to your medication regimen:
START ciprofloxacin for two more days to treat your urine
infection
DECREASE metoprolol to 25 mg by mouth twice a day
DECREASE magnesium to 250 mg by mouth once a day
STOP potassium as you had high levels on admission
Followup Instructions:
The following appointments were made for you:
Department: [**Hospital3 249**]
When: TUESDAY [**2147-6-6**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 23733**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) 32097**], [**Street Address(1) **], MA
Phone: [**Telephone/Fax (1) 3632**]
Appt: [**6-26**] at 1:30pm
|
[
"78552",
"5849",
"2762",
"99592",
"V4581",
"25000",
"4019",
"V1582",
"2859",
"53081",
"4280"
] |
Admission Date: [**2161-4-10**] Discharge Date: [**2161-4-17**]
Date of Birth: [**2098-9-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
[**2161-4-10**] Aortic Valve Replacement utilizing a [**Street Address(2) 66683**].
[**Male First Name (un) **] mechanical valve
History of Present Illness:
This is a pleasant 62 year old female who was recently diagnosed
with critical aortic stenosis back in [**2161-1-15**] after being
hospitalized initially for shortness of breath and cough.
Cardiac catheterization at that time confirmed aortic stenosis
with a valve area of 0.6cm2 with a peak gradient of 73 mmHg.
Coronary angiography showed a right dominant system and clean
coronary arteries. Since that time, she has experienced multiple
syncopal episodes. She also has required hospitalization earlier
this month for congestive heart failure. Her most recent echo is
from [**2161-3-23**] which revealed severe aortic stenosis with peak and
mean gradients of 113 and 78 mmHg respectively. There was no
aortic insufficiency and only 1+ mitral regurgitation. Her LVEF
was normal, greater than 55%. She now presents for cardiac
surgical intervention.
Past Medical History:
Aortic Stenosis, Congestive Heart Failure, Hypercholesterolemia,
Hypertension, Diabetes mellitus with neuropathy, SLE, Rheumatoid
arthritis, Pseudogout, Asthma, Anxiety, Depression, s/p
Hysterectomy, s/p Right Breast Lumpectomy, s/p Knee Surgery
Social History:
Smoked ~3 cigs/day X 15 years, quit 30 years ago. Admits to only
rare ETOH. Denies recreational drugs. She is married with
children.
Family History:
No premature coronary artery disease
Physical Exam:
Vitals: BP 126/79, HR 98, RR 18
General: obese female in no acute distress
HEENT: oropharynx benign, EOMI, PERRL
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 3/6 systolic murmur
Lungs: clear bilaterally, slightly decreased at bases
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities, dark lesions left lower
extremity
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2161-3-23**] Carotid Ultrasound - minimal disease of both internal
carotid arteries
[**Last Name (NamePattern4) 4125**]ospital Course:
On the day of admission, Mrs. [**Known lastname 106519**] underwent an aortic valve
replacement with a [**Street Address(2) 66683**]. [**Male First Name (un) 923**] mechanical prosthesis.
The operation was uneventful and she transferred to the CSRU in
stable condition. For further operative details, please see
seperate dictated operative note. Within 24 hours, she awoke
neurologically intact and was extubated. She maintained stable
hemodynamics but was noted to have decreased urine output in the
setting of a rising creatinine. Natrecor was initiated with a
good response. Her creatinine peaked to 2.0. As her renal
function, Natrecor was discontinued and she was transitioned to
intravenous Lasix. Her CSRU course was otherwise uneventful and
she transferred to the SDU on postoperative day three. She
tolerated beta blockade and remained in a normal sinus rhythm.
Her INR was monitored daily and Warfarin was dosed for a goal
INR between 2.0 - 3.0. She temporarily required Heparin for a
subtherapeutic prothrombin time. Over several days, she
continued to make clinical improvements and her renal function
returned to baseline. She was cleared for discharge on
postoperative day seven. At time of discharge, her BP was 113/57
with a HR of 82. Her chest x-ray showed small bilateral pleural
effusions and her oxygen saturations were 97% on room air. All
surgical wounds were clean, dry and intact. She will follow-up
with Dr. [**Last Name (Prefixes) **], her cardiologist and her primary care
physician as an outpatient.
Medications on Admission:
Allopurinol 300 qd, Aspirin 81 qd, Atrovent MDI, Benicar, Prozac
20 qd, Lasix, Glyburide, Humalog and Lantus Insulin, Lipitor 10
qd, Neurontin 400 qd, Plaquenil 200 qd, Albuterol MDI
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily). Capsule(s)
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
10. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Glyburide-Metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily):
3mg [**4-17**], check INR [**4-18**] with results called to Dr. [**Last Name (STitle) 3314**].
Disp:*90 Tablet(s)* Refills:*2*
13. Insulin Glargine 100 unit/mL Cartridge Subcutaneous
14. Insulin Lispro (Human) Subcutaneous
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1
weeks: 40mg [**Hospital1 **] x 1 week then resume preop dose of 20mg daily.
Disp:*30 Tablet(s)* Refills:*0*
16. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Packet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Aortic Stenosis - s/p mechanical AVR, Postoperative Acute Renal
Insufficiency, Postop Anemia, Congestive Heart Failure,
Hypercholesterolemia, Hypertension, Diabetes mellitus with
neuropathy, SLE, Rheumatoid arthritis, Pseudogout, Asthma,
Anxiety, Depression,
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.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**5-20**] weeks - call for appt.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**] in [**3-20**] weeks - call for appt.
Local cardiologist, Dr. [**Last Name (STitle) **] in [**3-20**] weeks - call for appt.
Coumadin to be followed by Dr. [**Last Name (STitle) 3314**]
Completed by:[**2161-5-15**]
|
[
"4241",
"4280",
"49390"
] |
Admission Date: [**2167-7-5**] Discharge Date: [**2167-7-10**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with bare metal stents to the proximal
and mid left anterior descending artery.
History of Present Illness:
89yoF with PMH CAD s/p LAD STEMI in [**2157**], DM II, h/o CVA, HL
presents after 1 day of generalized weakness. This morning,
patient was on the commode and felt presyncopal and unable to
transfer from the commode, therefore was brought to the ER. Per
daughter, patient has had five discrete episodes of weakness
over the past week, but none as bad as this. Patient denies
chest pain, shortness of breath. Previous STEMI was heralded by
pain between the shoulder blades, of which she denies. Denies
any jaw, back, or arm pain.
.
On review of systems, positive for chronic cough. No change in
her cough severity. She denies myalgias, joint pains,
hemoptysis, black stools or red stools. She denies recent
fevers, chills or rigors. She denies dysuria, urgency,
frequency. She denies new neurologic symptoms. Last BM this AM,
no diarrhea or abdominal pain. No history of GI bleed, no melena
or BRBPR. 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.
.
In the ED, initial vitals were 98.4 96 103/58 16 98% RA. EKG
showed 1-1.5mm ST elevations in V1 and V2 with depressions in I,
II, AVL. Code STEMI was called. She received ASA 325mg and was
started on heparin gtt. She was guaiac negative. Cardiology
reviewed the EKG's and did not feel that she needed to
emergently go to the cath lab. Troponin was 2.59. It was felt
that she should come to the CCU in light of known reduced EF of
35-40% and ACS. On CXR, she was found to have R sided
infiltrate, but was transported to CCU prior to receiving her
planned levaquin and ceftriaxone for CAP. VS on transfer to the
CCU were HR 79, RR 16, BP 96/50, Pox 97RA.
.
On the floor, the patient has no complaints. She denies chest
pain, n/v, diaphoresis, SOB, back pain/jaw pain/arm pain.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: s/p STEMI in [**2157**] w/ stent
to LAD
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
-Osteoporosis
-CVA - small vessel stroke in R MCA territory [**7-23**] (no residual
effects)
-Osteoarthritis (knees)
-b/l rotator cuff injuries
-Status post hysterectomy 20 years ago
-L posterior tibialis injury (L leg brace)
-R bimalleus fracture (external cast)
-Aspiration PNA in [**4-/2166**], treated with CTX, azithromycin,
clindamycin
-s/p cataracts surgery
Social History:
Lives with her daughter and mostly stays in the house. Able to
stand by the sink to wash dishes and brush her teeth.
Non-smoker, drinks rarely, no drug abuse.
Family History:
No cardiovascular disease. No diabetes mellitus.
Physical Exam:
On Admission:
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 7 cm in 45 degree angle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No edema, +venous stasis changes. +corn on left
foot
PULSES:
Right: trace DP and PT pulses, dopplerable
Left: trace DP and PT pulses, dopplerable
.
On Discharge:
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple without JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: CTA-B
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No edema, +venous stasis changes. +corn on left
foot
PULSES:
Right: trace DP and PT pulses, dopplerable
Left: trace DP and PT pulses, dopplerable
Pertinent Results:
CBC trend:
[**2167-7-5**] 09:58AM BLOOD WBC-14.6*# RBC-4.37 Hgb-13.9 Hct-42.0
MCV-96 MCH-31.8 MCHC-33.1 RDW-14.2 Plt Ct-142*
[**2167-7-6**] 03:22AM BLOOD WBC-7.8 RBC-3.78* Hgb-12.0 Hct-36.1
MCV-96 MCH-31.8 MCHC-33.2 RDW-14.1 Plt Ct-117*
[**2167-7-6**] 04:50PM BLOOD WBC-8.3 RBC-3.31* Hgb-10.9* Hct-31.7*
MCV-96 MCH-32.8* MCHC-34.2 RDW-14.2 Plt Ct-114*
[**2167-7-7**] 05:42AM BLOOD WBC-10.2 RBC-3.59* Hgb-11.5* Hct-34.1*
MCV-95 MCH-32.2* MCHC-33.9 RDW-14.2 Plt Ct-127*
[**2167-7-8**] 06:27AM BLOOD WBC-9.4 RBC-3.48* Hgb-10.9* Hct-33.5*
MCV-96 MCH-31.4 MCHC-32.6 RDW-14.2 Plt Ct-130*
[**2167-7-9**] 02:18AM BLOOD WBC-7.6 RBC-3.17* Hgb-10.4* Hct-30.3*
MCV-95 MCH-32.9* MCHC-34.5 RDW-14.1 Plt Ct-141*
[**2167-7-10**] 06:30AM BLOOD WBC-6.2 RBC-3.34* Hgb-11.0* Hct-32.0*
MCV-96 MCH-32.9* MCHC-34.3 RDW-14.1 Plt Ct-143*
[**2167-7-10**] 05:30PM BLOOD Hct-32.1*
Coags:
[**2167-7-5**] 09:58AM BLOOD PT-13.7* PTT-21.6* INR(PT)-1.2*
[**2167-7-6**] 03:38AM BLOOD PT-15.7* PTT-66.4* INR(PT)-1.4*
[**2167-7-7**] 05:42AM BLOOD PT-13.9* PTT-23.2 INR(PT)-1.2*
[**2167-7-7**] 03:02PM BLOOD PT-13.7* PTT-24.3 INR(PT)-1.2*
[**2167-7-8**] 06:27AM BLOOD PT-14.8* INR(PT)-1.3*
[**2167-7-9**] 02:18AM BLOOD PT-15.3* PTT-62.6* INR(PT)-1.3*
[**2167-7-10**] 06:30AM BLOOD PT-18.2* INR(PT)-1.6*
.
Chem panel
[**2167-7-5**] 09:58AM BLOOD Glucose-250* UreaN-21* Creat-0.7 Na-139
K-4.3 Cl-103 HCO3-23 AnGap-17
[**2167-7-6**] 03:22AM BLOOD Glucose-134* UreaN-21* Creat-0.8 Na-141
K-4.2 Cl-106 HCO3-25 AnGap-14
[**2167-7-7**] 05:42AM BLOOD Glucose-182* UreaN-25* Creat-1.0 Na-138
K-4.0 Cl-105 HCO3-24 AnGap-13
[**2167-7-7**] 03:02PM BLOOD Glucose-175* UreaN-28* Creat-1.2* Na-136
K-3.9 Cl-103 HCO3-23 AnGap-14
[**2167-7-8**] 06:27AM BLOOD Glucose-208* UreaN-35* Creat-1.6* Na-135
K-4.4 Cl-101 HCO3-24 AnGap-14
[**2167-7-9**] 02:18AM BLOOD Glucose-200* UreaN-45* Creat-1.9* Na-132*
K-4.8 Cl-101 HCO3-25 AnGap-11
[**2167-7-10**] 06:30AM BLOOD Glucose-231* UreaN-51* Creat-1.9* Na-136
K-4.7 Cl-102 HCO3-27 AnGap-12
.
Biomarkers:
[**2167-7-5**] 09:58AM BLOOD CK-MB-45* MB Indx-15.2* proBNP-9744*
[**2167-7-5**] 09:58AM BLOOD cTropnT-2.59*
[**2167-7-6**] 03:22AM BLOOD CK-MB-14* MB Indx-10.1* cTropnT-2.26*
[**2167-7-6**] 11:10PM BLOOD CK-MB-25* MB Indx-15.3*
[**2167-7-5**] 09:58AM BLOOD CK(CPK)-296*
[**2167-7-5**] 03:33PM BLOOD CK(CPK)-245*
[**2167-7-6**] 03:22AM BLOOD CK(CPK)-139
[**2167-7-6**] 11:10PM BLOOD CK(CPK)-163
.
HgA1c:
[**2167-7-5**] 03:32PM BLOOD %HbA1c-6.4* eAG-137*
.
Lipids:
[**2167-7-6**] 03:22AM BLOOD Triglyc-64 HDL-58 CHOL/HD-1.7 LDLcalc-27
.
TSH
[**2167-7-6**] 03:22AM BLOOD TSH-2.0
.
Dig
[**2167-7-8**] 06:27AM BLOOD Digoxin-0.6*
.
Imaging:
TTE: [**2167-7-6**]
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
moderate to severe regional left ventricular systolic
dysfunction with septal, anterior, and distal LV/apical
hypokiensis to akinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2162-11-30**], the LVEF has decreased.
.
Cardiac Cath: [**7-7**]
1. Coronary angiography in this right dominant system
demonstrated three
vessel disease. The LMCA had 50% stenosis. The LAD had 90%
origin
stenosis and was 100% occluded in the mid vessel (stent
occlusion). The
LCx had 70-80% origin stenosis. The RCA had 70-80% proximal
stenosis.
2. Resting hemodynamics revealed elevated left ventricular
filling
pressures with LVEDP 33 mmHg. There was no significant pressure
gradient
across the aortic valve on catheter pullback. There was systemic
arterial normotension.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Elevated left ventricular filling pressures.
.
CXR: [**7-9**]
There is continuous resolution of pulmonary edema, currently
almost completely resolved in upper and mid lung zones and
potentially may be minimally present in the lung bases in
conjunction with bibasilar atelectasis and pleural effusion.
There is no pneumothorax. Cardiomediastinal silhouette is
unchanged.
Brief Hospital Course:
89yoF with PMH CAD s/p LAD STEMI in [**2157**], DM II, h/o CVA, HL
presents with STEMI vs NSTEMI.
.
# NSTEMI: Pt was admitted with complaints of general weakness
and found to have positive troponin leak with EKG changes
including minimal ST elevation in V1-V2 and ST depressions and T
wave pseudonormalization in lateral and inferior leads in the
absence of symptoms of angina. There was question of STEMI due
to ST elevations in V1 and AVR but these did not appear
significantly changed from baseline ECG. She had a non-emergent
cath on [**7-6**] which showed multivessel disease: 50% LM, prox LAD
90% [**Last Name (un) **] circ 80% RCA 75%. BMS were placed in the prox and mid
LAD. Of note compared to [**2157**] cath [**Last Name (un) **] circ disease is new and
RCA is worsened from 50 to 75%. Echo showed hypokinesis in LAD
distribution (septal, anterior, and distal LV/apical hypokiensis
to akinesis. EF =30%) which was not new but worsened compared to
echo in [**2162**] (mild regional left ventricular systolic
dysfunction with severe hypokinesis to akinesis of the distal
anterior wall, distal septum, and apex, EF 35-40%). She was not
felt a candidate for CABG and was managed medically with plavix
(should continue daily for one month), aspirin 325, atorvastatin
80 (LDL 27, HDL 58), lisinopril, and metoprolol succinate.
.
# PUMP: On arrival in the CCU post cath, patient tachypneic w/
6L oxygen requirement (sats in mid 90s) and crackles b/l on
exam; to the 20 mg lasix IV given in cath lab put out about 1L
w/ no improvement in sxs. She had a brief period of SVT/flutter
and lasix 20 mg IV was repeated -> diuresed 1300 cc's in total.
Her echo showed EF of 30% with septal, anterior, and distal
LV/apical hypokiensis to akinesis. She was started on an ACEI
(first captopril and then lisinopril) and her home atenolol was
switched to metoprolol succinate. She was discharged on these
medications, as well as digoxin (see below).
.
# Atrial fibrillation/flutter: Patient was in NSR on admission,
but since was found to have paroxysmal episodes of SVT to 140??????s
which may be consistent with AVNRT vs Aflutter sustained upto 15
minutes, as well as paroxysmal Afib. Patient was asymptomatic
throughout these episodes with tendency to drop SBP to the 70's
which resolved with slower rate. It was speculated that her
initial presenting complaint of recurrent episodes of faintness
and weakness in recent days may all be due to similar paroxysmal
tachyarrythmias. She was treated with metoprolol 25 mg TID for
rate control (uptitrated to 100 mg succinate on discharge) and
digoxin loaded on [**7-7**] with a discharge dose of 0.125 qOD. She
was also loaded w/ amiodarone when she had a recurrent episode
of AF/AFlutter on dig. She was discharged on amiodarone 200 mg
TID for one week, followed by amiodarone 200 mg daily, as well
as coumadin for anticoagulation given a CHADS2 score 4 (she was
on a heparin gtt in house). Given she is on amiodarone she will
need monitoring of her LFTs and PFTs. She will also require INR
monitoring.
.
# Leukocytosis: Had leukocytosis on admission but this was
likely [**3-18**] to hemoconcentration. CXR on admission did show some
bibasilar infiltrates R>L and patient was witnessed to have
some coughing after thin liquids. UA was positive although
patient is not overtly symptomatic, culture came back with fecal
contamination. An infection could have triggered for her
tachyarrythmias and MI. Received levo and CTX on admission to
CCU on [**7-5**] but later in the setting of absence of fever and no
leukocytosis felt that pulmonary presentation was consistent
with congestion +/- pneumonitis rather than pneumonia. Was
treated with 3 days of bactrim for UTI. On [**7-9**], leukocytosis
resolved, temperatures were afebrile and urine cultures were
negative.
.
# Aspiration: Seen by Speech and swallow. There evaluation:
swallowing pattern correlates to a Functional Oral Intake Scale
(FOIS) rating of 5 out of 7. Per their recommendations patient
was started on soft solids and thin liquids and put on
aspiration precautions.
.
# Acute renal insufficiency: Patient developed increasing
creatinine (from 1->1.2->1.6->1.9 on discharge). Was attributed
to diuresis. She was discharged off of her home metformin and
glipizide to follow up with her PCP.
.
# Diabetes Mellitus: Was maintained on insulin sliding scale in
house and metformin was held. HbA1c was checked and 6.4. She
discharged off of metformin and glypizide given her [**Last Name (un) **] with
instructions to restart per her PCP.
.
CODE: DNR/DNI (There were numerous conversations about this, but
ultimately patient and daughter decided code status was
DNR/DNI).
Medications on Admission:
-Atorvastatin 10 mg daily
-Zestril 10 mg daily
-Aspirin 325 mg daily
-Clopidogrel 75 mg QSunday (regimen worked out with PCP for CVA)
-Atenolol 75mg daily
-Glipizide 2.5mg [**Hospital1 **]
-Metformin 500 mg [**Hospital1 **]
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
5. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
6. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*90 Tablet(s)* Refills:*2*
8. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
11. Outpatient Lab Work
please check Chem-7, CBC and INR on Tuesday [**2167-7-14**] with results
to Dr. [**Last Name (STitle) **] at phone: [**Telephone/Fax (1) 7477**] fax: [**Telephone/Fax (1) 12227**]
Discharge Disposition:
Home With Service
Facility:
Greater [**Location (un) 1468**] VNA
Discharge Diagnosis:
ST Elevation myocardial infarction
Acute Kidney Injury
dyslipidemia
diabetes mellitus type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had some dizziness and weakness at home and was admitted to
[**Hospital1 18**]. Your ECG and echocardiogram showed changes that were
consistant with a heart attack. A cardiac catheterization showed
you had 2 blockages in your left anterior descending artery that
were opened with 2 bare metal stents. These stents will remain
in your arteries forever but there is an increased risk over the
next month that they could clot off and cause another heart
attack. Therefore, it is critically important that you take
aspirin 325 mg and Plavix every day for the next month to
prevent a blood clot. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking
Plavix unless Dr. [**Last Name (STitle) **] says it is OK. You also developed
atrial fibrillation with a rapid heart rate. This rate was
controlled with digoxin and amiodarone. The atrial fibrillation
means that you are at an increased risk of stroke. Warfarin
(coumadin) was started to help prevent a stroke. You will need
to have your warfarin level (called an INR test) frequently to
make sure it is not too high or too low. The goal INR is
2.0-3.0. Your next INR check will be [**7-14**].
.
We made the following changes to your medicines:
1. Increase the plavix frequency to every day for at least one
month as noted above
2. Continue to take aspirin 325 mg daily
3. Change Atenolol to Metoprolol succinate to slow your heart
rate and help your heart recover from the heart attack
4. Increase the Lipitor to 80 mg daily for now to help your
heart recover
5. Decrease the Zestril to 2.5 mg daily. This may be increased
as your blood pressure rises
6. Start taking digoxin every other day to slow your heart rate.
7. Start taking amiodarone three times a day for one week for a
loading dose to slow the atrial fibrillation and hopefully
convert you in to a normal heart rhythm.
8. Hold metformin until after you see Dr. [**Last Name (STitle) **].
.
Your heart is weaker after the heart attack and you will need to
watch for fluid overload in the form of swelling or trouble
breathing. Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if
weight goes up more than 3 lbs in 1 day or 5 pounds in 3 days.
You received a varicella (shingles) vaccine on [**7-10**] to prevent a
shingles outbreak. You will need to have another injection in 1
month by Dr. [**Last Name (STitle) 27322**].
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 2191**] [**Name Initial (NameIs) **]. [**Last Name (un) 27323**]Date/Time:
Office will call you with an appt in [**Month (only) **]. Please call them if
you have not heard from them in a week.
Temporary PCP:
[**Telephone/Fax (1) 7477**] fax: [**Telephone/Fax (1) 12227**] Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**7-15**] at
9:30am.
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) **]CARDIOLOGY
Address: [**Location (un) **], 7TH FL, [**Location (un) **],[**Numeric Identifier 6422**]
Phone: [**Telephone/Fax (1) 5068**]
Appt: [**7-28**] at 3pm
Completed by:[**2167-7-13**]
|
[
"41071",
"5990",
"5849",
"42731",
"41401",
"4019",
"25000",
"2724",
"412",
"V4582"
] |
Admission Date: [**2190-2-3**] Discharge Date: [**2190-2-16**]
Date of Birth: [**2147-6-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2190-2-4**] Cardiac catheterization
[**2190-2-9**] Repair of anomalous right coronary artery from
pulmonary
artery by reimplantation into ascending aorta.
Repair of the pulmonary artery with a bovine
pericardial
patch
[**2190-2-9**] Mediastinal re-exploration for bleeding
[**2190-2-12**] Emergency mediastinal exploration for cardiac
tamponade and repair of tear in the acute marginal branch of the
right coronary artery induced by pacing wire removal
History of Present Illness:
42 year old male with history of polysubstance abuse and PTSD,
current smoker who presents with chest pain. He reports that
the chest pain started this morning at 2am. It was located in
the left anterior chest and radiated to his neck, not back. It
was severe [**6-30**] and lasted for approximately an hour. Nothing
seemed to make it better, no change with position or deep
inspiration. He sat up and rested for a while and eventually it
went away. He went to his PCP's office this morning and again
had chest pain. It developed while he was on the subway. It
was worse with walking around. He reported some associated
nausea, SOB and dizziness. His PCP did an EKG and was concerned
re: STE in V2 & V3; unfortunately, this EKG was not sent with
the patient to the ED. He was given aspirin 325mg and NTG at
PCP's office with no relief of CP per patient. The chest pain
did not go away until he was in the ED and got some morphine.
Of note, patient reports that his last cocaine use was 4 days
prior to admission
Past Medical History:
Polysubstance abuse, most recent crack cocaine use was 1.5
months ago
History of Depression and PTSD
Social History:
works in landscaping
lives with girlfriend
[**Name (NI) 1139**] history: currently smokes [**11-22**] PPD
ETOH: currently drinks 1 beer/day
Illicit drugs: cocaine, last used 4 days ago.
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T= 97.5 BP= 124/39 HR= 53 RR= 16 O2 sat= 98% ra.
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 6 cm.
CARDIAC: CP reproducible when palpating on the left sternal
border. PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: radial, DP 2+
Left: radial, DP 2+
Pertinent Results:
ADMISSION LABS
[**2190-2-3**] 02:01PM BLOOD WBC-5.1 RBC-4.59* Hgb-14.4 Hct-42.2
MCV-92 MCH-31.3 MCHC-34.1 RDW-12.7 Plt Ct-198
[**2190-2-3**] 02:01PM BLOOD Neuts-71.9* Lymphs-21.0 Monos-3.1 Eos-3.5
Baso-0.6
[**2190-2-3**] 02:01PM BLOOD PT-13.6* PTT-28.0 INR(PT)-1.2*
[**2190-2-3**] 02:01PM BLOOD Glucose-94 UreaN-11 Creat-1.2 Na-136
K-5.3* Cl-103 HCO3-26 AnGap-12
[**2190-2-4**] 07:45AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-139
K-3.7 Cl-104 HCO3-27 AnGap-12
.
DRUG SCREEN
[**2190-2-4**] 12:17AM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-POS amphetm-NEG mthdone-NEG
.
CARDIAC ENZYMES
[**2190-2-3**] 02:01PM BLOOD cTropnT-<0.01
[**2190-2-3**] 09:15PM BLOOD CK-MB-10 MB Indx-4.3 cTropnT-0.12*
[**2190-2-4**] 07:45AM BLOOD CK-MB-2 cTropnT-<0.01
.
IMAGING
Coronary CT [**2190-2-3**]
Structure and Function
The myocardium appeared to have homogenous signal intensity
without evidence of abnormal perfusion. The pericardial
thickness was normal. The diameters of the ascending and
descending thoracic aorta were normal. The main pulmonary artery
diameter was normal. The left atrial AP dimension was mildly
increased.
The left ventricular end-diastolic dimension was moderately
increased. The
end-diastolic volume was moderately increased. The calculated
left ventricular ejection fraction was normal at 65% with normal
regional systolic function. The anteroseptal and inferolateral
wall thicknesses were normal. The left ventricular mass was
normal.
.
Coronary Imaging
CT coronary angiography revealed an anomalous origin of a
dominant right
coronary artery from the pulmonary artery. The right coronary
artery was
increased in size but not aneurismal. The origin and orientation
of the left main coronary artery was normal. The left main was
increased in size but not aneurismal. The left main trifurcated
into the LAD, LCx and ramus intermedius without evidence of
disease. The LAD was increased in size but not aneurismal, with
large septal branches and multiple bridging collaterals to the
right coronary artery. The LAD had 1 diagonal branch and was
free of disease. The LCx had 1 OM branch and was free of
disease. The calcium score was 0.
.
Additional Findings
Please see the separate chest CT report for any additional
findings.
.
Impression:
1. Moderately increased left ventricular cavity size with normal
regional left ventricular systolic function. The LVEF was normal
at 65%.
2. The diameters of the ascending and descending thoracic aorta
were normal. The main pulmonary artery diameter was normal.
3. Mild left atrial enlargement.
4. Anomalous right coronary artery arising from the pulmonary
artery. Normal origin and orientation of the left main, LAD and
LCx coronary arteries. Increased size of the left main and LAD
coronary arteries with abundant left to right bridging
collaterals. No evidence of CAD.
.
[**2190-2-15**] 09:54AM BLOOD Hct-26.8*
[**2190-2-15**] 05:46AM BLOOD WBC-7.3 RBC-2.58* Hgb-8.2* Hct-22.8*
MCV-89 MCH-32.0 MCHC-36.1* RDW-14.3 Plt Ct-231
[**2190-2-12**] 12:30PM BLOOD Neuts-80.9* Lymphs-13.0* Monos-4.3
Eos-1.4 Baso-0.3
[**2190-2-15**] 05:46AM BLOOD Plt Ct-231
[**2190-2-12**] 02:31PM BLOOD PT-13.4 PTT-26.6 INR(PT)-1.1
[**2190-2-15**] 05:46AM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-135
K-3.6 Cl-101 HCO3-29 AnGap-9
[**2190-2-10**] 12:39AM BLOOD ALT-44* AST-58* AlkPhos-43 Amylase-44
TotBili-0.6
[**2190-2-4**] 07:45AM BLOOD ALT-21 AST-24 LD(LDH)-132 CK(CPK)-157
AlkPhos-73 Amylase-77 TotBili-0.6
[**2190-2-4**] 07:45AM BLOOD CK-MB-2 cTropnT-<0.01
[**2190-2-10**] 12:39AM BLOOD Lipase-17
INDICATION: Reimplantation of right coronary artery,
postoperative day 6,
decreasing hematocrit.
COMPARISON: Radiographs dated back to [**2190-2-7**] and most recently
[**2190-2-14**].
FINDINGS: Right middle and lower lobe atelectasis, moderately
large right
pleural effusion, and moderate cardiomegaly are relatively
unchanged since
[**2190-2-14**]. Blunting of the left costodiaphragmatic angle is
consistent with
small pleural effusion. Median sternotomy wires and right
internal jugular
central venous catheter are unchanged.
IMPRESSION: Persistent right middle and right lower lobe
atelectasis and
moderately large right pleural effusion.
Brief Hospital Course:
Presented to emergency department with chest pain and dynamic
EKG changes. He underwent workup that revealed anomalous origin
of a dominant right coronary artery from the pulmonary artery
found on cardiac catheterization. Due to no coronary artery
disease the chest pain was considered possibly due to coronary
spasm with recent cocaine use, with positive toxicology screen.
He was referred for surgical intervention due to ongoing chest
pain assumed from anomalous right coronary artery. On [**2-9**] he
was brought to the operating room for replacement of RCA and
repair of PA with patch, see operative report for further
details. He was transferred to the intensive care unit for
postoperative management. He had increased chest tube output
and was taken back to the operating room for mediastinal
exploration, see operative report for further details. After
returning from operating room he improved and was weaned off
pressors over the next 24 hours. Additionally he was weaned
from sedation, awoke neurologically intact, and was extubated
without complications. He continued to progress and was
transferred to the floor on postoperative day two, however on
postoperative day three his epicardial wires were removed with
acute onset of chest pain and hypotension. Echocardiogram was
obtained which revealed right ventricular collapse and he was
transferred to the intensive care unit and then the operating
room for emergent mediastinal exploration, see operative report
for further details. He was weaned and extubated without
complications, and was monitored for bleeding. He continued to
progress clinically and was transferred to the floor two days
after exploration. Betablockers were stopped due to recent
cocaine use and risk for coronary spasm, and he was started on
cardiazem for rhythm management. He was ready for transfer to
[**Hospital1 **] on [**2-16**] with continued telemetry monitoring.
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety: reduced from 1 mg to 0.5 mg on
[**2-15**] please continue to titrate down and discontinue .
7. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain: last decreased from 4 mg to 2mg on
[**2-15**] - please continue to decrease and then discontinue .
8. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
9. white petrolatum-mineral oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for LE dry skin.
10. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
11. peripheral IV
right forearm - please flush per protocol
discharged with IV due to telemetry
12. bupropion HCl 150 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO QAM (once a day (in the
morning)): increase to twice a day [**2-19**].
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Anomalous origin of a dominant right coronary artery from the
pulmonary artery s/p replacement of RCA and repair of PA with
patch
Coronary spasm due to cocaine use
Post traumatic stress disorder
Polysubstance abuse
Depression
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with dilaudid prn
Anxiety managed with ativan prn
Smoking cessation wellbutrin
Incisions:
Sternal - healing well, no erythema or drainage
Edema - none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**First Name (STitle) **] [**Telephone/Fax (1) 170**] [**2190-2-22**] 1:15
Cardiologist: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] [**2190-3-15**] 9:20
Please call to schedule appointments with your
Primary Care Dr [**First Name (STitle) 31365**] in [**2-23**] weeks [**Telephone/Fax (1) 7976**]
**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:[**2190-2-16**]
|
[
"311",
"3051"
] |
Admission Date: [**2151-9-15**] [**Month/Day/Year **] Date: [**2151-9-22**]
Date of Birth: [**2071-2-19**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
80F w/ c/o abdominal pain and distension for 4 days prior
to presentation in ED of OSH. Unknown severity, quality,
location, radiation. Undocumented whether tender on initial
exam
but later on evaluation by gastroenterologist patient reported
no
pain. CT scan revealing distended/dilated small bowel and
stomach with SBO and lower abdominal wall hernia. Unable to
pass
NGT (from esophageal tortuosity?). Decision made to place NGT
under endoscopic assistance given prior paraesophageal hernia
repair. For this she required intubation and her DNR order was
rescinded after discussion with her husband. She was electively
intubated and an EGD performed with decompression of the stomach
and 1L of gastric liquid contents aspirated. Also noted large
amount of fluid in distal esophagus with tortuous esophagus and
difficult to intubated GE junction. An NGT was placed under
direct vision in the stomach and the patient was then tranferred
to [**Hospital1 18**] for further management.
Past Medical History:
Past Medical History: Paraesophageal hernia, spinal stenosis,
osteoporosis, chronic LBP, chronic constipation, chronic
leukocytosis, CHF with diastolic dysfunction, idiopathic
pulmonary fibrosis, COPD, Htn, GERD, depression, HTN, h/o PNA,
h/o lyme disease, insomnia, former chronic steroid use
Past Surgical History: Paraesophageal hernia repair
(laparoscopic repair with toupet fundoplication and [**Last Name (un) **]
gastroplasty) [**2-20**], csection
Social History:
Married lives with husband. [**Name (NI) **] history of tobacco or ETOH
Family History:
non-contributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
Temp:98.1 HR:115->90s BP:114/60 Resp:18
O(2)Sat:100 on FiO2 1.0 on vent CMV setting
GEN: Intubated, sedated
HEENT: No scleral icterus, mucus membranes moist, NGT with
serosanguinous drainage turning to bilious later
CV: RRR/tachycardic
PULM: Coarse b/l
ABD: Soft, distended and tympanytic, some wincing with
palpation,
no obvious rebound or guarding, positive bowel sounds, no
palpable masses, soft and easily reducible lower abdominal wall
hernia
DRE: decreased tone, very small stool in vault, guaiac negative
Ext: Trace UE/LE edema, Feet cool b/l but pink with 3-4s cap
refill
Pertinent Results:
[**2151-9-15**] 03:53PM GLUCOSE-85 UREA N-10 CREAT-0.5 SODIUM-137
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-27 ANION GAP-9
[**2151-9-15**] 03:53PM CALCIUM-8.2* PHOSPHATE-2.8 MAGNESIUM-2.1
[**2151-9-15**] 02:58AM CK(CPK)-63
[**2151-9-15**] 02:58AM CK-MB-6 cTropnT-0.03*
[**2151-9-15**] 02:58AM CALCIUM-7.8* PHOSPHATE-2.6* MAGNESIUM-1.7
[**2151-9-15**] 02:58AM WBC-8.1 RBC-4.64 HGB-12.6 HCT-40.0 MCV-86
MCH-27.1 MCHC-31.4 RDW-16.9*
[**2151-9-15**] 02:58AM PLT COUNT-353
[**2151-9-14**] 09:26PM ALT(SGPT)-10 AST(SGOT)-17 ALK PHOS-44 TOT
BILI-0.7
[**2151-9-14**] 09:26PM cTropnT-0.02*
[**2151-9-14**] 09:26PM PT-13.0 PTT-35.0 INR(PT)-1.1
[**2151-9-14**] 09:26PM PLT COUNT-284
IMAGING:
[**9-14**] CXR: Endotracheal tube and nasogastric tube in standard
positions. Low inspiratory lung volumes with increased
interstitial markings bilaterally, right greater than left,
which is suggestive of underlying chronic lung disease. There is
likely atelectasis as well in both lung bases.
[**9-14**] CT abdomen (from OSH): unable to load, CD in chart
[**9-15**]: CXR-Pulmonary edema resolving, low lung volumes.
Brief Hospital Course:
She was admitted to the ACS and transferred to the Trauma ICU.
She remained vented, sedated and on pressors to maintain her
blood pressure. Her NG was placed to suction. She was extubated,
her pressors were weaned and on the second hospital day she was
transferred to the regular nursing unit. The Pulmonary team was
made aware that she was in house as she is followed by Dr.
[**Last Name (STitle) 2168**] for her IPF.
She was continued NPO for another 1-2 days along with
maintenance IVF. It was reported that her NG accidentally fell
out; the decision to not replace it was made. She was eventually
started on sips and advanced to clear liquids, then to a regular
diet for which she is tolerating.
She was evaluated by Physical therapy and is being recommended
for rehab after her acute hospital stay. At the time of
[**Last Name (STitle) **] she was tolerating a regular diet, out of bed, and
voiding.
Medications on Admission:
(on list from OSH): Alendronate 70mg qwk, Aspirin 81mg qday,
colace 100mg [**Hospital1 **], Arixtra 2.5mg SQ Qday, Lopressor 12.5mg [**Hospital1 **],
Protonix 40mg Qday, Zoloft 200mg Qday, Miralax, Trazodone 50mg
qhs, calcium 500mg [**Hospital1 **], Vitamin D 1000mg [**Hospital1 **], Fentanyl patch
25mcg/TD q3d, KCL 20mEQ qday, percocet q4h prn
(Another list from OSH documents): dulcolax pr prn qday, zofran
PO q8h prn, ativan 0.5mg q6h prn, MOM 30ml daily prn, atrovent
inh q6h prn, albuterol q6h prn, effexor XR 150mg po daily,
percocet q4h prn, colace 100mg [**Hospital1 **], Vitamin D 1000mg [**Hospital1 **],
Miralax
17grams qday, KCL 40mEq daily, Protonix 40mg Qday, Arixtra 2.5mg
SQ Qday, trazodone 50mg qhs, ritalin 5mg [**Hospital1 **], lopressor 12.5mg
[**Hospital1 **], Tums 500mg [**Hospital1 **], tylenol prn, compazine 25mg [**Hospital1 **] prn,
fosamax
70mg Qwk, aspirin 81mg daily, fentanyl patch q72hr
[**Hospital1 **] Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
3. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for Constipation.
6. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML
PO twice a day as needed for constipation.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours).
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for SBP>110 or HR<60 .
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 57850**] Healthcare Center - [**Location (un) **]
[**Location (un) **] Diagnosis:
Small bowel obstruction
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Location (un) **] Instructions:
You were hospitalized because of an obstruction in your bowels.
A special tube called a nasogastric tube was placed through your
nose an into your stomach in order to suction out extra
contents/fluids. over the course of your hsoptial stay your
bowel function returned and the obstruction resolved on it's own
without any operations.
Followup Instructions:
Follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab; you or your family will need to call for an appointment.
For any concerns related to your recent bowel obstruction you
may contact the [**Hospital 2536**] clinic to determine if you needto be seen;
the clinic number is [**Telephone/Fax (1) 600**].
|
[
"5990",
"4280",
"4019",
"496",
"53081",
"311"
] |
Admission Date: [**2169-12-26**] Discharge Date: [**2170-1-6**]
Date of Birth: [**2110-5-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Central Venous Line
Arterial Line
Lumbar Puncture
Intubation
Extubation
Hemodialysis
History of Present Illness:
59 year old male with ESRD on HD, dilated
cardiomyopathy, DM, HTN, ETOH abuse presents with respiratory
distress. Per the family, this evening he began to have
nausea/vomtiing, diaphoresis, chest discomfort and shortness of
breath. The shortness of breath/Chest pain came on relatively
suddenly; the family subsequently called EMS. On arrival EMS
noted him to be in respiratory distress,SBP 190s and
diaphoretic. The notes show that the monitior showed ?
elevations; SPO2 52% and put on NRB and then he became
bradycardic, PEA arrested; ventilated him and he regained
pulses, pulses regained en route to hospital. He was taken to
[**Hospital3 **], IO line placed en route. He was intubated on
arrival, found to have K of 8.1, received Ca
Gluconate/D50/insulin/sodium bicarbonate, 100mg IV lasix, and
started on nitro gtt for hypertension (SBP 200s). ABG was
7.04/64/118/17. He was subsequently transferred to [**Hospital1 18**] ED.
Upon arrival his vitals were 95.6 HR 80 BP 163/92 RR 21. An EKG
showed widening QRS (118) with peaked T waves. He was given
additional calcium gluconate 2mg,1 amp sodium bicarbonate, D50,
10U regular insulin, kayexlate 30g. He was continued on nitro
gtt for BP control in ED briefly for hypertension. CXR was done
which showed ET tube in the correct position as well as
pulmonary edema. His WBC was elevated at 30, blood cultures were
sent and Vancomycin/Zosyn were given. Renal was called for
urgent HD.
.
On arrival, pt sedated and intubated, unable to obtain further
history.
.
.
Past Medical History:
DM- no on insulin
ESRD on HD
HTN- on 2 meds unknown
Dilated cardiomyopathy
Left bundle branch block
Normal Cardiac Cath [**2164**]
Anxiety
Depression
Social History:
+1.5ppd, uses oxycodone daily, denies illicits or IVDA, history
of ETOH use
Lives with wife
Family History:
NC
Physical Exam:
GENERAL: Sedated and intubated
HEENT: Pupils are pinpoint, sclera anicteric, ET tube in place
CARDIAC: RRR, no murmurs appreciated
LUNG: Crackles bilaterally
ABDOMEN: Soft, NT, ND +BS throughout
EXT: Perfused, no edema
NEURO: sedated, unable to assess fully
Pertinent Results:
==================
ADMISSION LABS
==================
[**2169-12-26**] 12:34AM BLOOD WBC-31.5* RBC-4.20* Hgb-13.9* Hct-42.0
MCV-100* MCH-33.0* MCHC-33.0 RDW-13.9 Plt Ct-338
[**2169-12-26**] 12:34AM BLOOD Neuts-90* Bands-0 Lymphs-7* Monos-1*
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2169-12-26**] 12:34AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2169-12-26**] 12:34AM BLOOD PT-12.0 PTT-28.6 INR(PT)-1.0
[**2169-12-26**] 12:34AM BLOOD Glucose-90 UreaN-73* Creat-11.0* Na-141
K-8.8* Cl-103 HCO3-19* AnGap-28*
[**2169-12-26**] 12:34AM BLOOD ALT-43* AST-52* CK(CPK)-105 AlkPhos-115
[**2169-12-26**] 12:34AM BLOOD cTropnT-0.02*
[**2169-12-26**] 12:34AM BLOOD Albumin-4.1 Calcium-11.2* Mg-2.3
[**2169-12-26**] 03:23AM BLOOD Type-ART pO2-271* pCO2-43 pH-7.30*
calTCO2-22 Base XS--4 Comment-GREEN TOP
[**2169-12-26**] 12:34AM BLOOD Lactate-2.6*
[**2169-12-26**] 03:23AM BLOOD freeCa-1.38*
CHEST X-RAY: ([**2169-12-26**] 12:22 AM)
FINDINGS: An endotracheal tube is seen with tip positioned 4.4
cm above the level of the carina and a nasogastric tube is seen
with sideport and tip coursing below the diaphragm. Severe
bilateral air space consolidation has a generally symmetric
perihilar distribution, with interstitial abnormality,
consisting of thick septal lines and possible micronodulation,
at its periphery. There is no mediastinal venous engorgement,
cardiomegaly, or pleural effusion. The descending pulmonary
arteries are normal caliber; but the margins of the upper poles
of both hila are obscured by adjacent abnormal lung and could
[**Hospital1 **] adenopathy, particularly the left.
IMPRESSION: Although severe pulmonary consolidation and
interstitial
abnormality should be treated as largely or at least partially,
edema, the
absence of other features of heart failure, and the presence of
micronodularity, and possible hilar adenopathy, raise multiple
other
possiblities, including extensive malignancy, pneumonia and
pulmonary
hemorrhage. Repeat radiographs should be obtained after
treatment for
presumptive edema, and, if abnormalities persist, CT scanning
would be more definitive then.
.
ECHO [**2169-12-28**]
The left atrium is moderately dilated. Left ventricular systolic
function is hyperdynamic (EF 70-80%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. There is no pericardial effusion.
.
MRI head [**12-29**]:
IMPRESSION: No evidence of acute infarct, mass effect, or
hydrocephalus
identified.
.
[**1-1**] CXR:
Indwelling devices remain in standard position, and
cardiomediastinal contours are stable in appearance. Lungs are
clear except
for minimal patchy opacity in the left retrocardiac area, likely
atelectasis.
.
[**1-6**] ECG:
Sinus bradycardia. Left axis deviation. Left bundle-branch
block. Poor R wave
progression in the anterior precordial leads likely normal
variant. Compared to
the previous tracing of [**2170-1-5**] the findings are similar.
.
Discharge labs:
Hct 30.1
WBC 10.5
Cr 7.5
K 4.0
Brief Hospital Course:
59 yo male with DM, ESRD on HD, dilated cardiomyopathy & HTN
presented to OSH for shortness of breath and found to have
hyperkalemia with QRS changes, hypertension and pulmonary edema,
successfully weaned overnight however with persistant agitation
and hypertension
#Agitation- Patient persistantly agitated once extubated and off
of sedation, he was requiring large amounts of haldol; and in
order to better evaluate his mental status with imaging he was
reintubated and sedated. Per pts PCP he takes 30mg oxycodone at
home per day. Unclear if agitation due to withdrawal from
opiates given strong ETOH/? Drug abuse history. Other ddx may
include stroke vs viral encephalopathy. Patients family
interviewed again, have not found any evidence of other
substance use. Other Ddx considerations include embolic
phenomena from atrial fibrillation of unknown duration,
encephalitis (viral), withdrawal, etc. A CT head was negative. A
Lumbar Puncture was alsonegative. MRI done also without
evidence of anoxic brain injury or other acute pathology.
Psychiatry was consulted; sedation was changed from propofol to
Precedex. He was initially treated with Haldol for agitation
been changed to zyprexa after QT was prolonged to 500.
Acyclovir was given empirically pending HSV PCR. Patient
extubated on [**1-1**] with significant improvement in mental status
however with persitently high requirement; psychiatry was
consulted. He was changed to zyprexa for agitation and this
improved over the course of his stay. On the floor, held all
mood-altering agents and saw patient's agitation resolve. Likely
[**12-26**] anoxia s/p PEA arrest, plus medication-induced (multiple
high-dose antipsychotics and sedative given in ICU) plus ICU
delirium; needed time for meds to clear and mental status to
clear. Resolved. Disorientation improved.
.
#Respiratory Distress-Initially most likely due to volume
overload and pulmonary edema in setting of malignant
hypertension and missing HD session. Now intubated for airway
protection and agitation. Vent settings at minimum. He was
treated for pneumonia with positive sputum cultures with
Vanc/zosyn. On the floor, improved respiratory status.
# ESRD/Hyperkalemia ?????? Resolved now. On presentation Presumed [**12-26**]
to patient missing HD session over the weekend. His EKG was
consistent with hyperkalemia; widened QRS and peaked T waves. He
was initially treated with Ca gluconate, insulin, kalexlate and
bicarbonate followed by urgent dialysis in the ICU. His
potassium improved and EKG changes improved as well. Renal
continued to follow and he received HD per protocal. He was
started on Phoslo.
#Low Grade [**Name (NI) 59639**] Initially pt had low grade temp, presumed [**12-26**]
pneumonia seen on CXR. His sputum was growing 1+ GP cocci in
pairs/chains/clusters and 1+ GP rods. Blood cultures NGTD and
C.Diff neg. Overnight low grade 99.9.
-Continue vanc/zosyn to complete 8 day course (complete on [**1-2**])
# s/p PEA [**Name (NI) 59640**] Unclear if patient truly had PEA arrest;
documented that he lost pulse briefly but no CPR was done; pt
given supplemental Oxygen/NRB and pulses regained without
intervention. PEA documented at 2204 this evening. Differential
includes hyperkalemia vs hypoxia (pulmary edema/respiratory
distress) vs cardiac (initial symptoms of Chest pain, EKG
changes). 3 sets of cardiac enzymes negative. Not clear events
that occurred.
# Atrial fibrillation: Noted during agitation overnight, not
documented to have this in the past. Pt does have h/o dilated
cardiomyopathy. ECHO showed hyperdynamic EF 70% otherwise was
unrevealing. Previous Cardiac cath in [**2164**] without evidence of
coronary disease. Pt was started on PO diltiazem with diltiazem
gtt; this was subsequently weaned off and po meds in place
instead. Apparently appears to go into afib when getting HD but
then resolves.
# [**Name (NI) 12329**] Pt with hypertensive urgency at OSH on nitro gtt; now
weaned off; not clear if combination of medication
non-compliance and/or missing HD session. On multiple
medications to treat HTN.
# Normocytic anemia, w/large RDW: perhaps [**12-26**] renal disease, or
nutritional deficiency. Perhaps mixed picture.
# ESRD on HD - regular HD sessions resumed.
# Eosinophilia: resolved. unclear etiology. perhaps
medication-induced.
Medications on Admission:
unknown by patient:
home meds, per [**Location (un) **] HD: ([**Telephone/Fax (1) 59641**]:
amlodipine 5mg daily
ASA 81mg daily
levothyroxine 75 mcg daily
lorazepam 1mg daily prn
metoclopramide one tab tid
nadolol 40mg daily
omeprazole 20mg daily
prochlorperazine 10mg daily
tums 500mg tid with meals
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. Sevelamer Carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
4. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
8. Compazine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for nausea.
9. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- PEA arrest secondary to hyperkalemia.
- Acute diastolic heart failure
- Agitated delirium
- Paroxysmal atrial fibrillation
- Haldol related QTc prolongation
- Diabetes mellitus type II
Secondary:
- CKD stage IV on hemodialysis
- Alcohol related cardiomyopathy (resolved)
- Left bundle branch block
- Hypertension
- Hypothyroidism
- Anemia of chronic kidney disease
- Chronic low back pain
Discharge Condition:
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Mental Status: Alert and oriented x3. Appropriate.
Discharge Instructions:
You were admitted to the hospital with respiratory distress.
This was felt to be due to fluid volume overload as a result of
having missed a dialysis session. Your potassium was also
extremely high and was affecting your heart's conduction system,
also because of having missed dialysis. With fluid removal and
correction of your electrolytes through dialysis, these issues
resolved. Prior to arriving at our hospital, your heart was
reported to have stopped beating, likely secondary to the low
oxygen level you were experiencing due to fluid overload. This
did not re-occur once your respiratory status improved. You also
suffered from agitation and disorientation while in the ICU,
likely secondary to the brain's loss of oxygen before arrival at
the hospital. Once medications to help with agitation washed out
of your system, and you were back on a regular dialysis
schedule, your agitation and disorientation improved. Your heart
rhythm had an irregularity to it likely secondary to medications
given to you in the ICU - we monitored your heart rhythm closely
to ensure your safety.
.
Please call your doctor or return to the hospital if you develop
chest pain, lightheadedness, shortness of breath, chest
palpitations, or other symptoms that concern you.
.
It is very important that you go to all your regularly-scheduled
hemodialysis sessions.
.
We made the following changes to your medications:
We STOPPED the following medications: Lorazepam, Reglan
(Metoclopramide), and TUMS
We STARTED the following medications: Clonidine for blood
pressure and Sevelamer to bind phosphate instead of TUMS.
Nicotine patch to help you quit smoking.
We INCREASED the doses of the following medications: Aspirin and
Amlodipine.
Followup Instructions:
It is very important that you go to all your regularly-scheduled
hemodialysis sessions (Tuesday, Thursday, Saturday).
.
We recommend that you see your primary care doctor in the next
week. Please call Dr.[**Name (NI) 29049**] office to arrange an appointment
([**Telephone/Fax (1) 18203**]). You will need to discuss the risk and benefits
of taking blood thinner medications for your atrial fibrillation
with your doctor.
Please follow up with your nephrologist, Dr. [**First Name (STitle) **] at you dialysis
session on Tuesday. Please call to arrange an appointment.
Completed by:[**2170-2-19**]
|
[
"51881",
"5070",
"40391",
"2762",
"2767",
"4280",
"25000",
"42731"
] |
Admission Date: [**2198-11-18**] Discharge Date: [**2198-11-27**]
Date of Birth: [**2144-10-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ativan / Amoxicillin / Bactrim / Codeine / ibuprofen / Lamictal
/ naproxen / Tetanus Toxoid,Fluid / Cephalexin / Peanuts / Sulfa
(Sulfonamide Antibiotics) / golytely / citrate of magnesia /
Lithium
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Post tracheostomy and tracheostenosis.
Major Surgical or Invasive Procedure:
1. Cervical tracheal resection and reconstruction.
2. Flexible bronchoscopy with bronchoalveolar lavage.
History of Present Illness:
54F with ESRD [**2-7**] lithium toxicity s/p trach for prolonged
respiratory failure (happened [**2198-5-15**]) secondary to hyponatremic
seizure (pt was undergoing prep for colonoscopy as part of a
renal transplant workup, became hyponatremic and
started seizing), complicated by tracheal stenosis requiring
tracheostomy. Additionally, she later had a T tube placed at
[**Hospital1 18**] which failed 4 days later. She has been at [**Hospital **] Rehab
hospital recently where she was receiving ongoing antibiotics in
preparation for her upcoming surgery, per report. She was
recently transitioned from Peritoneal [**Hospital 2286**] to HD through a R
IJ tunneled catheter because of a line infection. Recently
completed AB course for VRE UTI. She is now s/p tracheal
resection and reconstruction
Past Medical History:
PMH: tracheostomy [**5-/2198**] for prolonged respiratory failure,
hyponatremic seizure following GoLytely prep [**5-/2198**], ESRD for
lithium toxicity, on HD, bipolar, GERD, HTN, breast cancer,
diverticulosis
PSH: parathyroidectomy with reimplantation in left arm, left
foot surgery in [**2180**], right knee surgery in [**2191**], lumpectomy for
breast cancer (DCIS), status post radiation, repeat mammograms
were all negative, history of tonsillectomy in the past.
Social History:
- Tobacco: Never
- Alcohol: Previously occasionally
- Illicits: Denies
Family History:
Mother with ovarian CA
Father with CAD
Physical Exam:
PE on discharge:
VS: 98.4, 92, 147/94, 18, 96% RA
GEN: NAD, AOx3
CV: RRR, nl s1 and s2
PULM: CTA b/l, no resp distress. Incision on neck c/d/i. No
erythema. no crepitus, normal voice and cough
ABD: Soft, NT, ND, + BS, dry skin in abd folds,
Back: mild erythematous area (2x3 cm) on saccrum
EXT: No c/c/e.
Pertinent Results:
[**2198-11-18**] 04:50PM BLOOD WBC-17.0*# RBC-3.34* Hgb-10.2* Hct-31.9*
MCV-96 MCH-30.6 MCHC-31.9 RDW-15.5 Plt Ct-155
[**2198-11-19**] 03:39AM BLOOD WBC-16.3* RBC-3.08* Hgb-9.3* Hct-29.4*
MCV-96 MCH-30.3 MCHC-31.7 RDW-15.5 Plt Ct-148*
[**2198-11-25**] 11:47AM BLOOD WBC-9.4 RBC-2.41* Hgb-7.4* Hct-22.8*
MCV-95 MCH-30.9 MCHC-32.6 RDW-15.5 Plt Ct-232
[**2198-11-18**] 04:50PM BLOOD Glucose-94 UreaN-33* Creat-6.5*# Na-131*
K-5.1 Cl-100 HCO3-22 AnGap-14
[**2198-11-19**] 03:39AM BLOOD Glucose-85 UreaN-36* Creat-7.2* Na-131*
K-5.4* Cl-100 HCO3-23 AnGap-13
[**2198-11-25**] 11:47AM BLOOD Glucose-84 UreaN-28* Creat-5.6*# Na-131*
K-4.7 Cl-94* HCO3-35* AnGap-7*
[**2198-11-18**] 04:50PM BLOOD Lithium-1.2
[**2198-11-19**] 06:26PM BLOOD Lithium-1.1
CXR [**2198-11-21**]
In comparison with the study of [**11-19**], there is continued
substantial enlargement of the cardiac silhouette with
double-lumen catheter in place. Continued low lung volumes. Mild
engorgement of pulmonary vessels is consistent with
overhydration. The left hemidiaphragm is better seen than
on the previous study, though there are still some atelectatic
changes in the retrocardiac region.
Bronchoscopy [**2198-11-26**]:
54 year old female with a history of tracheostomy placement for
prolonged respiratory failure secondary to hyponatremic seizure,
complicated by tracheal stenosis now s/p cervical tracheal
resection/ reconstruction. Flexible bronchoscopy performed to
evaluate anastomotic site post-operatively. Patient with
hypoxemia during procedure requiring mask ventilation.
Subsequently the procedure was well tolerated. The vocal cords
appeared normal. The tracheal anastomotic site was visualized
and was noted to have fibrinous exudate with mild residual focal
tracheomalacia. The distal airways were visualized to the
subsegmental level and were patent and normal in appearance. The
bronchoscope was subsequently removed. Following the procedure,
the suture maintaining neck flexion was removed.
Brief Hospital Course:
The patient was admitted to the thoracic surgery service on
[**2198-11-18**] and had the following procedures: 1. Cervical tracheal
resection and reconstruction 2. Flexible bronchoscopy with
bronchoalveolar lavage. There were no complications and the
patient tolerated the procedures well. She was transferred to
the TICU while intubated and sedated. She was extubated later
that day. She remained somnolent for a day after and was slowly
weaned off her O2 requirements. Foley was removed POD 1. Pureed
diet and soft food introduced POD 2 and J tube was removed POD
2. She was transferred to the floor on POD 3.
Neuro: Post-operatively, the patient received Dilaudid IV/PCA
with good effect and adequate pain control. On POD 2, the
patient was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. She was extubated in the
ICU the evening after surgery with no complications.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. Her diet was advanced on POD 2 to thin
liquids and purred diet, which was tolerated well. She was also
started on a bowel regimen to encourage bowel movement. Foley
was removed on POD#1. Intake and output were closely monitored.
She was closely followed by the HD team while inpatient and
underwent several HD treatments while in the hospital to treat
her on going renal failure.
ID: Post-operatively, the patient's temperature was closely
watched for signs of infection. She spiked low grade fevers on
POD 2 and 3. A full work up revealed no obvious causes for the
temperatures and the pt remained a febrile thereafter.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD 5, the patient was doing well,
afebrile with stable vital signs, tolerating a regular soft
diet, ambulating, voiding without assistance, and pain was well
controlled. She went home with VNA and outpatient [**Date Range 2286**] set
up.
Medications on Admission:
ATENOLOL 25', CALCIUM ACETATE 667 3 cap w meals, EPOETIN ALFA
25,000qweek, ERGOCALCIFEROL 20,000qmonth, FLUOXETINE 20',
LITHIUM CARBONATE 150" [**Hospital1 **] aim for level of 7, NIFEDIPINE 60 mg
2tab qam 1tab qpm, OLANZAPINE 10', OMEPRAZOLE 20", TOPIRAMATE -
25qhs, VIT B CPLX #11-FA-C-BIOT-ZINC 1mg', DOCUSATE SODIUM -
100", FERROUS SULFATE - 325"
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. topiramate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
3. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal DAILY
(Daily) as needed for hemorrhoids.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
7. 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*
8. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for Dry eyes.
9. lithium carbonate 150 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
10. olanzapine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
11. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
12. nifedipine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO qAM.
Disp:*60 Tablet Extended Release(s)* Refills:*0*
13. nifedipine 60 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO qPM.
Disp:*30 Tablet Extended Release(s)* Refills:*0*
14. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1)
PO BID (2 times a day).
15. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-7**] Sprays Nasal
QID (4 times a day) as needed for NASAL CONGESTION.
Disp:*1 Bottle* Refills:*0*
16. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
18. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/head ache.
Disp:*30 Tablet(s)* Refills:*2*
19. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
20. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
21. olanzapine 5 mg Tablet Sig: One (1) Tablet PO BEFORE HD PRN
() as needed for anxiety.
Disp:*15 Tablet(s)* Refills:*0*
22. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for fungal infection: Apply to areas
under pannus with rash/irritation. .
Disp:*1 Tube* Refills:*0*
23. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Post tracheostomy and tracheostenosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the thoracic surgery service for tracheal
reconstruction. Please call Dr.[**Name (NI) 2347**] office
[**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough or chest pain
-neck incision develops drainage
-No Driving for 1 month
-No lifting greater than 10 pounds
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No lotions, creams, powder or ointment to incision
Pain
-Acetaminophen 650 mg every 6 hours as needed for pain
-Hydromorphone ??? 2 mg every 4-6 hours as needed for pain
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed. Please take the prescribed
analgesic medications as needed. You may not drive or heavy
machinery while taking narcotic analgesic medications. You may
also take acetaminophen (Tylenol) as directed, but do not exceed
4000 mg in one day. Please get plenty of rest, continue to walk
several times per day, and drink adequate amounts of fluids.
Avoid strenuous physical activity and refrain from heavy lifting
greater than 20 lbs., until you follow-up with your surgeon, who
will instruct you further regarding activity restrictions.
Please also follow-up with your primary care physician.
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-Walk 4-5 times a day for 10-15 minutes increase to a Goal of 30
minutes daily
Followup Instructions:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2198-11-28**]
7:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2198-12-18**]
9:00
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2198-12-18**] 10:00
--> Please arrive 30 minutes before appointment with Dr. [**Last Name (STitle) **]
to have a chest X-ray.
Completed by:[**2198-11-27**]
|
[
"40391",
"2859",
"53081"
] |
Admission Date: [**2147-7-21**] Discharge Date: [**2147-8-5**]
Date of Birth: [**2147-7-21**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 48422**] was born at 34 and
6/7 weeks gestation to a 32-year-old gravida 1, para 0 (now
1) woman. The mother's prenatal screens were blood type O+,
antibody negative, rubella immune, RPR nonreactive, hepatitis
surface antigen negative, and group B strep unknown.
DELIVERY COURSE: The mother's pregnancy was complicated by
chronic hypertension and hypothyroidism. She was treated with
the medications labetalol and levothyroxine. The delivery was
induced for evolving pregnancy-induced hypertension. Rupture
of membranes occurred 8 hours prior to delivery. The mother
did receive antepartum antibiotics. The infant delivered by
spontaneous vaginal delivery. Apgar's were 8 at one minute
and 8 at nine minutes.
The birth weight was [**2111**] grams, the birth length was 42 cm,
and the birth head circumference was 29.5 cm.
PHYSICAL EXAMINATION: Revealed a vigorous preterm infant
with mild respiratory distress. Anterior fontanel open and
flat. Intact palate. Breath sounds course with minimal
aeration. Mild grunting. Heart was regular in rate and
rhythm. No murmur. Femoral pulses present. Abdomen was soft,
nontender, nondistended. No masses. Normal female genitalia.
Patent anus. Moving all extremities.
NEONATAL INTENSIVE CARE UNIT COURSE BY SYSTEMS:
1. RESPIRATORY STATUS: [**Known lastname **] required nasopharyngeal
continuous positive airway pressure for the first 24
hours and then weaned to nasal cannula oxygen. She weaned
to room air on day of life #6 and has remained there. She
has had some apnea and bradycardia; her last episode
occurring on [**2147-7-30**].
On exam, her respirations are comfortable. Lung sounds are
clear and equal.
1. CARDIOVASCULAR STATUS: She has remained normotensive
throughout her NICU stay. She has a heart with a regular
rate and rhythm. No murmur. There are no cardiovascular
issues.
1. FLUIDS, ELECTROLYTES AND NUTRITION STATUS: Her weight at
discharge is 2185 grams. Enteral feeds were begun on day
of life #1 and advanced without difficulty to full-volume
feedings by day of life #5. At the time of discharge, she
is eating breast milk or 24-calorie per ounce formula on
an ad lib schedule.
1. GASTROINTESTINAL STATUS: She was treated with
phototherapy for hyperbilirubinemia of prematurity from
day of life #3 until day of life #5. Her peak bilirubin
occurred on day of life #3 and was total 9.1, direct 0.4.
Her last bilirubin on day of life #6 was total 6.3,
direct 0.4.
1. HEMATOLOGY: She has received no blood product
transfusions during this NICU stay. Her hematocrit at the
time of admission was 51.9; and a recheck on [**2147-8-3**] was 39.9.
1. INFECTIOUS DISEASE STATUS: She was started on ampicillin
and gentamicin at the time of admission for sepsis risk
factors. The antibiotics were discontinued after 72 hours
when the infant clinically well, and the blood culture
remained negative.
1. AUDIOLOGY: Hearing screening was performed with automated
auditory brain stem responses, and the infant passed in
both ears.
1. PSYCHOSOCIAL: The parents have been very involved in the
infant's care throughout her NICU stay.
CONDITION ON DISCHARGE: The infant is discharged in good
condition.
DISCHARGE DISPOSITION: She is discharged home with her
parents.
PRIMARY PEDIATRIC CARE: Will be provided by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of
[**Hospital 1475**] Pediatrics. Address: [**Street Address(2) 68011**], [**Location (un) 1475**], [**Numeric Identifier 68012**]. Telephone number is
([**Telephone/Fax (1) 68013**].
RECOMMENDATIONS AFTER DISCHARGE:
1. Feeding: Breast feeding. She will need some lactation
support and 24-calorie per ounce breast milk or formula
until weight gain permits a decrease in calories.
2. The infant is discharged on 2 medications:
1. Ferrous sulfate (25 mg/mL) 0.2 mL p.o. daily; to
provide 2 mg/kg/day of elemental iron.
2. Infant multivitamins 1 mL p.o. daily.
3. The infant passed a car seat position screening test.
4. A State screen was sent on [**2147-7-24**] and again on
[**2147-8-5**].
5. The infant received her first hepatitis B vaccine on [**8-1**].
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and 6/7 weeks gestation.
2. Status post mild transitional respiratory distress.
3. Sepsis ruled out.
4. Status post apnea of prematurity.
5. Status post hyperbilirubinemia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2147-8-5**] 03:41:23
T: [**2147-8-5**] 09:45:18
Job#: [**Job Number 68014**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2191-8-31**] Discharge Date: [**2191-9-5**]
Date of Birth: [**2139-3-6**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old
woman with diabetes for many years who uses an Insulin pump.
She reported dyspnea with activity over the past couple of
years without chest pain or pressure. She is from [**State 531**]
originally and had nuclear scan there which suggested normal
left ventricular function with mild anterior ischemia but no
infarction and was subsequently referred for catheterization
and possible intervention in [**State 531**].
Hemodynamically she was found to have left ventricular
pressure of 150 with an end diastolic pressure of 14 mmHg per
ventriculogram. Left ventricular pressure was 158 with an
end diastolic pressure of 17 mmHg post ventriculogram.
Aortic pressure was 156/67 with a mean of 98 mmHg. There
was no significant aortic valve gradient.
Left ventriculography showed that the patient had normal
contractility throughout. Ejection fraction was estimated to
be 65-70% with no mitral regurgitation seen.
Coronary angiography showed that the patient had right
dominant mildly diffuse calcification throughout her coronary
arteries. Her arteries were all relatively small in caliber.
Left anterior descending was a small vessel with severe
diffuse proximal to midvessel disease up to 90% stenosis.
The first diagonal branch was small with an 80% proximal
lesion.
She requested to be sent to [**Location (un) 86**] for her coronary artery
bypass grafting to be near where her diabetologist was. She
was thus admitted to [**Hospital6 256**] on
[**2191-8-31**], and referred for coronary artery bypass
grafting times two with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**].
PAST MEDICAL HISTORY: Diabetes mellitus; the patient uses an
Insulin pump. There is some question of asthma. Anemia.
Hypothyroidism. Chronic renal insufficiency.
ALLERGIES: SULFA, CAUSING TONGUE SWELLING.
FAMILY HISTORY: No significant family history.
SOCIAL HISTORY: Teacher. The patient lives with husband.
The patient quit tobacco 27 years ago. No alcohol. No
recreational drugs.
MEDICATIONS ON ADMISSION: Lisinopril 10 mg q.d., Naproxen
500 mg q.d., Synthroid 175 mcg q.d., Fluoxetine 20 mg q.d.,
Insulin pump, Calcium 1 g q.d., Vitamin B complex, Aspirin 81
mg, Imdur 30 mg q.d., Toprol XL 25 mg q.d., [**Doctor First Name **] D.
REVIEW OF SYSTEMS: The patient denied any recent illness.
She had no orthopnea. She has palpitations.
PHYSICAL EXAMINATION: Vital signs: Blood pressure 114/60 on
admission, heart rate 59. Lungs: Clear. Cardiovascular:
Regular, rate and rhythm. Normal S1 and S2. There was a
1-2/6 systolic ejection murmur over the left sternal border.
Extremities: Mild edema. There were 2+ pulses bilaterally
throughout.
HOSPITAL COURSE: The patient was then taken to the Operating
Room on [**2191-8-31**], with the diagnosis f coronary
artery disease and had a coronary artery bypass grafting
times two with LIMA to left anterior descending and saphenous
vein graft to ramus intermedius under general endotracheal
anesthesia by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1537**] and assistant [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 40734**].
Two chest tubes were placed, one mediastinal and one left
pleural. The patient was transferred to the unit on a
Propofol, Insulin, Neo-Synephrine and Nitroglycerin drip.
On postoperative day #1, the patient did extremely well, and
chest tubes were discontinued, and all drips were
discontinued except for Nitroglycerin drip for cardiac
protection.
[**Last Name (un) **] Diabetes continued to follow the patient for Insulin
pump management. The patient was started back on Imdur on
postoperative day #2, and all drips were discontinued.
Physical Therapy began to see the patient throughout the
hospital course until clearance for discharge. On
postoperative day #2, the patient was transferred to the
floor and did very well on the floor. The patient was
discharged on postoperative day #5 without event.
DISCHARGE MEDICATIONS: Colace 100 mg b.i.d., Aspirin 325 mg
q.d., Percocet [**12-9**] tab p.o. q.4-6 hours pain, Imdur 60 mg
p.o. q.d., Protonix 40 mg p.o. q.d., Lopressor 12.5 mg p.o.
b.i.d., Levoxyl 175 mcg p.o. q.d., Iron Complex, Vitamin C,
Multivitamin, Paxil 20 mg p.o. q.d., Lasix 20 mg q.d. x 1
week.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass grafting with incomplete revascularization.
2. Diabetes.
3. Chronic renal insufficiency.
FOLLOW-UP: The patient was instructed to follow-up with Dr.
[**Last Name (STitle) 40735**], primary care physician, [**Last Name (NamePattern4) **] [**12-9**] weeks, and with the
cardiologist in [**1-10**] weeks, with Dr. [**Last Name (STitle) 1537**] in three weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern4) 10197**]
MEDQUIST36
D: [**2191-9-5**] 09:33
T: [**2191-9-5**] 09:35
JOB#: [**Job Number 40736**]
|
[
"41401",
"2449"
] |
Admission Date: [**2169-5-13**] Discharge Date:
Service: MEDICINE
HISTORY OF THE PRESENT ILLNESS: This is a 79-year-old
[**Year (4 digits) 595**] female who is non-English speaking who has a history
of multiple medical problems including [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], CAD, breast
cancer, who presents to the ED with abdominal pain, nausea,
and vomiting. The patient has had this abdominal pain
chronically for many months. It is a sharp pain. She has
also had two episodes of vomiting. She denied blood in the
vomit. She denied bloody stools or tarry black stools. The
patient also describes chest pain, exertional, without any
associated shortness of breath, nausea, vomiting, or
diuresis. The pain the patient described in her stomach
feels like her "ulcer pain" and like "constipation".
Review of systems was positive for cough, weight loss of
25-35 pounds, night sweats, negative for fevers and chills
and diarrhea.
PAST MEDICAL HISTORY:
1. Status post CCY.
2. Status post appendectomy.
3. Sigmoid diverticulosis.
4. Hypertension.
5. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **].
6. History of CVA.
7. History of breast cancer, status post lumpectomy,
radiation, and Arimidex treatment with no negative
dissection.
8. History of CAD.
9. History of choledocholithiasis.
10. Status post TAH/BSO.
11. Status post inguinal hernia repair.
12. Status post left arm fracture.
13. History of lung nodules.
14. Mild AS. EF 55%.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Clonidine patch 0.2 q. week.
2. Toprol XL 100 b.i.d.
3. Lotrel.
4. HCTZ 12.5 q.d.
5. Zoloft 100 q.d.
6. Arimidex 1 q.d.
7. Hydrea 500 four times a week.
8. Aciphex 20 b.i.d.
9. Compazine 10 q. six hours p.r.n.
10. Meclizine 12.5 q. eight p.r.n.
11. Ativan 1 q. six hours p.r.n.
12. Tylenol #3 p.o. q. six hours p.r.n.
13. Tylenol 500 mg p.o. q. six hours p.r.n.
14. Nitroglycerin 0.4 sublingual p.r.n.
15. Lactulose.
16. Metamucil.
17. Senna.
18. Sucralfate 1 gram q.i.d.
19. Plavix 75 q.d.
20. Fluoxetine.
21. Cipro.
This medication list was compiled from the patient's doctor's
office and may include some medications that the patient is
not currently taking and by report of the patient's PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 100645**], the patient frequently does not take her medications.
SOCIAL HISTORY: The patient lives with her husband. She is
a nonsmoker, nondrinker. She has a son who lives in the area
as well as a daughter in [**Name (NI) 531**].
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
95.6, heart rate 74, blood pressure 187/80, 94% on room air,
respirations 19. General: She is a chronically ill
cachectic, elderly female moaning. HEENT: The oropharynx
was slightly erythematous. There were dry mucous membranes.
Cardiovascular: Regular rate and rhythm. There was a II/VI
systolic murmur in the left lower sternal border. Lungs:
Decreased at the left bases, crackles bilaterally. Abdomen:
Soft, nontender, hypoactive bowel sounds. No rebound
tenderness. Guaiac negative brown stool. Extremities: No
edema. Dorsalis pedis palpable.
LABORATORY/RADIOLOGIC DATA: Significant for a white count of
14.8, hematocrit 53.5 which is elevated for her but the
patient is chronically polycythemic from her [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],
platelets 798,000, 89.5 neutrophils, 7 lymphs, 0 monos.
Chem-7 was normal. The patient's initial CK was 21 and
troponin less than 0.01. The patient's LFTs were normal and
albumin was 4.8.
The patient's U/A did not show evidence of a urinary tract
infection.
The patient's chest x-ray showed left midzone
consolidation/collapse and a large left-sided pleural
effusion which is new from previous x-rays but has been seen
on x-rays here as recently as last year.
An EKG was sinus with right bundle branch block.
HOSPITAL COURSE: 1. ABNORMAL CHEST X-RAY: Given the
patient's nonspecific complaints and lack of further
information for the patient in the OMR secondary to a new MR
number being assigned in the ER, the patient underwent a CT
of the torso while in the ER. The CT demonstrated left upper
lobe with a dense consolidation as well as a small opacity,
1.7 by 1.2 cm in the right upper lobe as well as a large
left-sided pleural effusion and some small pretracheal nodes.
Abdomen and pelvis were within normal limits. Given this new
pleural effusion, the patient had a thoracentesis the night
of admission which demonstrated an exudative effusion with
600 white cells, 54 lymphs, 5 polys, 9 mesothelials, 29
macrophages, and 15,000 reds. The Gram's stain was negative
and the AFP was negative on direct smear.
Given the concern for possible tuberculosis infection, the
patient was placed on respiratory precautions the following
day. However, the patient's story was much much more
suspicious for a malignancy and indeed two days following
admission the cytology for the pleural fluid was positive for
adenocarcinoma, either metastatic from breast or new lung
adenoma CA. The patient had two negative AFB sputums and a
negative PPD and her respiratory precautions were
discontinued.
Oncology was consulted. At this time, they are awaiting
further stains to determine whether it is metastatic or lung
cancer as this will determine possibility of further
(palliative) treatment. On chest x-ray following the
thoracentesis, a small 10% apical pneumothorax was
demonstrated. Interventional Pulmonary was consulted. They
felt that the malignant effusion and pneumothorax warranted a
pleurex catheter with pleuroscopy and possible pleurodesis.
However, because the patient had been on Plavix, they would be
unable to do it for five to seven days. They did a bronchoscopy
with normal bronchi seen and no abnormalities on [**2169-5-18**].
The patient did have an oxygen requirement during her
hospital stay. The patient was 88% on [**4-6**] liters after the
revealing of the pneumothorax. The patient was placed on
100% nonrebreather. She was 100% on this. On room air, the
patient was approximately 88% oxygen saturation without
shortness of breath except on exertion.
2. CONGESTIVE HEART FAILURE: The patient, two days
following admission, became acutely more short of breath. An
ABG demonstrated respiratory acidosis and on examination, the
patient sounded wet and she was then diuresed 2 liters with
some improvement in her sats and symptoms. The patient was
continued to be diuresed as her daily chest x-rays revealed
worsening pulmonary edema, although no change in the apical
pneumothorax. Her oxygen saturations remained 92-94% on [**4-6**]
liters, 100% on 100% nonrebreather mask.
The patient did undergo a bedside echocardiogram in the
hospital which demonstrated diastolic dysfunction with a
normal EF and moderate aortic stenosis.
3. ABDOMINAL PAIN: Outside records were obtained from
[**Hospital 882**] Hospital which demonstrated that the patient had a
recent EGD with duodenal ulcer. Her stools had been Guaiac
negative. The patient was treated with Protonix and
sucralfate and this appeared to improve her symptoms
dramatically.
4. QUESTIONABLE PNEUMONIA: The patient did initially have a
white count on admission but no fever. She was started on
levo and Flagyl for a possible postobstructive pneumonia.
Her white count decreased. She should be continued on the
Levo and Flagyl for at least ten days and possibly until
after the interventional pulmonary procedure is completed.
5. ACUTE RENAL FAILURE: The patient initially was in acute
renal failure which was prerenal by electrolytes. She was
given some IV fluids but secondary to CHF, the patient was
encouraged to take p.o. Her creatinine did improve during
her hospital course.
6. POLYCYTHEMIA [**Doctor First Name **]: The patient was continued on her
Hydrea in-house.
7. CODE STATUS/END OF LIFE AND COMMUNICATION ISSUES: During
initial family meeting with the patient and her husband,
using a [**Name (NI) 595**] interpreter, the patient said that she did
not want to be intubated or resuscitated. However, after
calling the son to inform the whole family of the next cancer
diagnosis, the son insisted that the patient not be told
about her diagnosis. Ms. [**Known lastname 75607**] was directly questioned several
times, and seemed equivocal about knowing the results of her
tests. The patient also wanted to be at that time a full code.
DISPOSITION: Due to the fact that the patient is on Plavix
and it was discontinued on [**2169-5-18**], she will need five to
seven day stay before Interventional Pulmonary can do the
pleurodesis and pleuroscopy. Therefore, the patient will go
to an acute rehabilitation facility and then return and at
that time special stains that will diagnose the patient's
cancer will be available and treatment options can be
discussed as well as possible consultation with the
Palliative Care Service.
DISCHARGE DIAGNOSIS: Adenocarcinoma.
CONDITION ON DISCHARGE: Serious.
DISCHARGE MEDICATIONS:
1. Ceftriaxone 1 IV q. 24 hours.
2. Clonidine patch, one patch q. Saturday, 0.2.
3. Colace.
4. Subcutaneous heparin 5,000 q. eight.
5. Hydrea 500 q. Sunday, Tuesday, Thursday, and Saturday.
6. Flagyl 500 IV q. eight hours.
7. Lopressor 100 p.o. b.i.d.
8. Zyprexa 5 p.o. h.s.
9. Protonix 40 q.d.
10. Sucralfate 1 gram q.i.d.
11. Lasix 20 q.d.
DISCHARGE FOLLOW-UP: The patient is to follow-up with Dr.
[**First Name (STitle) **] [**Name (STitle) **] in the Interventional Pulmonary Clinic as well as
Dr. [**Last Name (STitle) **] who follows her polycythemia [**Doctor First Name **] and Dr. [**Last Name (STitle) **]
who has followed her for her breast cancer.
Addendum: Ms. [**Name14 (STitle) **] was admitted under the MR# [**Medical Record Number 100646**].
However, upon further inspection, it appears that her true MR#[**Medical Record Number **]is [**Medical Record Number 100647**] ([**First Name8 (NamePattern2) **] [**Known lastname 75607**]). Medical records is currently
investigating, and may need to merge the two records.
The remainder of her hospital course will be dictated in an
addendum.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 8141**]
MEDQUIST36
D: [**2169-5-18**] 03:58
T: [**2169-5-18**] 16:02
JOB#: [**Job Number 100648**]
|
[
"486",
"4280",
"5849"
] |
Admission Date: [**2170-5-3**] Discharge Date: [**2170-5-6**]
Date of Birth: [**2098-10-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Left thoracotomy with left ventricular epicardial
lead placement times 2 on [**5-3**]
History of Present Illness:
Mr. [**Known lastname 38315**] is a 71 year old man with cardiomyopathy and
extensive cardiac history listed below. He has been seeing his
cardiologist and [**Known lastname 1834**] LV mapping during which it was felt
he might benefit from biventricular pacing. In addition, his
current device is "low on battery." He has a baseline dyspnea
with low level exersion but not at rest.
Past Medical History:
1. MI/CAD (CABG x2; LIMA-ramus, SVG-LADm 28mm CE [**Doctor Last Name 405**] band
in [**10-22**])
2. CHF (ECHO [**12-13**] EF<20%)
3. pacer VVI DCCV for WCT
4. RF ablation for VTach
5. gout
6. HTN
7. hypothyroidism
8. TIA
9. recent bronchitis
10.PAF
Social History:
Mr. [**Known lastname 38315**] lives at home with his wife. [**Name (NI) **] is retired.
Family History:
non-contributory
Physical Exam:
Pulse: 60 Resp: 12 O2 sat: 100% RA
B/P Right artm 135/81 left arm 147/89
General: awake, alert, oriented
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]; healed sternotomy scar;
Heart: RRR [x] Irregular [] Murmur 3/6 systolic ejection
murmur
Abdomen: Soft [x] non-distended [x] non-tender [x]
+ bowel sounds;
Extremities: Warm [x], well-perfused [x]
no Edema, no Varicosities
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Carotid Bruit Right: no Left: no
Discharge
VS: 98.6 HR: 66-83 VP BP: 117-155/70-90 Sats: 100% RA
General: 71 year-old male in no apparent distress
HEENT: normocephalic
Card: RRR
Resp: clear breath sounds
GI: benign
Extr: warm no edema
Incision: Left axilla clean, dry intact
Neuro: awake,alert oriented.
Pertinent Results:
Date/Time: [**2170-5-3**] Test Type: TEE (Complete)
Left Ventricle - Septal Wall Thickness: *0.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *0.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *8.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 15% to 20% >= 55%
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four
pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Severely
dilated LV cavity. Severely depressed LVEF. LV dysnchrony is
present.
RIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV
free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).
Thickened MVR leaflets.. Moderate mitral annular calcification.
Moderate thickening of mitral valve chordae.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity is severely dilated. Overall left
ventricular systolic function is severely depressed (LVEF=15-20
%). Left ventricular dysnchrony is present. The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened . There is no aortic
valve stenosis. No aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The prosthetic mitral valve
leaflets are thickened. There is moderate thickening of the
mitral valve chordae. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is no pericardial effusion.
CXR:
[**2170-5-4**]:
FINDINGS: In comparison with the study of [**5-3**], there has been
removal of the endotracheal and nasogastric tubes. The Swan-Ganz
catheter also has been removed. Continued enlargement of the
cardiac silhouette without substantial vascular congestion. The
monitoring leads are otherwise intact. There has been
substantial clearing of the opacification in the region of the
aberrant nasogastric tube.
The left chest tube appears to have been removed. No evidence of
pneumothorax. Some subcutaneous gas is seen along the left
lateral chest
well.
Brief Hospital Course:
On [**5-3**] Mr. [**Known lastname 38315**] [**Last Name (Titles) 1834**] a lead placement. Please see the
operative note for details. He tolerated the procedure well and
was transferred in critical but stable condition to the surgical
intensive care unit. He was extubated and his chest tubes were
removed. He progressed well and was transferred to the step
down floor. [**Company 1543**] ICD interrogated with normal device
funtion. A 7 day course of antibiotics was started [**2170-5-4**].
He will follow-up in the Device clinic in 1 week. His warfarin
was restarted [**2170-5-5**] and he will follow-up with his PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 104795**] as an outpatient for further coumadin management.
Physical therapy saw him and deemed him safe for home. By
post-operative day 3 he was ready for discharge to home. All
follow-up appointments were advised.
Medications on Admission:
ALLOPURINOL 300 mg Tablet daily
DIGOXIN 125 mcg Tablet 3x/week - M, Wed, Fri
FUROSEMIDE 20 mg PRN (takes 1-2 times/week based on SOB)
LEVOTHYROXINE 100 mcg Q AM
LISINOPRIL 5 mg Tablet Q PM
TOPROL XL 50 mg Tablet alternating with 25 mg daily
SIMVASTATIN 40 mg daily
WARFARIN 2.5 mg Tablet daily - LD [**4-30**] - followed by [**Doctor Last Name 1270**]
ASPIRIN 81 mg Tablet daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO every other day alternate with
25 mg daily.
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
INR Goal 2.0-3.0.
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): take while taking narcotics.
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**2-21**]
hours as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
13. cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a
day for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
mitral regurgitation
Coronary Artery Disease s/p Anterior MI with LV aneurysm
Complete heart Block s/p Right sided PPM [**2137**]
VT ablation [**2153**]
ICD ([**Company **]) implant [**2164**] via left side with explant of right
PPM
Ischemic Cardiomyopathy and Congestive heart Failure (Systolic)
Atrial flutter s/p ablation [**2167**]
Atrial fibrillation on coumadin
Gout
Embolic CVA [**2137**] after boating accident
PSH
CABG/MVR (annuloplasty) [**2163**] complicated by Acute renal failure
TURP
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
No showering for 1 week or until in Device clinic.
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 5 pounds, pulling or pushing with your left
arm for 6 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**
Complete the 7 day antibiotic course.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2170-5-8**]
11:00
Please call for an appointment in [**1-19**] weeks
Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) **] call for a follow-up appointment
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 1270**] [**0-0-**] in [**2-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2.0-3.0
First draw: Wednesday
Results to Dr. [**Last Name (STitle) 1270**] [**0-0-**]. Fax: [**Telephone/Fax (1) 8474**]
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2170-5-8**]
11:00
Please call for an appointment in [**1-19**] weeks
Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) **] call for a follow-up appointment
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 1270**] [**0-0-**] in [**2-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2.0-3.0
First draw: Wednesday
Results to Dr. [**Last Name (STitle) 1270**] [**0-0-**]. Fax: [**Telephone/Fax (1) 8474**]
Completed by:[**2170-5-8**]
|
[
"4280",
"412",
"42731",
"2449",
"2859",
"V5861",
"V4581",
"V1582"
] |
Admission Date: [**2116-1-15**] Discharge Date: [**2116-1-19**]
Date of Birth: [**2036-3-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
1. Cardiac Catheterization with stent placement and angioplasty
History of Present Illness:
79 year old female with ANCA + vasculitis came into the ED after
experiencing a dull, non radiating SSCP at 9am this morning. The
patient thought that she strained a muscle while reaching for
something. Since the pain was persistent, she decided to call
her nephrologist who sent her to the [**Hospital1 18**] ED where she was
noted to have STE V2-V6, Q waves in V2-3, I and AVL. She was
started on ASA, Lopressor, heparin, integrilin, NTG and sent to
Cath lab. Denied SOB, diaphoresis, orthopnea, PND, LE edema.
Noted an episode of nausea.
On admission to ED, VS: 95.6; HR: 126; BP: 162/97; RR:16; 100%
on RA
Past Medical History:
ANCA + GN - Wegener's
HTN
Physical Exam:
PE on discharge:
Gen: AAO x 3; thin female in NAD
HEENT: (-) JVD
Heart: +s1+s2 Reg rhythm and rate
Lungs: CTA B/L No crackles or wheezing
Abd: +BS Soft NT ND
Ext: No pretibial edema. Extremities warm and well perfused x
4. No mottling. Good distal pulses.
Pertinent Results:
Cath [**1-15**]
- 2VD - 100% mid-LAD - > Cypher DES, 70% ostial stenosis of 1st
diagonal branch-> got PTCA
- LCx - diffuse disease with as much as 40% stenosis
- RCA - 40% prox, 80% mid
- R heart cath revealed elevated L sided filling P ,
- PCWP: 20mmHg, CO: 2.72L/min, CI: 1.72 L/min/m2
- RA: 4mmHg, PA: 33/16 (PA mean 24)
- RV: 43/5
.
ECHO: [**1-16**]:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (ejection fraction
30-40 percent) secondary to akinesis of the apex, and severe
hypokinesis of the anterior free wall and anterior septum; the
basal segments are hyperdynamic. Right ventricular chamber size
is normal. There is focal hypokinesis of the apical free wall of
the right ventricle. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**2-3**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior report (images
unavailable for review) of [**2114-2-8**], left ventricular
contractile function is significantly reduced.
Brief Hospital Course:
#Cardiac:
79 yar old female with AMI s/p DES for 70% mid LAD occlusion and
PTCA for stent obstruction of "jailed" diagonal. The
cathterization demonstrated elevated PCWP and RV pressure. Post
procedure ECHO showed an EF of 30-40% with 1-2+ MR, akinesis of
the apex, and severe hypokinesis of the anterior free wall and
anterior septum; the basal segments were hyperdynamic.
.
Patient tolerated the catheterization well. She did not
experience any subsequent episodes of chest pain while in house.
She was cleared by PT for return home.
.
- cont ASA as outpatient
- start plavix as outpatient for the newly placed stent
- started on toprol XL low dose and titrated up to 25mg daily on
discharge
- Losartan for remodeling and afterload reduction (was on [**Last Name (un) **] as
outpatient)
- discharged with statin
- was heparinized in anticipation for coumadin anticoagulation
as outpatient -> patient was started on warfarin as inpatient
and discharged home with 5mg daily of warfarin. Arrangements
were made to have patient's blood drawn by VNA and faxed to Dr. [**Name (NI) 26892**] office with subsequent monitoring/adjustment. Dr. [**Last Name (STitle) **]
was also contact[**Name (NI) **] with this information.
- Patient had a 3 point HCT drop in house, and was transfused
without any further Hct drops. This was likely related to blood
loss during cath. There was no change in stool color, no new
back pain or flank ecchymosis. No hypotension or tachycardia
accompanyied this event.
.
# CRI
- Patient's baseline Cr is 1.7-1.9. Hence meds were renally
dosed.
- She received mucormyst and bicarbonate after catheterization
.
# Low grade fever
- No clear evidence of infection or accompanying leukocytosis.
Cultures were negative. This may have been due to post MI
inflammation.
.
# FEN
- Patient was maintained on a heart healthy diet
.
# Dispo: PAtient was discharged home with VRN services. Her INR
would be monitored as above. She was instructed to make an
appointment with Dr.[**Name (NI) 26893**] office over the next 7-10 days in
order for Dr. [**Last Name (STitle) 26894**] to assess her new status post-MI and to help
her to manage her coumadin levels. In addition, she was given
the office number for Dr. [**Last Name (STitle) **] and instructed to make a follow
up appointment in the next 4 weeks for a follow up. She was
stressed the importance of only undertaking low stress
activities over the next few days post discharge.
Medications on Admission:
Cozaar 25mg daily
Imuran 25mg QOD
Fosamax 35mg weekly
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**2-3**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
5. Azathioprine 50 mg Tablet Sig: 0.5 Tablet PO Q48H (every 48
hours).
Disp:*20 Tablet(s)* Refills:*2*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Toprol XL 25 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*
9. FOSAMAX 35 mg Tablet Sig: One (1) Tablet PO once a week:
Resume taking this on your regularly scheduled day.
Disp:*4 Tablet(s)* Refills:*2*
10. Zantac 150 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary ARtery Disease
Discharge Condition:
AAOx3
Ambulating
Chest pain free
Breathing comfortably on room air.
Discharge Instructions:
Please call Dr. [**Last Name (STitle) 26895**] office, Dr.[**Name (NI) 26896**] office or come to
the emergency room if you develop chest pain, shortness of
breath, fast heart rates or any other concerning symptoms.
.
Weigh yourself every morning, call Dr. [**Last Name (STitle) 26894**] if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please take the medications listed on this discharge paperwork.
Followup Instructions:
You have had a major heart attack. As such, you need to be
closely monitored and followed up in the next few weeks.
.
You need to follow up with Dr. [**Last Name (STitle) **] - the cardiologist who saw
you in the hospital - within the next month. Please call his
office at [**Telephone/Fax (1) 4022**] to arrange an appointment at your
convenience in approximately 3-4 weeks.
.
Please call Dr. [**Last Name (STitle) 26895**] office at [**Telephone/Fax (1) 3329**] to set up an
appointment over the [**Last Name (un) 10128**] of the next 7-10 days. I have called
her office and am also going to email her regarding your
hospitalization and follow up.
.
You have the following pre-scheduled appointment for your kidney
disease:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2116-4-2**] 1:00
Completed by:[**2116-1-22**]
|
[
"41071",
"41401",
"4019",
"2859"
] |
Admission Date: [**2193-5-6**] Discharge Date: [**2193-5-11**]
Date of Birth: [**2127-2-14**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Occasional chest pain
Major Surgical or Invasive Procedure:
[**2193-5-6**] Three Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary to left anterior descending; vein
grafts to obtuse marginal and posterior descending artery.
History of Present Illness:
This is a 66 year old female with diabetes mellitus and
hypertension. She recently complained of intermittent left sided
chest pain for which she underwent an ETT which was suggestive
of ischemia. Subsequent cardiac catheterization in [**2193-3-16**]
was notable for severe three vessel disease and normal LV
function. Coronary angiography was notable for a right dominant
system with 80% lesion in the left anterior descending; 60-80%
stenoses in the circumflex, and 60% lesion in the right coronary
artery. LV gram showed an LVEF of 55% and no mitral
regurgitation. Based upon the above results, she was referred
for cardiac surgical intervention.
Past Medical History:
Coronary Artery Disease, Type II Diabetes Mellitus,
Hypertension, Hypothyroidism, Knee Pain, Right Breast Nodule
Social History:
Denies tobacco and ETOH. She lives with her husband. She is
retired.
Family History:
Brothers underwent CABG at ages 39 and 45. Mother with "enlarged
heart".
Physical Exam:
Vitals: BP 140-150/80-90s, HR 62, RR 13
General: well developed female in no acute distress
HEENT: oropharynx benign, PERRL
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: alert and oriented, CN 2-12 intact, nonfocal, gait steady
Pertinent Results:
[**2193-5-6**] 11:25AM BLOOD WBC-9.4# RBC-3.10*# Hgb-9.0* Hct-25.8*
MCV-83 MCH-28.9 MCHC-34.8 RDW-14.0 Plt Ct-108*#
[**2193-5-6**] 11:25AM BLOOD Plt Ct-108*#
[**2193-5-9**] 07:46AM BLOOD WBC-9.1 RBC-3.16* Hgb-9.3* Hct-26.5*
MCV-84 MCH-29.4 MCHC-35.0 RDW-15.0 Plt Ct-142*
[**2193-5-9**] 07:46AM BLOOD Plt Ct-142*
[**2193-5-7**] 02:43AM BLOOD Glucose-158* UreaN-18 Creat-0.7 Na-138
K-5.0 Cl-110* HCO3-19* AnGap-14
[**2193-5-10**] 07:20AM BLOOD Glucose-95 UreaN-17 Creat-0.6 Na-136
K-4.1 Cl-102 HCO3-25 AnGap-13
Brief Hospital Course:
On [**5-6**], Mrs. [**Known lastname **] was admitted and underwent three vessel
coronary artery bypass grafting by Dr. [**Last Name (STitle) 1290**]. The operation
was uneventful and she transferred to the CSRU for invasive
monitoring. Within 24 hours, she awoke neurologically intact and
was extubated. She maintained stable hemodynamics and weaned
from inotropic support without difficulty. On postoperative day
one, she transferred to the SDU. All chest tubes and pacing
wires were removed without complication. Of note, her
preoperative chest x-ray revealed a right breast mass which
warrants further work-up by mammogram, a breast surgery consult
was obtained. During her stay on the floor, gentle diuresis was
pursued and physical therapy assisted with mobilizing and
clearing for discharge on POD 5.
Medications on Admission:
Toprol XL 25 qd, Avandia 4 qd, Glipizide 5 qd, Levoxyl 100 mcg
qd, Fosamax, Aspirin 81 qd, Glucosamine, MVI, Calcium
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. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Rosiglitazone 8 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 5
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA
Discharge Diagnosis:
Coronary artery disease - s/p CABG; Diabetes mellitus type II;
Hypertension; Hypothyroidism, Right Breast Nodule
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.
[**Last Name (NamePattern4) 2138**]p Instructions:
Cardiac surgeon, Dr. [**Last Name (Prefixes) **] in [**3-20**] weeks. Call [**Telephone/Fax (1) 170**]
for an appointment.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8162**] in [**1-18**] weeks. Call for an appointment.
Local cardiologist, Dr. [**Last Name (STitle) 5874**] in [**1-18**] weeks. Call for an
appointment.
Breast Surgeon, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10656**]. Please call [**Doctor Last Name 1060**] (nurse
for Dr. [**Last Name (STitle) 10656**] on Tuesday [**5-14**] at [**Telephone/Fax (1) 66875**] for an
appointment, who will then assist you in scheduling an
appointment with radiology for a mammogram. Obtain copies of
any prior breast imaging (eg, mammograms) on film (not a CD),
with the reports, and bring them with you to the mammogram for
the radiologist to compare.
|
[
"41401",
"25000",
"2859",
"2449",
"4019",
"2720"
] |
Admission Date: [**2167-1-5**] Discharge Date: [**2167-1-9**]
Date of Birth: [**2117-1-14**] Sex: M
Service: MICU/BLOOM
Admitted to the Medical Intensive Care Unit then transferred
to the [**Hospital 48098**] Medical Service.
HISTORY OF PRESENT ILLNESS: This is a 49-year-old male with
a history of hepatitis C and alcoholic cirrhosis also with a
history of transjugular intrahepatic portosystemic shunt done
in [**5-/2166**] secondary to variceal bleeding who presents with
bright red blood per rectum times two episodes that "filled
the toilet." Patient reports lightheadedness as well. The
blood is mixed with brown stool. Patient complains of having
constipation for the previous two days and thus leading to
increased straining, which then resulted in the bloody stool.
In the Emergency Department the patient was hemodynamically
stable with a blood pressure of 108/56, pulse 91, hematocrit
28, and INR of 2.3. His baseline hematocrit is around 33 and
then three hours later his hematocrit dropped to 25. In
addition, he had recurrent episodes of bright red blood per
rectum while in the Emergency Department. He did not
tolerate nasogastric tube placement, thus did not undergo
nasogastric lavage. He was admitted to the Medical Intensive
Care Unit on [**2167-1-5**].
HIS MEDICAL INTENSIVE CARE UNIT COURSE: Transfused three
units of packed red blood cells and four units of fresh
frozen plasma. An EGD was performed as the most worrisome
cause of gastrointestinal bleeding in his case would be
recurrent gastric variceal bleeding. He was found to have
gastropathy and esophageal varices with no active bleeding.
Several varices were banded.
He had a right upper quadrant to evaluate TIPS which showed
stenosis and, thus, he underwent revision of his TIPS on
[**2167-1-7**]. In addition, he had alcohol-ablated varices
during his TIPS revision. He was started on Octreotide the
day before the TIPS.
PAST MEDICAL HISTORY:
1. Child's class C cirrhosis secondary to alcohol and
hepatitis C; on the transplant list.
2. Hepatitis C diagnosed in [**2159**].
3. Multiple upper gastrointestinal bleeds secondary to
varices.
4. Peptic ulcer disease.
5. TIPS in [**5-/2166**] with revision in [**5-/2166**] complicated by
local hepatic infarctions.
6. Known hemorrhoids.
7. Diabetes type 2.
8. Lumbar disc herniation.
HOME MEDICATIONS:
1. NPH, 22 units in the morning, 22 units at night.
2. Regular insulin, four units in the morning.
3. Ursodiol 600 mg two times a day.
4. Spironolactone 50 mg once a day.
5. Protonix 40 mg two times a day.
6. Lactulose one teaspoon three times a day.
7. Caltrate.
8. Mycelex troches, five, a day.
FAMILY HISTORY: Significant for his mother with diabetes and
his father with alcoholic cirrhosis. He died at the age of
68.
SOCIAL HISTORY: He lives with his mom, is unemployed, has a
history of smoking one pack per day times 20 years. Has now
weaned himself to a cigarette p.r.n. Denies current alcohol
use. Has a history of marijuana use and intravenous drug use
back in the '70s.
PHYSICAL EXAMINATION UPON TRANSFER TO THE FLOOR: Vital
signs: Temperature is 100.8, heart rate ranges from 81 to
100, blood pressure 104 to 131/31 to 62, breathing 20,
satting 95% on room air. Fingersticks are anywhere between
110 and 120 on a regular insulin sliding scale. In general,
he is in no acute distress, slightly jaundiced, answering
questions appropriately. HEENT is positive for scleral
icterus. Pupils equal, round, and reactive to light.
Extraocular muscles are intact. Clear oropharynx. Internal
jugular triple lumen in his right internal jugular. No
lymphadenopathy in his neck. Chest: He has spider
angiomata. His lungs are clear to auscultation bilaterally.
Cardiovascular: Regular rate and rhythm without murmur.
Abdomen: Positive bowel sounds; quite distended; nontender;
difficult to appreciate hepatosplenomegaly; positive fluid
wave; almost a tense belly but nontender. Extremities: A
very slight slap; has asterixis on the left; Pneumoboots in
place with trace pedal edema. Dorsalis pedis pulse is 2+
bilaterally. Cranial nerves II-XII intact. Strength 5/5
throughout. Sensation to light touch intact bilaterally.
Gait not tested, although later on patient is observed
walking up and down the hallways and does not have
difficulty.
LABORATORY DATA: This patient's hematocrit Nadired at 25 and
was 35 upon discharge. White blood cells were within normal
limits. Patient consistently had low platelets in the 40s to
50s range. INR was 2.3 upon admission and went down with
administration of fresh frozen plasma and one dose of vitamin
K but then went back up on the day of discharge. Chem-7
within normal limits and calcium 7.5 but corrected for the
low albumin. Phosphorous 3.3, magnesium 1.6. LFTs: ALT 82,
AST 143, alkaline phosphatase 187, amylase 75, total
bilirubin 9.4, albumin 2.0.
STUDIES: On [**2167-1-5**] EGD: Three cords of grade 2 varices
on the lower esophagus, banded. Portal hypertensive
gastropathy.
On [**2167-1-5**] right upper quadrant ultrasound showed ascites
with left portal vein thrombosis, TIPS stenosis, and
hepatopetal flow in the portal vein.
[**2167-1-7**] TIPS revision with embolization of varices
supplying the splenorenal shunt, enlarged gastric varices
with absolute alcohol. There was balloon angioplasty of the
TIPS and also a stent across the existing TIPS stent.
Pre-procedure portal hepatic gradient was 18 mm/Hg; post
procedure was 9 to 10 mm/Hg.
EKG on [**2167-1-5**] showed normal sinus rhythm, normal axis and
intervals, no ST-T wave changes or Qs. No changes compared
to 02/[**2165**].
HOSPITALIZATION COURSE: Please refer to the Medical
Intensive Care Unit course described above in the History of
Present Illness.
1. Bright red blood per rectum: The EGD revealed portal
gastropathy with no evidence of bleeding and had grade 2
esophageal varices times four with no bleeding. Varices were
banded. Right upper quadrant ultrasound revealed narrowing
of the TIPS, and thus patient underwent TIPS revision, as
described above. Right upper quadrant ultrasound on
[**2167-1-8**] showed wall-to-wall flow in the TIPS. Patient did
have episodes of melena on [**2167-1-6**] and [**2167-1-7**] although
no episodes of melena or bright red blood per rectum on the
day of discharge and the day prior to discharge.
He was kept on Sucralfate and proton pump inhibitor.
Hematocrits were checked two times a day and were stable as
of midnight the night prior to discharge through discharge.
He has a colonoscopy scheduled as an outpatient on [**2167-1-27**]
by Dr. [**Last Name (STitle) 497**].
Additionally, Nadolol was added on the day of discharge to
decrease portal hypertension, which may have led to bleeding
of the varices. It is unclear exactly what caused his bright
red blood per rectum at this time.
2. Anemia: Patient had no significant coronary artery
disease on recent exercise stress test and MIBI. He was
transfused for hematocrit less than 27. He was given a total
of five units of packed red blood cells and four units of
fresh frozen plasma. Hematocrit upon discharge was 35,
although this may reflect some hematoconcentration secondary
to beginning diuretics on the day of discharge.
3. Coagulopathy: INR of 2.3. He was transfused four units
of fresh frozen plasma and given vitamin K times one at the
beginning of his hospitalization course. His goal INR was
1.1 to 1.2 while bleeding.
4. Ascites: Spironolactone was held until his hematocrit
was stable. The patient did spike a temperature to 101.7 at
midnight on [**2167-1-8**]. Blood and urine cultures were sent,
and a chest x-ray was done, and a paracentesis was performed
on [**2167-1-8**] by ultrasound which showed 100 red blood cells.
This patient never displayed any mental status changes or
abdominal pain with the spike in his fever to suggest
spontaneous bacterial peritonitis.
Cultures at the time of discharge include no growth seen on
fluid culture of the peritoneal fluid. Blood cultures were
pending at the time of discharge. Urine culture showed mixed
bacterial flora consistent with scant anterogenital
contamination.
He was started on Nadolol, Aldactone, and Lasix on the day of
discharge.
5. Cirrhosis: Patient is on the transplant list and was
continued on his Lactulose and Clotrimazole troches.
6. Fluid, electrolytes, nutrition: He was transitioned to a
soft solids diet, [**Doctor First Name **] diet, low salt. His electrolytes were
followed closely. He was seen by Nutrition, which
recommended no supplements as of right now as his weight has
been unchanged over the past two months. Patient was
educated on dietary issue.
7. Diabetes: He was maintained on a regular insulin sliding
scale with two fingersticks while in house. He was informed
not to go back to his regular outpatient regimen of insulin
as it may be too much as it may lead to hypoglycemia. He has
a good understanding of diabetes and his diabetic regimen and
is followed at [**Last Name (un) **], and he checks his fingersticks four
times a day at home.
8. Lines: The patient had a right internal jugular triple
lumen which was needed for his TIPS revision and pulled on
[**2167-1-8**]. Good hemostasis was obtained, and the TIPS was
sent for culture, which is pending at the time of discharge.
DISCHARGE DIAGNOSES:
1. Gastrointestinal bleed.
2. Esophageal varices.
3. Hepatitis C.
4. Alcoholic cirrhosis.
5. Ascites.
6. Diabetes mellitus.
DISCHARGE INSTRUCTIONS:
1. He should check in with the transplant coordinator on
Monday, [**2167-1-12**].
2. He should have labs drawn on Monday, [**2167-1-12**], a CBC,
INR, LFTs, Chem-7, and fax those to [**Telephone/Fax (1) 697**].
3. Colonoscopy by Dr. [**Last Name (STitle) 497**] on [**2167-1-27**] at 10:30 a.m.
4. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22924**] on [**2167-2-4**] at 2 p.m.
5. Primary care physician with Dr. [**First Name (STitle) **] [**Name (STitle) **] on Friday,
[**2167-1-16**], at 1:30 p.m., [**Hospital Ward Name 23**], Sixth Floor.
6. Otorhinolaryngology appointment with Dr. [**First Name (STitle) **] on
[**2167-2-6**] at 8:45 a.m.
7. Dr. ................... at the [**Last Name (un) **] Diabetes Center
on [**2167-1-15**] at 2:30 p.m.
DISCHARGE CONDITION: Improved.
DISPOSITION: To home.
DISCHARGE MEDICATIONS:
1. Lactulose 10 grams/15 ml. He should take 38 ml. p.o.
four times a day, titrate to three to four loose stools a
day.
2. Ursodiol 600 mg two times a day.
3. Pantoprazole 40 mg two times a day.
4. Clotrimazole troches five times a day.
5. Sucralfate 1 gram four times a day.
6. Calcium carbonate 500 mg four times a day.
7. Nadolol 20 mg a day.
8. Spironolactone 100 mg a day.
9. Furosemide 40 mg a day.
10. Insulin regimen: He checks his fingersticks four times a
day, and based on his fingersticks and the rise of his
fingersticks, he will contact his [**Name (NI) **] physician for
changes in his regimen.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7619**]
Dictated By:[**Last Name (NamePattern1) 9789**]
MEDQUIST36
D: [**2167-1-9**] 16:32
T: [**2167-1-10**] 16:41
JOB#: [**Job Number 48099**]
cc:[**Name8 (MD) 48100**]
|
[
"2875",
"2851"
] |
Admission Date: [**2186-7-13**] Discharge Date: [**2186-7-24**]
Date of Birth: [**2186-7-13**] Sex: F
Service: Neonatology
HISTORY: This is a 34-5/7th week premature infant born to a
25-year-old G8, P 2-0-5-2 who presented with late prenatal
care. She presented in preterm labor and was found to have a
possible abruption and a second twin that was [**Last Name (LF) 53034**], [**First Name3 (LF) **] she
was brought for emergent cesarean section. This infant was
delivered second with spontaneous respirations with suction
and given blow-by. Apgars were 7 at 1 minute and 8 at 5
minutes.
The prenatal labs were O positive, Coombs negative, hepatitis
B negative, rubella immune, RPR nonreactive. The infant at
delivery had inspiratory crackles and grunting, flaring, and
retracting, and was admitted to the Newborn ICU and required
CPAP initially after delivery for increased work of breathing
and oxygen need. She also was started on ampicillin and
gentamicin at that time and a blood culture was done.
SUMMARY OF HOSPITAL COURSE:
Respiratory: The infant was initially started
on CPAP of 5 and required mild amounts of oxygen. She weaned
quickly over the first 12 hours off of CPAP to room air, from
which she stayed in room air for the rest of the
hospitalization. She never required any intubation or
surfactant, and did not exhibit any apnea or bradycardia of
prematurity.
Cardiovascularl: She has had no issues: no murmur and has had
normal blood pressures and pulses throughout her
hospitalization.
Fluids, electrolytes, and nutrition: She initially was made
n.p.o. and stared on D10W. She was started on p.o. feedings
on [**2186-7-16**] and advanced quickly by p.o. ad-lib schedule, and
she quickly took her full volumes by day of life 5. She
feeds well and was taking in 150 cc per kg of NeoSure 24. She
was started on caloric fortification on day of life 6 and
advanced to NeoSure 24 by day of life 7. Her discharge
weight is 2180 g (her admit weight was 2170 g).
GI: She had hyperbilirubinemia, which did not require
phototherapy and has started to go down on its own. The most
recent bilirubin was 7.8 on day of life 6.
Hematology: Her hematocrit on admission was 49.7. She did
not receive any transfusions.
Neurology: The infant had some jitteriness in the first
several days of life, which has gradually improved with time.
She is not quite as jittery as her sister, but certainly has
some. She did have a urine toxicology screen on admission,
which was negative, as did the mother, which was also
negative. She has not had any screening test or head
ultrasound, but will have early intervention follow-up.
Sensory: Audiology hearing screen was performed with
automated auditory brainstem responses and was normal. She
passed.
Ophthalmology exam was not required due to her gestational
age.
Psychosocial: [**Hospital1 18**] Social Work was involved with the
family, and she could be reached at [**Telephone/Fax (1) **]. Follow-up will
be provided by early intervention.
Infectious disease: The infant was initially ruled out for
sepsis with a blood culture and was found to not have
bacterial sepsis. She was initially started on ampicillin
and gentamicin for 48 hours and was then discontinued. She
has shown no signs of sepsis.
DISCHARGE CONDITION: The infant was stable at discharge.
DISCHARGE DISPOSITION: She was discharged to home with the
parents.
The primary pediatrician is Dr. [**Last Name (STitle) **] at [**Location (un) 669**]
Comprehensive Health.
CARE AND RECOMMENDATIONS: NeoSure 24 kcal per ounce
for 6 to 9 months for good growth. She is on no medications.
She did receive her newborn screening. She received her
hepatitis B immunization, and she is to follow up with her
pediatrician on [**2186-7-24**]. She will also have early
intervention follow-up and a nursing visit at home.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Rule out sepsis.
DR.[**First Name (STitle) **],[**First Name3 (LF) 36400**] 50-595
Dictated By:[**Last Name (NamePattern1) 57693**]
MEDQUIST36
D: [**2186-7-20**] 15:59:02
T: [**2186-7-20**] 20:00:51
Job#: [**Job Number 57694**]
|
[
"7742",
"V290",
"V053"
] |
Admission Date: [**2170-5-18**] Discharge Date: [**2170-5-30**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Lasix / Diazoxide /
hydrochlorothiazide / tripranavir / Probenecid
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
Fever and altered mental status
Major Surgical or Invasive Procedure:
Removal of right IJ line
History of Present Illness:
88 yo F with PAF, dementia, CHF, stage 4 sacral decub, IDDM, and
other medical issues went to OSH from nursing home with fever
and altered mental status today. She vomited 1x prior to
transfer to OSH, tachypneic with O2Sat down to 82% on 3L
(baseline 2L since [**Month (only) **]). It was thought she has a UTI and PNA
on CXR (bilateral increased reticular nodular interstitial
markings R>L). She became hypotensive with SBP in the 80s, but
there was no unit bed in the OSH. She was noted to fever up to
102.6F and tachycardia up to 130s. She received Zosyn and 2L
IVF with requirments of 4L O2 (on home oxygen). She was
transferred to [**Hospital1 18**].
.
Per HCP/son, patient has had 3 TIAs around [**Month (only) **] this year with
minimal residual deficit, although there is ? of left sided
weakness and swallowing problem. Since that time, a sacral
decubitus wound was noted and begin to get treated in [**Hospital **] rehab.
Her wound was debrided at [**Last Name (un) 27217**] in the beginning of [**Month (only) 958**]
with several days of ICU stay. Per family, she had + culture of
a very resistant bacteria that is not MRSA. She required 2 IV
antibiotics. Later, she was transferred to [**Hospital1 **] North for
long term care for her wound for a total of about 6 weeks. She
had wound vac and Foley catheter which is c/b frequent UTIs.
Later, she was transferred to Country Rehab, initially wound was
healing well, but found to have necrotic tissue, requiring
debridement again in [**Month (only) 116**]. Patient's mental status since [**Month (only) 116**] has
gradually deteriorated. She was able to meet with a lawyer to
work on her living will in the beginning of [**Month (only) 116**], but over the
last week, was confused about her name and her location.
.
On transfer, she got a 3rd L of IVF with improvement of SBP to
the 100s
.
In the ED, she was noted to be afebrile at 97.2, sinus
tachycardia up to 120s with BP 95/70, RR 30 on 94% 4L. Exam was
significant for sacral decubitus ulcer 10 cm with granulation
tissue on outer circumfirential segment with central necrotic
area. She was noted to have leukocytosis up to 32 and mildly
elevated LFTs. Coagulatons were normal. Lactate...after 3L
normalized. CXR suggests interstitial and alveolar process.
Per report, she received vancomycin and Flagyl, for concern of
C. diff given leukocytosis, diarrhea, and recent Abx. However,
only flagyl was noted on ED chart. SBP improved to 100 after 3L
IVF, but then dropped again to the 80s, so Levophed was started
through PIV first. She got RIJ CVL. CVP improved from 5-> [**7-27**]
after 4L, SvO2 90s. Prior to transfer, T 97.6 (temporal), 98
NSR, BP 102/62 (72), RR 27, O2Sat 97% 4L on 0.05 mcg/kg/min
norepinephrine.
.
On the floor, patient reports not feeling very well, threw up 1x
this morning and has been having diarrhea but could not tell
when it started. Denies pain currently.
Past Medical History:
- PAF
- IDDM
- dementia
- h/o TIAs/CVA [**1-/2170**] without deficit
- stage 4 sacral decub
- h/o cellulitis
- osteomyelitis- rx with ertapenem 1g IV qd and daptomycin 440
mg iv qd (to be complete on [**4-14**] per note from [**Hospital 27217**]
Hospital)
- hypothyroidism
- CAD
- HTN
- CHF, per report, normal EF 70% in [**Hospital3 **] ([**First Name8 (NamePattern2) **] [**Hospital 27217**]
Hospital note)
- spinal stenosis
- hypercholesterolemia
- osteoarthritis
- BPPV
- h/o duodenal ulcer with bleed [**1-/2170**]
- h/o gallstones
- h/o bile duct obstruction
- parotid gland mass
- s/p bilateral total hip replacements
- s/p TAH
Social History:
- lived independently prior to TIAs in 2/[**2169**]. Per report, was
working part-time and driving until then.
- never smoked
- rare EtOH
- no drugs
Family History:
- non-contributory
Physical Exam:
VITAL SIGNS - BP 128/65 mmHg, HR 92 BPM, RR 19, O2-sat 98% on 4L
GENERAL - lying on the right, appropriate, pale skin
HEENT - PERRLA, mucous membrane dry, OP clear
NECK - supple, no JVD, RIJ in place
LUNGS - dependent crackles on the right and diminished lung
sound, clearer on the left but + crackles, no wheeze or rhonchi,
no accessory muscle use
HEART - borderline tachycardia, unable to appreciate any m/r/g
ABDOMEN - soft, diminished bowel sound, non-distended, but
diffused tenderness, no mass, no HSM, no rebound
EXTREMITIES - warm, dry, no cyanosis/clubbing/edema, 2+ DP and
radial pulses bilaterally
SKIN - deep ulcerated area in the sacrum, tendon/bone are
visible, no purulent drainage
NEURO - alert, awake, oriented to [**Last Name (LF) 86**], [**2170-5-17**], CNs
II-XII grossly intact,
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation. Non
papilledema on fundoscopic exam. Extraocular movements intact
bilaterally, no nystagmus. Sensation intact V1- V3. Facial
movement symmetric. Hearing decreased to finger rub bilaterally,
L>R.
Palate elevation symmetrical. Sternocleidomastoid and trapezius
normal bilaterally. Tongue midline, movements intact.
Pertinent Results:
1. Labs on admission:
[**2170-5-18**] 08:43AM BLOOD WBC-32.0* RBC-4.81 Hgb-13.8 Hct-41.0
MCV-85 MCH-28.7 MCHC-33.7 RDW-16.4* Plt Ct-299
[**2170-5-18**] 08:43AM BLOOD Neuts-91* Bands-2 Lymphs-6* Monos-0 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2170-5-18**] 08:43AM BLOOD PT-12.4 PTT-27.2 INR(PT)-1.0
[**2170-5-18**] 08:43AM BLOOD Glucose-205* UreaN-32* Creat-0.8 Na-134
K-4.8 Cl-99 HCO3-21* AnGap-19
[**2170-5-18**] 08:43AM BLOOD ALT-32 AST-56* LD(LDH)-251* AlkPhos-131*
TotBili-0.4
[**2170-5-18**] 08:43AM BLOOD Lipase-17
[**2170-5-19**] 03:25AM BLOOD proBNP-[**2112**]*
[**2170-5-18**] 08:43AM BLOOD Albumin-2.4* Calcium-8.5 Phos-3.1 Mg-1.5*
[**2170-5-18**] 08:43AM BLOOD CRP-193.6*
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2170-5-30**] 06:25 9.0 3.86* 10.8* 32.7* 85 27.9 32.9 16.4* 369
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2170-5-30**] 06:25 [**Telephone/Fax (2) 88563**] 3.7 95* 38* 11
.
DIscharge labs:
**** MICROBIOLOGY ****
[**2170-5-22**] 3:14 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT [**2170-5-25**]**
Respiratory Viral Culture (Final [**2170-5-25**]):
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 [**2170-5-23**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
.
[**2170-5-18**] 8:50 am BLOOD CULTURE SETS #1 and #2.
**FINAL REPORT [**2170-5-21**]**
Blood Culture, Routine (Final [**2170-5-21**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 4 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
Anaerobic Bottle Gram Stain (Final [**2170-5-19**]):
Reported to and read back by DR. [**Last Name (STitle) **]. [**Doctor Last Name **] ON [**2170-5-19**] AT
0520.
GRAM POSITIVE COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2170-5-19**]):
GRAM POSITIVE COCCI IN CLUSTERS.
.
MRSA screen positive ([**2170-5-18**])
Urine culture negative ([**2170-5-18**])
Blood cultures negative on [**2170-5-19**], NGTD on [**2170-5-20**]
Urine legionella negative ([**2170-5-18**])
C diff toxin negative ([**2170-5-21**])and [**2170-5-27**]
.
[**2170-5-20**] 6:46 pm SWAB Source: decubitus ulcer.
**FINAL REPORT [**2170-5-23**]**
GRAM STAIN (Final [**2170-5-21**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2170-5-23**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
.
**** IMAGING ****
CXR ([**2170-5-19**]): In comparison with the study of [**6-17**], there are
lower lung volumes. Continued enlargement of the cardiac
silhouette with pulmonary vascular congestion. The possibility
of supervening pneumonia in the right perihilar or the left
lower lung zone would have to be considered in the appropriate
clinical setting. Marked displacement of the lower cervical
trachea to the right wrist is consistent with a large thyroid
mass.
.
Abdomen plain film ([**2170-5-18**]): No previous images. Bowel gas
pattern is essentially within normal limits with no evidence of
obstruction. Ill-defined opacification in the left upper zone
could conceivably lie within the upper pole of the kidney. Of
incidental note are total hip arthroplasties bilaterally.
.
CT ABD & PELVIS W/O CONTRAST Study Date of [**2170-5-21**] 1:13 PM
OSSEOUS STRUCTURES: The patient is status post bilateral total
hip
arthroplasties. No lytic or sclerotic focus concerning for
osseous malignant process is seen. Mild degenerative changes are
noted in the lumbar spine. Mild height loss is seen in the T9
vertebral body which is likely chronic, direct comparisons are
not available. Sacral decubitus ulcer is noted with loss of
tissue along the midline overlying the coccyx.
.
IMPRESSION:
1. Sacral decubitus ulcer with soft tissue thickening/fluid in
the presacral space.
2. Small hiatal hernia.
3. Diverticulosis without evidence of diverticulitis.
.
CT chest w/o contrast [**2170-5-21**]:
1. Cardiomegaly, with extensive coronary vascular calcification,
in conjunction with bilateral pleural effusions and diffuse
interstitial and bronchovascular thickening, all likely
reflecting congestive failure with hydrostatic edema. This
proces is asymmetrically worse on the right, which may reflect
asymmetric pulmonary edema or superimposed pneumonia. In the
absence of more remote radiographs or CT scans for comparison,
follow up radiographs are recommended to ensure resolution. If
this process fails to clear, dedicated HRCT may be helpful to
exclude progressive lung diseases such as chronic interstitial
fibrosis or lymphangitic carcinomatosis.
2. Numerous prominent mediastinal and hilar lymph nodes, most
likely reactive.
3. Large peripherally calcified hypoattenuating left thyroid
nodule.
.
TTE (Complete) Done [**2170-5-21**] at 2:32:50 PM
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is severe
mitral annular calcification. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
.
MRI PELVIS W/O CONTRAST Study Date of [**2170-5-24**] 8:52 PM
MPRESSION:
1. Markedly limited evaluation secondary to patient motion.
2. Edema of the inferior sacrum and coccyx. Per discussion with
the
referring physician, [**Name10 (NameIs) **] ulcer probes to bone and the findings
are concerning for osteomyelitis. Unchanged large amount of
presacral edema.
.
CHEST (PORTABLE AP) Study Date of [**2170-5-24**] 11:20 AM
IMPRESSION: Marked improvement of congestive pattern, not
completely
eliminated, no new discrete pulmonary processes.
Brief Hospital Course:
88 yo F with diabetes, chronic stage 4 sacral decubitus,
osteomyelitis, dementia, CHF, and other medical issues found to
have fever and AMS, admitted to [**Hospital Unit Name 153**] for unstable hemodynamics.
.
#. Septic Shock, bacteremia: On admission, patient had high
fevers, hypotension (SBP 80s), tachycardia, and altered mental
status. Source was thought to be most likely sacral decubitus
wound [**Hospital Unit Name 2**] and pneumonia. UA was underwhelming. History of
diarrhea and high leukocytosis was concerning for C. Diff.
Patient initially treated with linezolid + meropenem (history of
VRE wound [**Hospital Unit Name 2**]) and IV flagyl + po vancomcyin. The latter
two were stopped after patient had no diarrhea, and C diff toxin
was negative. CXR was concerning for pulmonary edema but could
not exclude pneumonia. KUB negative for bowel obstruction.
Patient was on Levophed very transiently but then was
hemodynamically for the remainder of the ICU stay. Mental status
improved and was at baseline per family. After sepsis, she was
treated for pneumonia, bacteremia, and soft tissue [**Hospital Unit Name 2**]
with linezolid (given history of VRE) and meropenem. Linezolid
was later changed to vancomycin, given that VRE was not highly
suspected, and she remained stable on vancomycin and meropenem.
She should remain on these for AT LEAST of 14 days (not to be
stopped prior to ID appointment on [**2170-6-14**]), to treat presumed
deep soft tissue [**Date Range 2**]. Osteomyelitis could not be ruled in,
but she will be followed as an outpatient to determine whether a
longer course should be warranted.
.
#. Dyspnea, hypoxemia-acute diastolic heart failure- Per family,
patient did not have oxygen requirement prior to her stroke in
[**1-26**] and subsequent rehab/hospital stays. Initially on 4L but
weaned to 2-3 liters prior to transfer to floor. TTE from OSH
showed LVEF >70% (1+MR). However her chest imaging, including CT
was consistent with volume overload. TTE was repeated with
normal EF, but it was thought that she was in acute on chronic
diastolic heart failure. Her oxygen requirements improved during
diuresis. Pneumonia was also considered, but this was broadly
treated by her antibiotics above. She did not produce any sputum
for culture, and her respiratory viral culture and screen were
negative. Of note, there was some question that she may have
developing ILD, given that she had no O2 requirement prior to
her recent hospitalization and rehab months ago. CT showed no
evidence of ILD, but the proper study would be a HRCT. On
discharge her oxygen requirement was weaned to 2.2L. Her
clinical exam was consistent with improved but some residual
pulmonary edema plus likely dependent atelectasis, given
crackles only in lower midlungs. She was encouraged to use
incentive spirometry. Pt should continue diuresis with a goal of
-500 to 1L daily until oxygen is able to be titrated to off. Pt
diureses well to 20mg IV. Weight on discharge bed scale
145.4lbs.
.
#. Stage 4 decubitus wound, question of osteomyelitis: Tendon
and bone are visible by visual exam. Likely has chronic
osteomyelitis given depth of her wound and by history. Routine
wound care provided. Albumin low at 2.4 which inhibits wound
healing. Patient was advanced to soft diet once mental status
improved; nutritional supplements were added to promote wound
healing. Her sacral wound area was evaluated by both CT and MRI.
Both showed some soft tissue swelling, but no drainable fluid
collection. MRI showed marrow edema, which could be consistent
with osteomyelitis, but this was uninformative given previous
osteomyelitis. Bone biopsy was considered later in her
hospitalization, but it was thought that the risks of the
procedure did not outweight the diagnostic yield, given that she
was on antibiotics. Although our wound culture did not grow
much; we obtained outside hospital records when she first
presented, which showed abundant MRSA and abundant fecal flora.
See above for antibiotic regimen. She received pain control,
including tylenol and prn oxycodone. Near discharge, a wound
vacuum was initiated to improve healing. Further wound care can
be continued at rehab facility. ESR 89, CRP 27.1
.
#. Diabetes mellitus: Metformin was held and patient placed on
insulin sliding scale. Long-standing insulin was also started
for basal control. Pt may resume her home metformin therapy upon
discharge as well as continue glargine and insulin sliding scale
if needed.
.
#. Tachycardia: She had persistent sinus tachycardia following
her ICU stay. This improved and resolved.
.
#. Hypothyroidism: Continued on home levothyroxine.
.
#. Normocytic anemia was likely due to acute on chronic illness.
It was stable on monitoring, and her stools were guaiac
negative.
.
#. History of TIA with PAF: She was continued on aspirin. She
can consider restarting coumadin as outpt (was apparently d/c'd
in setting of hip surgery [**9-29**] y/a). She was started on
metoprolol 6.25mg [**Hospital1 **] to improve rate control and hopeful
improve diastolic heart failure.
.
#. History of GERD/PUD: Continued [**Hospital1 **] PPI.
.
#. HTN, benign: Her antihypertensives were held given her recent
septic episode. Given afib metoprolol 6.25mg [**Hospital1 **] was slowly
initiated. This can be further uptitrated as needed to ensure
good rate control. HR in 90's-100's during admission. BP
~systolic 100's.
.
#. CAD/HL: Unclear history. Continued asa/statin.
.
#INCIDENTAL RADIOGRAPHIC FINDINGS: PT WAS NOTED TO HAVE EVIDENCE
OF A POSSIBLE THYROID MASS ON CXR. THIS CAN BE FOLLOWED UP WITH
ULTRASOUND IN THE OUTPATIENT SETTING.
.
#CHEST CT SCAN-RECOMMENDS REPEAT EXAMINATION TO EVALUATE FOR
IMPROVEMENT IN ABOVE PROCESSES. ALSO HRCT SHOULD BE CONSIDERED
TO RULE OUT INTERSTITIAL LUNG DISEASE AND TO EVALUATE
LYMPHADENOPATHY.
.
.
Medications on Admission:
- Novolin R SS
- Aspirin 325 mg PO Daily
- Florastor 250 mg PO BID
- Simvastatin 20 mg PO Daily QHS
- MVI
- acidophilus 1 tab daily
- vitamin D 1000 units daily
- Tumbs 2 tabs daily
- Vitamin C 500 mg [**Hospital1 **]
- lansoprazole 30 mg [**Hospital1 **]
- metformin 500 mg [**Hospital1 **]
- heparin sq
- synthroid 112 daily
- fentanyl patch 25 mcg/hr patch q72 hr
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. cholecalciferol (vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
5. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours): CONTINUE UNTIL INSTRUCTED TO
STOP BY ID. Until at least [**6-14**].
6. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever.
9. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
10. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
13. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
15. insulin
10 units of glargine daily with humalog insulin sliding scale.
Please see attached.
16. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
17. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours): CONTINUE UNTIL INSTRUCTED TO
STOP BY ID. Until at least [**6-14**].
18. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
19. furosemide 10 mg/mL Solution Sig: 20-40 mg Injection once a
day: to achieve daily fluid balance -500 to 1L.
20. Outpatient Lab Work
please check vancomycin trough on [**5-31**]. Please check weekly CBC,
LFTs, chemistries while on antibiotic therapy.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]
All questions regarding outpatient antibiotics should be
directedto the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**]
.
Daily chemistries while being diuresed
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 8957**]
Discharge Diagnosis:
septic shock
hypoxia
stage 4 sacral decubitus ulcer
coagulase negative staphylococcus bacteremia
soft tissue [**Location (un) 2**]
acute on chronic diastolic heart failure
pneumonia
Discharge Condition:
Mental status: clear, coherent
Level of consciousness: alert, oriented to place, year, and
month
Activity status:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with fever and confusion and found to have
sepsis (a severe [**Location (un) 2**] in your blood). For this, you were
initially in the ICU, but then improved and were transferred to
the regular medical floor. You were given antibiotics for this
[**Location (un) 2**] and should continue this antibiotics until instructed
to stop by the infectious disease doctors. [**First Name (Titles) **] [**Last Name (Titles) 2**] was
likely due to your sacral wound.
In addition, you were noted to have heart failure (extra fluid
in your lungs). For this, you were given a "water pill" (lasix)
in order to remove extra fluid. You will continue his medication
while at rehab.
.
Medication changes:
1.Antibiotics-continue vancomycin and meropenem for AT LEAST a 2
week course. Do not stop until instructed by ID. Your
appointment is on [**2170-6-14**].
2.IV lasix 20-40mg daily to achieve -500 to 1L daily fluid
balance.
3.metoprolol started for heart rate.
.
Please talk to you doctors about the need for a thyroid
ultrasound and need for repeat chest ct scan.
.
Please take all of your medications as prescribed and follow up
with the appointments below.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 32949**] to
schedule a follow up appointment after discharge from your rehab
facility.
.
Department: INFECTIOUS DISEASE
When: THURSDAY [**2170-6-14**] at 1:30 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"78552",
"486",
"99592",
"4280",
"25000",
"42789",
"2449",
"42731",
"53081",
"41401",
"2724"
] |
Admission Date: [**2103-2-7**] Discharge Date: [**2103-2-21**]
Date of Birth: [**2035-9-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
transfer from OSH for evaluation and treatment of new lung mass
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt has h/o NSCLC diagnosed [**2096**] s/p L pneumonectomy and 3 vessel
CABG in [**2101**], presented to Bay State Hospital on [**2103-2-5**] with
20# weight loss over 1 month, malaise, RLQ abdominal pain. Pain
was dull, continuous, and radiates to his R flank and back at
times. C/o nausea/vomiting. Admitted to Bay State Hospital,
where cause of abdominal pain not found; however, imaging showed
new RUL lung mass. Pt was transferred here for further care on
[**2103-2-7**] as had been treated here for previous lung Ca.
Past Medical History:
Oncologic History: Locally advanced non-small cell lung CA
diagnosed in [**2096-6-5**], s/p chemotherapy, radiation, and L
pneumonectomy. Course complicated by osteomyelitis of the
sternum, with a long course of antibiotics. There had been no
evidence of recurrence on followup as recently as fall of [**2102**].
3 vessel CABG in [**10-10**]
DVT in [**2094**]
History of depression
Type II DM
GERD
hyperlipidemia
s/p bilateral inguinal hernia repair
s/p lipoma resection
Social History:
He lives with his son. Retired postmaster. He quit smoking 20
years ago, has a 30 pack year history. He drinks alcohol very
occasionally.
Family History:
Significant for mother with cancer (uncertain type) and DM,
brother with [**Name2 (NI) 27339**] cancer, another brother with CAD and DM.
Physical Exam:
AF, 104, 145/68, 98%%5L
Gen: laying in bed, non-toxic appearing
HEENT NCAT, MM slightly dry
Neck supple, JVP 6 cm
Chest scattered rales in RUL, R lung base, otherwise clear
CVS tachy without murmur
Abd benign
Extrem Tr edema
Neuro A & O x 3
Pertinent Results:
OSH Studies:
.
[**2103-2-5**] Chest CT:
1. RUL mass extending from the hilum to the chest wall, most
likely malignancy, malignant LAD with poss postobstructive PNA
2. Peripheral ill-defined nodules likely due to metastatic
disease, but could potentially be granulomatous/infecious.
3. Mediastinal lymphadenopathy.
4. Prior L pneumonectomy. Loculated L pleural effusion. Left
sided calcific pleural thickening.
5. Hypodense lesion in the liver maybe due to metastatic
disease. Small intra-abdominal paraaortic nodule of
indeterminate signifance.
.
[**2-5**] CT abd/pelvis: No urolithiasis or obstructive uropathy. L
renal cyst.
.
Admission Labs:
[**2103-2-7**] 05:00PM BLOOD WBC-7.3 RBC-3.56* Hgb-9.8* Hct-28.9*
MCV-81* MCH-27.5 MCHC-33.9 RDW-13.6 Plt Ct-286
[**2103-2-7**] 05:00PM BLOOD PT-14.6* PTT-27.7 INR(PT)-1.3*
[**2103-2-7**] 05:00PM BLOOD Plt Ct-286
[**2103-2-7**] 05:00PM BLOOD Glucose-57* UreaN-20 Creat-0.7 Na-134
K-4.1 Cl-94* HCO3-29 AnGap-15
[**2103-2-7**] 05:00PM BLOOD ALT-16 AST-25 AlkPhos-206* TotBili-0.3
[**2103-2-7**] 05:00PM BLOOD Albumin-3.1* Calcium-10.7* Phos-3.9
Mg-1.3*
.
[**2103-2-8**] Bone Scan: Findings concerning for diffuse osseous
metastases.
.
[**2103-2-8**] MR [**Name13 (STitle) 430**]: No sign of an enhancing intracranial mass to
indicate the presence of a parechymal metastatic disease.
.
[**2103-2-9**] Biopsy Pathology: Combined invasive carcinoma with a
squamous component and an undifferentiated component with marked
cell size variation. Immunohistochemical studies have been
performed. The tumor cells are positive for cytokeratin
cocktail (squamous component greater than undifferentiated
component) and synaptophysin (undifferentiated component) and
negative for LCA and chromogranin. TTF-1 is equivocal. The
synaptophysin positivity suggests the presence of neuroendocrine
differentiation within the tumor. In the appropriate clinical
setting, the tumor is compatible with a lung primary.
.
[**2103-2-17**] CXR: New right upper lobe opacity which likely
represents pneumonia. A followup after clinical resolution is
recommended as this could be post-obstructive in nature.
.
[**2103-2-17**] Head CT: No intracranial hemorrhage or mass effect. No
significant change allowing for differences in technique.
.
Discharge Labs:
[**2103-2-21**] 06:25AM BLOOD WBC-5.8 RBC-3.88* Hgb-10.9* Hct-31.2*
MCV-81* MCH-28.0 MCHC-34.8 RDW-14.3 Plt Ct-245
[**2103-2-21**] 06:25AM BLOOD Plt Ct-245
[**2103-2-21**] 06:25AM BLOOD Glucose-116* UreaN-21* Creat-0.7 Na-134
K-4.3 Cl-94* HCO3-30 AnGap-14
[**2103-2-21**] 06:25AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.6
Brief Hospital Course:
67y/o M with h/o NSCLC s/p L pneumonectomy, admitted for workup
and treatment of a fnew right lung mass.
.
# Lung cancer - The patient was found to have a new right lung
mass, which was revealed to have small cell and non small cell
features on pathology. The patient underwent a bronchoscopy by
interventional pulmonology to obtain the tissue diagnosis. A
bone scan revealed diffuse osseous mets. MRI was negative for
brain mets. Chemotherapy (etoposide and carboplatin) was
initiated during this hospital course. Neupogen was started 24h
after chemotherapy. Further treatment is to be determined by
the patient's oncologist, Dr. [**Last Name (STitle) 3274**], on followup as an
outpatient.
.
# mental status changes/hypotension - The patient had an episode
of acute mental status changes, unresponsiveness, and
hypotension which was likely multifactorial in etiology. It was
likely partly due to medications (narcotic pain medications
among them) as well as a possible contribution of infection
(pneumonia as described below). There was no intracranial
hemorrhage by CT scan, no brain mets by recent MRI. Electrolytes
were within normal limits. The patient was found to be
hypercarbic, though it was difficult to say whether this is a
cause or result of MS changes. He was alert and oriented shortly
after arrival in the ICU. Some of his pain medications were
then discontinued, and narcotics were used with caution for his
pain. His antihypertensives were initally held, then restarted
once his blood pressure recovered.
.
# Hypercarbic resp failure: The patient had an elevated CO2 on
blood gas in association with the altered mental status and
hypotension described above. This was likely secondary to
medication effect, with the respiratory failure being secondary
to sedation. This improved as the patient became more awake.
.
# Pneumonia - The patient had a new RUL infiltrate on chest
xray, likely a postobstructive vs. aspiration pneumonia. As he
was also hypotensive at the time (see above) vancomycin,
levofloxacin, and flagyl were all started. Vanco was then
discontinued, and treatment with levo/flagyl was continued, with
a planned course of 10 days.
.
# abdominal pain - The patient presented with abdominal pain of
unclear etiology, and had a negative CT abd/pelvis at an outside
hospital. Possible etiologies included metastatic disease,
hypercalcemia, constipation, or a combination of these. He was
given bowel regimen for constipation, treatment for
hypercalcemia as below, and pain medications. He ultimately had
good control of his pain, as well as resolution of his
constipation.
.
# hypercalcemia - Calcium was 11.2 on admission, likely related
to the patient's malignancy. This improved somewhat with
hydration and lasix, but remained above normal. The patient
received a dose of pamidronate on [**2103-2-9**], after which the
calcium level remained normal.
.
# Anemia: Hematocrit drifted downward slowly, and reached a
nadir of [**2109-3-1**] (this in the setting of IV
hydration). Iron studies were consistent with anemia of chronic
disease (ferritin >[**2097**]). Stools were guaiac negative. Some of
the decrease in hematocrit may also have been related to
chemotherapy. The patient received a total of 3 units of PRBC
during the hospital course, after which his hct remained stable.
.
# DM: We continued metformin per home regimen, but discontinued
glipizide when blood glucose levels became too low. We checked
QID fingersticks and covered with insulin sliding scale. The
patient was on [**First Name8 (NamePattern2) **] [**Doctor First Name **] diet.
.
# Hyponatremia: Na was 131 on [**2-20**]. This was likely
hypervolemic hyponatremia, in the setting of IVF and blood
products. Sodium returned to [**Location 213**] after a small dose of
lasix.
.
# h/o CAD: Currently asymptomatic. Cardiac enzymes were negative
when checked in the ICU in the setting of hypotension and mental
status changes as above. We continued his home regimen of beta
blocker, ACE inhibitor, aspirin, and statin.
.
# h/o depression: Paxil had been discontinued in [**Month (only) **], but
then was restarted at the outside hospital, and was continued
here.
Medications on Admission:
lisinopril 5 daily
glipizide 10 [**Hospital1 **]
coreg 6.25 [**Hospital1 **]
paroxetine 20 daily
skelaxin 800mg TID prn back spasms
metformin 1000mg [**Hospital1 **]
lipitor 40 daily
oxycodone-APAP 7.5-325 q4h prn pain
aspirin 81mg daily
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed for wheezing, shortness of
breath.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
11. Filgrastim 300 mcg/mL Solution Sig: Three Hundred (300) mcg
Injection Q24H (every 24 hours).
12. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
13. Outpatient Lab Work
Please check a CBC on Monday [**2103-2-26**] and on Monday [**2103-3-5**].
Please fax the results to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3274**] at [**Telephone/Fax (1) 22294**].
14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 27340**]
Discharge Diagnosis:
Primary Diagnoses:
lung cancer metastatic to bone
hypercalcemia
right upper lobe pneumonia, likely post-obstructive
anemia of chronic disease
Secondary diagnoses:
hypertension
type II diabetes
depression
coronary artery disease
Discharge Condition:
stable
Discharge Instructions:
If you experience fever, chills, worsening abdominal pain,
nausea, vomiting, shortness of breath, or any other new or
concerning symptoms, please call your doctor or return to the
emergency room for evaluation.
.
Please take all medications as prescribed.
- We have been holding your glipizide because your sugars have
been too low. Please continue taking your metformin.
.
Please attend all followup appointments.
Followup Instructions:
Please call Dr.[**Name (NI) 3279**] office as soon as possible to make an
appointment for followup after discharge. Please call
[**Telephone/Fax (1) 15512**].
.
You have the following appointments already scheduled:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2103-4-23**] 2:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2103-5-3**] 11:00
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Date/Time:[**2103-5-3**] 2:00
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
|
[
"486",
"2761",
"4280",
"4019",
"25000"
] |
Admission Date: [**2181-5-23**] Discharge Date: [**2181-5-26**]
Service:
CHIEF COMPLAINT: Shortness of breath
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 84 year old
[**Doctor First Name **] speaking gentleman with a history of severe interstitial
lung disease, congestive heart failure, coronary artery
disease and chronic renal failure who experienced worsening
shortness of breath over the day prior to admission. The
patient at home had oxygen saturations in the 70s on 3.5
liters by nasal cannula and right-sided chest pain. The
patient had been drinking Ensure the few days prior to
admission. In the Emergency Room the patient was diagnosed
with presumed congestive heart failure exacerbation and
worsening of his interstitial lung disease. He received
Lasix and was admitted to the Medical Intensive Care Unit for
further treatment.
PHYSICAL EXAMINATION: The patient was well-appearing elderly
man in mild respiratory distress. Sclera were clear. Neck,
notable for jugulovenous distension and tenderness in his
right calf. His chest showed audible crackles bilaterally
but cleared anteriorly. His cardiac examination was normal
S1 and S2, II/VI holosystolic murmur at the apex. His
abdomen was benign with mild hepatomegaly. His extremities
showed trace bilateral pedal edema and neurologically he was
intact.
LABORATORY DATA: The patient had an elevated white count of
19.1, hematocrit of 38.4, platelets 264. Chem-7 134, 5.5,
95, 24, 58, 119, 274. The patient's INR was noted to be 7.4.
Creatinine kinase was 71, troponin was 3.7. His
electrocardiogram was ventricularly paced in 70's, no
ischemic changes. His chest x-ray showed diffuse alveolar
interstitial changes, likely superimposed congestive heart
failure or interstitial lung disease.
HOSPITAL COURSE: 1. Pulmonary - The patient suffers from
respiratory distress, likely secondary to both congestive
heart failure and worsening of his interstitial lung disease.
This has been an acute and chronic progression of this
disease which is likely a terminal process. Despite
aggressive treatment with Prednisone and antibiotics, the
patient was aggressively diuresed for congestive heart
failure component, continued on his Prednisone and treated
with Nitroglycerin drip, Captopril, Digoxin, Azithromycin,
Ceftriaxone and Morphine. He continued to have significant
oxygen requirement and intermittently complained of shortness
of breath. After extensive conversations with the family it
was agreed that the patient would be taken home for home
hospice care given the likely terminal prognosis and
progression of his interstitial lung disease and congestive
heart failure, and the fact that there was little medical
treatment that we could provide at this point to cure this
condition.
2. Cardiac - The patient has a history of coronary artery
disease and congestive heart failure. He was treated with
Nitroglycerin, Lasix and Morphine. The Nitroglycerin drip
was weaned off and the patient was started on Nitroglycerin
patch. When the Nitroglycerin drip was turned initially the
patient experienced some right-sided neck pain and chest
tenderness that possibly could have been ischemic in origin.
The patient requires aggressive treatment with Morphine,
Nitroglycerin and ACE inhibitor to minimize his discomfort
related to the ischemic pain. In addition, the patient has a
history of paroxysmal atrial fibrillation which was
supertherapeutic in his INR. The Warfarin was discontinued
on his admission and was not restarted given the hospice
disposition.
CONDITION ON DISCHARGE: Poor.
DISCHARGE STATUS: To home hospice.
DISCHARGE DIAGNOSIS:
1. Severe interstitial lung disease
2. Congestive heart failure
3. Paroxysmal atrial fibrillation
4. Hypertension
5. Chronic renal insufficiency
DISCHARGE MEDICATIONS:
1. Fluoxetine 10 mg p.o. q.d.
2. Prednisone 60 mg p.o. q.d.
3. Bactrim one DS tablet three times a week, Monday,
Wednesday and Friday
4. Digoxin 125 mcg p.o. q.d.
5. Nitroglycerin patch 0.6 mg per hour, transdermal to be
changed every 24 hours, titrate to no chest pain
6. Lasix 80 mg p.o. q.d.
7. Captopril 25 mg p.o. t.i.d.
8. Dextran 70/HPM cell one to two drops ophthalmic prn
9. Morphine Sulfate 15 mg p.o. q. 12 hours
10. Roxanol 20 mg per ml solution, 5-20 mg p.o. q. 2 hours as
needed for shortness of breath, cough or pain
11. Thiamine Sulfate .125 mg tablet q. 4 hours as needed for
congestion
12. Acetaminophen 650 mg suppository q. 4-6 hours as needed
for fever and pain
13. Ativan 1 to 2 tablets 2 mg q. 4-6 hours prn anxiety and
restlessness
14. Oxygen titrated to comfort via shovel mask or
nonrebreather
15. AVHRGL which is Ativan, Haldol, Benadryl, Reglan
combination one by mouth q. 4 hours prn nausea and vomiting
FOLLOW UP PLANS: The patient will have hospice care at home.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**]
Dictated By:[**Last Name (NamePattern1) 11801**]
MEDQUIST36
D: [**2181-5-25**] 16:35
T: [**2181-5-25**] 18:43
JOB#: [**Job Number 21554**]
|
[
"4280",
"41071",
"42731",
"40391",
"41401"
] |
Admission Date: [**2156-2-20**] Discharge Date: [**2156-2-24**]
Date of Birth: [**2091-10-28**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
PICC
History of Present Illness:
64 F h/o migraine headaches, anxiety, depression p/w rectal
bleeding, melena. On [**2-10**] pt was eating dinner at home, noticed
pain in her lower abdomen and when she went to the bathroom
noted dark black stool, then blood mixed with watery stool
described as dark red blood. This has never happened before, pt
denies any history of melena. She has had an anal fissure in
the past however has not been an issue for several years.
Denied any nausea or vomiting at home. She has a history of
migraines and was taking aspirin for pain control, takes [**6-4**]
aspirin per day.
Pt was initially admitted to [**Hospital3 **] on [**2-10**], Hgb/Hct
initially were 7.5/22.1 and underwent EGD the day after
admission which showed multiple erosions in the stomach and
shallow ulceration, no active bleeding. She also was transfused
for low Hgb. Colonoscopy was done which showed abundant amount
of blood coating the colon, unable to examine adequately. On
[**2-15**], pt had a nuclear medicine bleeding scan which was
negative. Hb continued to drop and on [**2-17**] she had repeat EGD
and push enteroscopy which showed a duodenal AVM, and bleeding
was cauterized and clipped. Hgb stabilized initially, then
continued to have melena so had a third EGD on [**2-18**] that showed
no active bleeding from the AVM. On [**2-19**], she dropped her Hgb
from 9.8 to 8.1 over 6 hours, so she had a fourth EGD which
showed no active bleeding from AVM.
On [**2-20**] which is the day of transfer she was prepped for
colonoscopy, however decision was made after discussion with GI
at [**Hospital1 18**] to be transferred for single balloon enteroscopy, to
evaluate for small intestine lesions and possible repeat
colonoscopy. In total he had EGD x 4 and one colonoscopy.
Received total 19 units PRBC and a five day course of
moxifloxacin for treatment of acute bronchitis. Pt was
continued on her celexa, neurontin, and depokote for depression
and anxiety, and her propranolol (prophylactic for migraine
headaches) was held. She was on propranolol initially in spite
of active GI bleed, but after EGD on [**2-17**] she had significant AV
dissociation with bradycardia (no EKG, this is per discharge
summary from OSH), and after propranolol was stopped she was
stable in sinus rhythm. It is possible per OSH assessment that
reason for bradycardia was vagal stimulation from EGD. She was
given atropine for this event. On discharge from OSH her Hgb was
9, Hct 26.2, Na 136, K 2.7, Cl 102, HCO3 32, BUN 15, Cr 0.5,
LFTs wnl, total protein 3.8. Pt was not noted to have
hypotension or tachycardia during this admission. She was on a
clear liquid diet on discharge. PICC line was placed during
admission.
On arrival to the ICU, pt complains of nausea but otherwise
denies any complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
anxiety
chronic migraine headaches
depression
larynx surgery
anal fissure x 10 years
Social History:
not employed, lives with fiance, sister is involved in her care
and is HCP
- [**Name (NI) 1139**]: 1 ppd x 40 years, has quit before and is interested
in quitting now
- Alcohol: denies
- Illicits: denies
Family History:
Sister with depression, no history of GI disease
Physical Exam:
Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils unequal
and not reactive to light (baseline per pt), L pupil 4 mm and
irregular, R pupil 2 mm
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2,III/VI systolic
murmur at base
Abdomen: soft, mild ttp in LLQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place with yellow urine
Ext: warm, well perfused, 2+ pulses, 2+ pitting edema to knees
bilaterally, 2+ pitting edema in upper extremities bilaterally
.
Discharge Exam:
AVSS
Abdomen Benign
Pertinent Results:
Admission Labs
[**2156-2-20**] 05:40PM BLOOD WBC-7.9 RBC-3.12*# Hgb-9.5*# Hct-27.1*#
MCV-87 MCH-30.3 MCHC-34.9 RDW-15.5 Plt Ct-196
[**2156-2-20**] 05:40PM BLOOD Neuts-74.7* Lymphs-15.3* Monos-7.2
Eos-2.7 Baso-0.2
[**2156-2-20**] 05:40PM BLOOD PT-12.7* PTT-27.5 INR(PT)-1.2*
[**2156-2-20**] 05:40PM BLOOD Glucose-107* UreaN-9 Creat-0.5 Na-144
K-3.6 Cl-107 HCO3-35* AnGap-6*
[**2156-2-20**] 05:40PM BLOOD Calcium-8.0* Phos-4.5 Mg-2.4
Micro:
None
Imaging:
CHEST (PORTABLE AP) Study Date of [**2156-2-20**] 6:06 PM
A right subclavian PICC line is present -- the tip overlies the
proximal SVC. No pneumothorax is detected. There is cardiomegaly
with left ventricular configuration. There is borderline upper
zone redistribution, but no overt CHF. There is scarring,
possibly with some bullous change, noted in the right upper lung
medially.
GI BLEEDING STUDY Study Date of [**2156-2-21**]
Following intravenous injection of autologous red blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen for 90 minutes were obtained. A left lateral view of the
pelvis was also obtained.
Blood flow images show normal blood flow.
Dynamic blood pool images show no evidence of gastro-intestinal
bleeding or evidence of bleeding elsewhere.
IMPRESSION: No GI bleed detected.
.
Colonscopy:
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. The
efficiency of a colonoscopy in detecting lesions was discussed
with the patient and it was pointed out that a small percentage
of polyps and other lesions can be missed with the test. A
physical exam was performed. The patient was administered
moderate sedation. Supplemental oxygen was used. The patient was
placed in the left lateral decubitus position.The digital exam
was normal. The colonoscope was introduced through the rectum
and advanced under direct visualization until the cecum and
terminal ileum were reached. The appendiceal orifice and
ileo-cecal valve were identified. Careful visualization of the
colon was performed as the colonoscope was withdrawn. The
colonoscope was retroflexed within the rectum. The procedure was
not difficult. The quality of the preparation was Fair. The
patient tolerated the procedure well. There were no
complications.
Findings:
Protruding Lesions Grade 1 internal hemorrhoids were noted.
Impression: Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: Follow-up with referring physician as needed
Additional notes: FINAL DIAGNOSES are listed in the impression
section above. There was no blood loss. No specimens were taken
for pathology.
.
Discharge Labs:
[**2156-2-23**] 05:15AM BLOOD WBC-9.2 RBC-3.93* Hgb-12.0 Hct-34.7*
MCV-88 MCH-30.4 MCHC-34.5 RDW-15.6* Plt Ct-279
[**2156-2-23**] 05:15AM BLOOD Glucose-119* UreaN-5* Creat-0.6 Na-145
K-3.6 Cl-105 HCO3-32 AnGap-12
[**2156-2-22**] 05:12AM BLOOD Calcium-7.9* Phos-4.9* Mg-2.4
Brief Hospital Course:
64 F h/o migraine headaches, depression, anxiety transfered with
rectal bleeding, melena and 19 unit PRBC GI bleed thought to be
secondary to duodenal AVMs cauterized and clipped at an outside
hospital (prior to transfer to [**Hospital1 18**]).
ACTIVE ISSUES
# Upper GI Bleed: Pt reported both hematochezia and melena.
There was been evidence of possible bleeding sources on EGDs
from OSH (duodenal AVM, ulcers in stomach which could be [**1-29**] use
of aspirin and NSAIDs). Pt had not successfully undergone
colonoscopy (poor prep and inadequate visualization per records
from OSH) however with hematochezia a lower GI bleed is also
possible. Per pt report she has had normal screening
colonoscopies in the past however no records of these and
unclear when last one was. During the ICU course, patient was
transfused 2 units PRBCs. Her hematocrit went from 27.1 -> 26.0
-> 22.1 (possibly spurious) -> 33.0 (after 2 units PRBCs). A
tagged RBC scan was not remarkable for any bleeding source. We
held home propranolol and gave protonix 40 mg IV BID and 5mg
Vitamin K for an INR 1.5 as well as zofran, morphine PRN for
pain and nausea. The pt was called out to the floor, remained
clinically stable and underwent a colonscopy that revealed grade
I hemorrhoids that were not likely the source of bleeding.
**The pt was discharged on [**Hospital1 **] Omeprazole for a planned 2 weeks
before being titrated down to once daily. The patient was
instructed to hold their aspirin until evaluated by their PCP**
- There were no plans for GI follow-up at the time of discharge,
however the pt was instructed to call if she experiences dark
black stools or BRBPR.
CHRONIC ISSUES:
# Depression: We held home celexa, zyprexa, depakote while NPO.
Home meds restarted on discharge.
# Tobacco abuse: counseled regarding smoking cessation, patient
would like to try to quit and has felt that the nicotine patch
started at OSH has been helping. We continued nicotine patch in
house.
# Migraine headaches: We continued PRN morphine and zofran for
now, takes aspirin at home however with GI bleed she should not
take aspirin any longer.
.
# Transitional:
- Pt to establish care with new PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 78645**], shortly after
discharge. A voicemail was left with Dr. [**Last Name (STitle) 78645**] to call with any
questions or concerns.
Medications on Admission:
Medications on transfer:
protonix 40 mg IV q12H
zofran 4 mg IV q4H prn
morphine sulfate 2 mg IV q2H prn pain
D5NS at 75 mL/hr
albuterol nebs 2.5 mg q2H PRN shortness of breath
zyprexa 7.5 mg QHS
depakote ER 250 mg TID
valium 10 mg TID
Medications at home (per pt, different from list in chart)
celexa 40 mg daily
zyprexa 10 mg HS
depakote ER 250 mg TID
diazepam 10 mg TID
neurontin 400 mg TID
propranolol 50 mg TID
aspirin 325 mg Q4-6H PRN
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. olanzapine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO TID (3 times a day).
4. diazepam 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for headache.
7. propranolol Oral
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
- Upper GI Bleed
.
Secondary Diagnoses:
- Depression
- Migraines
- Tobacco Abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to BIMDC from another hospital with a GI
Bleed. While here you underwent a colonscopy that did not reveal
further evidence of bleeding.
.
Please continue to take all of your medications with exception
to Aspirin until you are told do so by your doctor. We have
started Omeprazole 40mg twice daily for the next two weeks, then
going to once a day. Please continue this until instructed to
stop by your PCP.
.
Please keep all of your appointments.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 78645**] on Wednesday as previously
scheduled.
|
[
"2851",
"3051",
"311"
] |
Unit No: [**Numeric Identifier 72864**]
Admission Date: [**2182-6-13**]
Discharge Date: [**2182-6-21**]
Date of Birth: [**2182-6-13**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: This is a 33 and [**6-27**] week twin
#1 with birth weight [**2170**] grams, [**Year (4 digits) **] to a 34 year-old, G1,
P0 now 2 mother with estimated date of confinement of [**2182-7-26**].
Her prenatal labs include the following: 0 positive,
antibody negative, RPR nonreactive, Rubella immune, hepatitis
B surface antigen negative and GBS unknown.
PAST MEDICAL HISTORY: Notable for Crohn's disease in the
mother, not treated with medication.
PREGNANCY HISTORY: IVF assisted di/di twin gestation.
Pregnancy was complicated by the development of PIH and pre-
eclampsia prompting maternal admission on [**2182-6-10**]. Mother
received betamethasone which was complete prior to delivery.
Mother did not receive any medications for pre-eclampsia.
The baby was [**Name2 (NI) **] via Cesarean section at 3:06 p.m. for pre-
eclampsia. Apgars were [**8-29**] and the infant was admitted to
the NICU. Birth history: Birth weight was [**2170**] grams; 25th
to 50th percentile, head circumference 25th percentile.
Length 44.5 cm, 25 to 50th percentile.
PHYSICAL EXAMINATION: Temperature 99.7; heart rate 160;
respiratory rate 60; blood pressure 70/30 (45); oxygen
saturation 95 to 98% on room air.
GENERAL: Premature infant, active with exam, no distress.
SKIN: Warm, pink, no rash.
HEENT: AFOF, palate intact. Ears and nares normal. Normal
facies.
NECK: Supple without lesions.
CHEST: Clear, well aerated, minimal retractions.
CARDIAC: Regular rate and rhythm, no murmur. Femoral pulses
2+.
ABDOMEN: Soft, nontender, nondistended. No masses. Quiet
bowel sounds.
GENITOURINARY: Normal female. Anus patent.
EXTREMITIES: Hip and back normal.
NEUROLOGIC: Appropriate tone and activity. Positive Moro,
weak suck.
LABORATORY ON ADMISSION: Dextrose was 66.
Discharge weight=2040 g.Head circumference=28cm.Length=44 cm.
HOSPITAL COURSE: Respiratory: The patient breathed room air with
no supplemental respiratory support since birth. No apnea of
prematurity. no caffeine therapy. No assisted ventilation.
Cardiovascular: Stable. BP and circulatory status wnl.no murmur.
Fluids, electrolytes and nutrition: Feedings advanced without
problems. Fed breast milk and/or special care formula. Full
feeds by day of life 6. At time of discharge she is breast
feeding and breast milk 24 calorie (with added Similac powder) to
maintain additional caloric intake. Infant can advance to full
breast feeding as determined by weight gain and no need for
caloric enhancement added to expressed Breast milk.
Maximum bilirubin= 7.6 on day of life 3. No phototherapy.
Hematology: CBC obtained on day of life 1 to evaluate
infant's Hct, WBC, and Plt due to fact that mother had pre-
eclampsia. Hematocrit= 58%. Platelets=453K. WBC=11.800 and no
left shift. Blood cultures were negative. No antibiotic
therapy.
Neurology: Stable by examination. No indication for head
ultrasound screening.
Sensory: Audiology: Hearing screen with automated auditory brain
stem responses. Results: passed both ears.
Ophthalmology: Positive red reflex bilat noted on physical
examination. dilated exam was not indicated.
CONDITION ON DISCHARGE: Stable. healthy appearing premature
infant.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) 553**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38676**], MD.
Appointment with Dr. [**Last Name (STitle) 38676**] [**2182-6-25**].
[**Hospital6 **] will assess infant [**2182-6-22**]
CARE RECOMMENDATIONS:
1. Feedings at discharge: Breast milk supplemented with
Similac powder to 24 calories per ounce and breast
feeding. Advance to full breast feeding as noted above.
2. Medications: Goldline Multivitamins 1 ml po daily. Ferinsol
0.15 ml po daily. .Iron supplementation is recommended for
preterm and low birth weight infants until 12 months corrected
age as well as multi-vitamins. All infants fed predominantly
breast milk should receive vitamin D supplementation at
200 IU daily until 12 months corrected age. Multi-
vitamins typically provide this amount as a minimum.
4. Car seat screening: passed on [**2182-6-21**]
5. State newborn screening status:
6. Immunizations: Hepatitis B vaccine was received on [**2182-6-20**].
1. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following four
criteria: (1) [**Month (only) **] at less than 32 weeks; (2) [**Month (only) **] between
32 weeks and 35 weeks with two of the following: Day care
during RSV season, a smoker in the household, neuromuscular
disease, airway abnormalities or school age siblings; (3)
chronic lung disease or (4) hemodynamically significant
congenital heart disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age, and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out-of-home caregivers.
This infant has not received ROTA virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable or at least 6 weeks but fewer
than 12 weeks of age.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Twin gestation.
3. Sepsis ruled out. No antibiotics.
[**First Name4 (NamePattern1) 1154**] [**Last Name (NamePattern1) 72865**] [**Name8 (MD) **], MD [**MD Number(2) **]
Dictated By:[**Last Name (NamePattern1) 72866**]
MEDQUIST36
D: [**2182-6-20**] 17:04:34
T: [**2182-6-20**] 18:25:41
Job#: [**Job Number 72867**]
|
[
"7742",
"V053"
] |
Admission Date: [**2173-7-27**] Discharge Date: [**2173-8-3**]
Date of Birth: [**2094-6-13**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Penicillins / Lipitor / Adhesive Tape
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2173-7-27**] Aortic Valve Replacement (21mm [**Company **] mosaic), Mitral
Valve Replacement (27mm [**Company **] mosaic), Reveal device removal
History of Present Illness:
79 y/o female with known AS/MR
Past Medical History:
Aortic Stenosis, Mitral Regurgitation, Hypoparathyroidism,
Hypomagnesemia, Hypertension, Chronic Atrial Fibrillation,
Cataracts s/p surgery, Osteopenia, Obesity, Congestive Heart
Failure, Granulomatous Hepatitis, Gastroesophageal Reflux
Disease, s/p bilateral total kneee replacements, s/p lumpectomy,
s/p cholecystectomy, s/p appendectomy and left ovarian
cystectomy, s/p reveal implantation
Social History:
Denies tobacco use. Denies ETOH use for a few years.
Family History:
Grandparents died from MI in 50's.
Physical Exam:
VS: 70AF 20 120/63 5'1" 200#
Gen: SOB with any exertion
HEENT: PERRL, EOMI, OP Benign
Neck: Supple, FROM, -JVD
Chest: CTAB with bibasilar rales
Heart: Irreg rate with murmur
Abd: Soft, NT/ND, +BS, well healed abd. scars
Ext: Warm, well-perfused, -c/c/e
Neuro: MAE, non-focal, A&O x 3
Pertinent Results:
[**7-27**] Echo: Prebypass: 1. The left atrium is elongated. No atrial
septal defect is seen by 2D or color Doppler. 2.Left ventricular
wall thicknesses and cavity size are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). 3.Right ventricular
chamber size and free wall motion are normal. 4.The ascending
aorta is mildly dilated. There are simple atheroma in the
ascending aorta. There are simple atheroma in the descending
thoracic aorta. 5. There are three aortic valve leaflets. The
aortic valve leaflets are severely thickened/deformed. There is
severe aortic valve stenosis (area <0.8cm2). Mild to moderate
([**1-19**]+) aortic regurgitation is seen. 6. There is mild valvular
mitral stenosis (area 1.5-2.0cm2). Due to co-existing aortic
regurgitation, the pressure half-time estimate of mitral valve
area may be an OVERestimation of true mitral valve area.
Moderate to severe (3+) mitral regurgitation is seen. The
leaflets appear restricted and the jet of mitral regurgitation
is central. 7.There is a trivial/physiologic pericardial
effusion. Post Bypass: 1. Patient is being AV paced and
receiving an infusion of phenylephrine. 2. Biventricular
systolic function is unchanged. 3. There is a bioprosthetic
valve seen in the aortic position. The valve appears well seated
and the leaflets move well. There is no aortic insufficiency. 4.
There is a bioprsthetic valve seen in the mitral position. The
valve appears well seated and the leaflets move well. There is
no mitral insufficiency. 5. Aorta is intact post decannulation.
[**2173-7-27**] 11:27AM BLOOD WBC-13.0*# RBC-3.27* Hgb-9.5*# Hct-27.8*
MCV-85 MCH-29.0 MCHC-34.2 RDW-14.6 Plt Ct-200
[**2173-7-30**] 07:05AM BLOOD WBC-8.8 RBC-2.63* Hgb-7.8* Hct-22.8*
MCV-87 MCH-29.6 MCHC-34.2 RDW-15.3 Plt Ct-PND
[**2173-7-27**] 11:27AM BLOOD PT-15.3* PTT-64.0* INR(PT)-1.4*
[**2173-7-29**] 02:26AM BLOOD PT-12.3 PTT-28.8 INR(PT)-1.1
[**2173-7-27**] 12:45PM BLOOD UreaN-21* Creat-1.0 Cl-110* HCO3-24
[**2173-7-30**] 07:05AM BLOOD Glucose-96 UreaN-21* Creat-1.1 Na-136
K-3.6 Cl-102 HCO3-27 AnGap-11
Brief Hospital Course:
Ms. [**Known lastname **] was a same day admit after undrergoing all
pre-operative work-up as an outpatient. On day of admission she
was brought to the operating room where she underwent and aortic
and mitral valve replacment. Please see operative report for
details. Following surgery she was transferred to the CSRU for
invasive monitoring. Within 24 hours she was weaned from
sedation, awoke neurologically intact and extubated. On post-op
day one she was started on beta blockers and diuretics. She was
gently diuresed towards her pre-op weight. On post-op day two
she was transferred to the telemetry floor for further care.
Chest tubes and epicardial pacing wires were removed per
protocol. On post op day 3 she went into atrial fibrillation for
which her lopressor dose was increased, and she was started on
coumadin and amiodarone. She remained in rate controlled atrial
fibrillation. She was ready for discharge to rehab on POD #6
Medications on Admission:
Caltrate 600mg [**Hospital1 **], Calcitrol 0.25mcg qd, Lopressor 25mg [**Hospital1 **],
Uromag 140mg [**Hospital1 **], Aspirin 81mg qd, Lasix 40mg [**Hospital1 **], Kcl 20meq,
Diltiazem SR 300mg qd, Protonix 40mg qd, ProAir HFA prn, Home O2
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain. Tablet(s)
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO BID (2 times a day).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
for 1 days: Check INR [**8-4**], target INR is 2.0-3.0 for Atrial
Fibrillation.
Disp:*30 Tablet(s)* Refills:*2*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg BIDx 5 days, then 400 mg daily x 7 days then 200
mg ongoing until dc'd by cardiologist.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
14. Uro-Mag 140 mg Capsule Sig: One (1) Capsule PO twice a day.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]
Discharge Diagnosis:
Aortic Stenosis s/p/ Aortic Valve Replacement
Mitral Regurgitation s/p Mitral Valve Replacement
Reveal device removal
PMH: Hypoparathyroidism, Hypomagnesemia, Hypertension, Chronic
Atrial Fibrillation, Cataracts s/p surgery, Osteopenia, Obesity,
Congestive Heart Failure, Granulomatous Hepatitis,
Gastroesophageal Reflux Disease, s/p bilateral total kneee
replacements, s/p lumpectomy, s/p cholecystectomy, s/p
appendectomy and left ovarian cystectomy, s/p reveal
implantation
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] in 4 weeks
Dr. [**First Name (STitle) 1075**] in [**2-20**] weeks
Dr. [**First Name (STitle) 4640**] in [**1-19**] weeks
Completed by:[**2173-8-3**]
|
[
"42731",
"4019"
] |
Admission Date: [**2182-5-4**] Discharge Date: [**2182-5-5**]
Date of Birth: [**2160-8-31**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
s/p kick in the head
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 21yo RHM with no significant PMH here after
being assaulted around 1 am by several people. Patient recalls
that he believes he recalls everything but he was told by his
friend he was knocked out. He was hit in the head by boots but
he does not believe he fell and hit his head. He was able to
walk home but because his chin was bleeding, he asked his friend
to drive him to the hospital ([**Last Name (un) 1724**]) for possible stitching. At
the OSH, he had imaging including head CT that revealed SAH
hence
he was transferred to [**Hospital1 18**].
Patient reports that he drank 4~5 drinks prior to be attacked -
he does not know his attackers. He denies prior concussions.
He
currently reports severe throbbing/pressure like HA especially
on
the sides and the top of his head. He also vomited x1 while in
the ED but denies any further nausea or blurry/double vision.
Past Medical History:
1. Asthma
2. Hx of R buttock abscess s/p I&D
Social History:
Senior at BU - majoring in accounting. Social drinking but
denies tobacco or illicit drugs including cocaine.
Family History:
Parents alive and healthy - Dad 69 and Mom is 56.
Physical Exam:
Upon discharge:
Oriented x 3.
PERRL, EOMS intact.
Right ear hematoma.
He has facial swelling and bruising and a stitched laceration on
the chin.
No drift.
Full strength and sensation throughout.
Pertinent Results:
Head CT [**5-4**]:
Small right perimesencephalic SAH.
Head CT [**5-5**]:
Stable SAH.
Brief Hospital Course:
The patient was admitted to the ICU for neuro checks. His chin
was sutured in the ER. Plastic surgery was consulted and they
did not recommend surgery for his auricular hematoma. The
patient remained neurologically stable and his repeat head CT
was stable. He was discharged to home on [**2182-5-5**].
Medications on Admission:
none
Discharge Medications:
1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain: No driving while on this medication.
Disp:*40 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
traumatic right SAH
right auricular hematoma
? left mandibular fx
Discharge Condition:
Neurologically stable
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
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.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 548**] in [**5-7**] weeks with a non-contrast head
CT. Call [**Telephone/Fax (1) 1669**] to schedule this appointment.
Follow-up with plastic surgery for your right ear and to remove
the suture in your chin in [**6-7**] days. They should also
re-evaluate your jaw. Please call the office at [**Telephone/Fax (1) 6742**] to
schedule this appointment with Dr. [**First Name8 (NamePattern2) 3788**] [**Last Name (NamePattern1) 437**]. The office is on
the [**Location (un) **] of the [**Hospital Unit Name **].
Completed by:[**2182-5-5**]
|
[
"49390"
] |
Admission Date: [**2194-4-3**] Discharge Date: [**2194-4-12**]
Date of Birth: [**2135-10-1**] Sex: M
Service: MEDICINE
Allergies:
Aleve / Lisinopril / Heparin Agents
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**4-3**]- cardiac catherization, Angiosculpt balloon & promus [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] to prox ramus
History of Present Illness:
58-yo M w/ CAD, ischemic cardiomyopathy (TTE '[**85**] LVEF 30%),
Stage III/IV CKD (baseline Cr 2.5-3.0), DM2 with neuropathy,
HTN, HL, COPD, OSA on BiPap, and morbid obesity (366 lbs) who
presented to OSH w/ [**Hospital **] transferred to [**Hospital1 18**] for cardiac cath.
His cardiac history began in [**2185**] when he experienced an
inferior MI and underwent RCA stenting. He developed in-stent
restenosis in [**2187**] and had Taxus stent placed. In [**1-/2194**] he
started developing chest discomfort w/ minimal exertion and even
at rest, somewhat improved w/ SL NTG. He presented to the ED in
[**1-/2194**] where he r/o for MI. Follow-up stress test showed
moderate inferolateral and anterolateral ischemia; TTE showed
LVEF 40%.
He underwent cardiac cath in [**1-/2194**] at [**Hospital3 417**] Hospital
which revealed 50% LAD, 70% ramus, 80% lower pole of ramus, and
total occlusion of RCA and Cx. He was referred to Dr. [**Last Name (STitle) **]
for consult regarding potential CABG, but deemed inappropriate
for surgery d/t poor targets. He was scheduled to have planned
ramus PCI on [**2194-4-3**], but patient was admitted to [**Hospital3 417**]
Hospital on [**2194-3-25**] with chest pain, shortness of breath, and
found to be in CHF and with elevated troponin, ruled in for
NSTEMI w/ peak of 0.41. He was diuresed and creatinine rose to
4.4. With IVFs, his creatinine improved to 3.9.
In the cath lab pt was on BiPAP, had lower pole of distal ramus
dilated w/ 2.5x10mm Angiosculpt balloon and prox ramus lesion
direct stented w/ Promus DES. Pt transferred to CCU from cath
lab for respiratory distress requiring BiPAP. In CCU, pt is
[**Name (NI) 41627**], comfortable, alert and conversant w/ stable VS
Past Medical History:
- CAD- s/p stenting of RCA [**2185**], s/p Taxus stent [**2187**] for ISR
- MI [**2185**]
- Ischemic Cardiomyopathy LVEF 30-35%
- CKD stage III/IV w/ 4g of daily proteinuria, base Cr 2.5-3.0
- Obesity related glomerulosclerosis
- Diabetic nephropathy and nephrosclerosis
- Morbid obesity
- Insulin dependent diabetes mellitus
- Hypertension
- Hyperlipidema
- Cerebrovascular disease (Known occluded Right ICA)
- COPD
- Dilated retinopathy
- Obstructive sleep apnea(on nocturnal CPAP)
- Thyroid nodule s/p partial thyroidectomy '[**90**]
- AICD/Biventricular pacemaker placement [**2188**](St. [**Male First Name (un) 923**])
- Left carotid angioplasty/stent [**2187**]
Social History:
Lives with: Wife
Occupation: Disabled
has 2 daughters, involved in care
Tobacco: 40 pack year. Quit 1 year ago.
ETOH: Rare, infrequent use.
Family History:
Brother underwent CABG in his 40's. Mother died at 86 with
CVA/CAD. Father died at 47 of cerebral hemorrhage
Physical Exam:
VS: T: afebrile HR: 76 BP: 137/62 RR: 32 SaO2: 99% on BiPAP
settings
GEN: morbidly obese hirsute middle aged male in NAD wearing
BiPAP
HEENT: Sclera anicteric. PERRL, EOMI. MM dry
Neck: cannot assess JVP 2/2 body habitus
CV: soft S1,S2; II/VI SEM @ base
Chest: posterior exam limited, ant exam clear, on BiPAP
Abd: +BS, obese Soft, NTND
Ext: 2+ pitting edema anterior shins, 2+ DP/PT pulses B/L,
R radial dressing c/d/i
NEURO: A&Ox3, no focal neuro deficits
Pertinent Results:
[**2194-4-3**] CARDIAC CATHETERIZATION:
1. Coronary angiography of this right dominant system showed 2
vessel
coronary artery disease. The LMCA and LAD had no angiographic
flow-limiting disease. The LCX was occluded. The ramus
intermedius had
an ulcerated proximal 80% stneosis and an origin 80% stenosis of
a lower
pole. The RCA was known occluded and not selective injected.
2. Limited resting hemodynamics revealed a central aortic
pressure of
144/73 mmHg.
3. Successful PTCA and placement of a 3.0x23mm Promus drug
eluting stent
in the ramus intermedius were performed. Final angiography
showed
normal flow, no apparent dissection, and no residual stenosis.
(See
PTCA comments.)
FINAL DIAGNOSIS:
1. PTCA and placement of a drug eluting stent in the ramus
intermedius.
[**4-4**] TTE:
Due to very suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF ? 55%). The aortic valve is
not well seen. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen.
Brief Hospital Course:
Mr. [**Known lastname 41628**] is a 58 year-old gentleman with CAD s/p PCI to RCA
'[**85**] c/b in-stent restenosis w/ Taxus '[**87**], DM2, HTN, HL, COPD,
OSA on Bi-PAP, and morbid obesity s/p catheterization w/ DES to
ramus, transferred to CCU for management of respiratory
distress.
1. RESPIRATORY DISTRESS: Mr. [**Known lastname 41628**] was admitted to the CCU
after cardiac cath (details below) due to persistent need for
BiPAP to maintain adequate oxygenation. Necessity for BiPAP
likely multifactorial including underlying COPD, OSA requiring
CPAP at home, volume overload and possible pneumonia. He was
continued on BiPAP, completed antibiotic course for aommunity
acquired pneumonia, and attempted to diurese. Initially, his
fluid balance was positive and he did not respond to lasix gtt
or bolus due to presumed post-contrast ATN. After discontinuing
lasix gtt, urine output imrpoved temporarily, however, after
renal consult lasix gtt was restarted with improved diuresis.
He was transitioned to his home CPAP at night with intermittant
use during the day (alternating with high flow oxygen). His
breathing improved with diuresis. When off of BiPAP, his
outpatient COPD medications were restarted. His breathing
continued to improve over his hospital course with no oxygen
requirement during the day and continued CPAP usage at night.
He was evaluated by PT who cleared him for discharge. His O2
requirement continued to improve and by the time of discharge he
was satting 95% on room air, even while ambulating with Physical
therapy.
2. NSTEMI/CAD: Mr. [**Known lastname 41628**] was transferred from an outside
hospital for cardiac catheterization in setting of chest pain
and ruling in for NSTEMI by cardiac enzymes. On cardiac
catheterization he had DES placed to ramus and was chest pain
free post-procedure and for rest of admission. Continue on high
dose aspirin. Plavix 75 mg daily started, will need to be
continued for 1 year. Continued metoprolol and Imdur as
prescribed as an outpatient. His simvastatin was changed to
Lipitor 80 mg with no adverse effect, however based on lipid
studies, statin was changed back to simvastatin that he took as
outpatient. Ranexa was continued for angina. Echo was very
suboptimal post-procedure with limited information interpreted
from it, possible LVEF of 55%. Mr. [**Known lastname 41628**] was previously on [**First Name8 (NamePattern2) **]
[**Last Name (un) **]/HCTZ combination, however given his acute renal failure this
was held during the course of his admission and no ACE-I or
other [**Last Name (un) **] was started. He remained chest pain free for the rest
of the admission.
3. ACUTE ON CHRONIC RENAL FAILURE: Mr. [**Known lastname 41629**] renal function
was impaired on admission with concern for possible new baseline
at OSH of approx [**2-6**]. His creatinine on admission was 3.7 and
worsened daily post-catheterization, felt to be consistent with
post-contrast ATN. Initial volume status was positive due to
poor urine output. Urine output improved with lasix gtt and Mr.
[**Known lastname 41628**] diuresed steadily. Nephrology was consulted and
recommended monitoring patient to avoid dialysis. Creatinine
peaked at 8.3 and trended down there after with good urine
output. He was started a phospherus binder during the admission
but at time of discharge, it was no longer needed. Creatinine
continued to trend down and plan at the time of discharge was
for pt to f/u with Dr. [**Last Name (STitle) **] his outpatient nephrologist as
soon as possible, ideally early next week. After discussion with
the renal team, it was decided that he would restart lasix 120mg
PO daily on Monday [**4-14**].
4. HYPERTENSION: Mr. [**Known lastname 41628**] was continued on his outpatient
medications while admitted - amlodipine, metoprolol, Imdur. Due
to acute on chronic renal failure, Diovan was held. In setting
of ACS, hydralazine was started and titrated as tolerated for
optimal blood pressure control. He tolerated this medication
well. As he was diuresed, hydralazine was decreased slightly.
During later portion of hospitalization, blood pressure
parameters were relaxed to keep renal perfusion optimal.
5. DIABETES TYPE 2: poorly controlled as HgA1c 10%. He was
continued on NPH 100u qAM and qPM during admission, with
modifications as needed due to Po intake. He was covered with a
humalog sliding scale for meals.
6. HYPOTHYROIDISM: Patient is s/p partial thyroidectomy for
thyroid nodules in [**2190**]. Levothyroxine 50mcg /daily as per
outpt dosing was continued in house.
Medications on Admission:
Mucomyst pre cath
Lopressor 75mg
Allopurinol 200mg daily
Amlodipine 10mg daily
Isosorbide Mononitrate 90mg [**Hospital1 **]
Diovan 320mg daily
Simvastatin 20mg daily
Ezetimibe 10mg
Plavix 75mg
Aspirin 81mg daily
Renexa 500mg [**Hospital1 **]
Levaquin 500mg qod (for ? right sided pneumonia, urine + for
bacteria)
Levothyroxine 50 mcg daily
Insulin NPH 100u qAM and 100u qPM
Humalog sliding scale
Vitamin D
Advair Diskus 250/50 1 puff [**Hospital1 **]
Spiriva
Trazadone 50mg QHS
Senna
Colace 100mg PRN
Albuterol PRN
Furosemide
Loratidine 10mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*6*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO BID (2 times a day).
9. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
14. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Fifty
(50) units Subcutaneous twice a day: 50 units qAM and 50 units
qPM .
16. Humalog 100 unit/mL Cartridge Sig: ASDIR Subcutaneous
ASDIR: per home sliding scale.
17. Isosorbide Mononitrate 120 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
18. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
19. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic Renal Failure
Acute on Chronic Systolic congestive Heart Failure
Coronary Artery Disease
Chronic obstructive pulmonary disease (COPD)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure being involved in your care, Mr. [**Known lastname 41628**]. You
came to the hospital with chest pain and difficulty breathing,
underwent cardiac catheterization, where you received a stent to
one of the small blood vessels that supplies your heart. You
came to the CCU (cardiac intensive care unit) because of
difficulty breathing after the procedure, which required BiPAP.
Your course was also complicated by renal failure which could
have been caused by the contrast load needed for catheterization
on top of your underlying kidney dysfunction.
Your Medications have CHANGED as follows:
1. INCREASED your aspirin from 81mg to 325mg daily
2. ADDED PLAVIX 75mg daily. It is VERY IMPORTANT to take this
medication EVERY DAY. Do NOT miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] of this medication
as it is crucial to keep your stent working- to supply blood
flow to your heart.
3. We DISCONTINUED your Diovan (valsartan 320mg daily) Because
of your renal function. Please do not restart this unless it is
safe to do so per your outpatient kidney doctor.
4. We ask you restart your LASIX 120mg daily on Monday [**4-14**].
Per the kidney doctors, take this ONCE PER DAY. (You used to
take it twice daily).
5. We DECREASED Your Allopurinol from 200mg daily to 100mg EVERY
OTHER DAY due to your kidney function
6. CHANGED Imdur 90mg twice per day--> to 120mg daily
7. ADDED hydralazine 10mg three times per day
8. ADDED ranitidine 150mg daily for your stomach upset/acid
** PLEASE CALL YOUR KIDNEY DOCTOR TO MAKE AN APPOINTMENT FOR
EARLY NEXT WEEK
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] M. Phone: [**Telephone/Fax (1) 17919**] Date/time: Thursday [**4-17**] at 1:00pm.
.
Nephrology: PLEASE CALL YOUR OUTPATIENT NEPHROLOGIST DR. [**Last Name (STitle) **]
AND MAKE AN APPOINTMENT TO SEE HIM WITHIN ONE WEEK
.
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) 488**] D. Phone: [**Telephone/Fax (1) 8725**] Date/time: [**5-7**] at
12;30pm.
DR[**Doctor Last Name **] Office number is [**Telephone/Fax (1) 2037**] so you can call and
make an appointment regarding your pacer.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2194-4-12**]
|
[
"41071",
"5845",
"486",
"51881",
"41401",
"2724",
"496",
"32723",
"40390",
"2449",
"4280"
] |
Admission Date: [**2188-6-9**] Discharge Date: [**2188-6-14**]
Date of Birth: [**2154-1-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
34M HIV (?CD4 100, VL 115K), DM here with hyperglycemia after
episode of cough and abdominal pain. USOH until ~5d prior to
admission, began to have nausea, vomiting, diarrhea, mild
abdominal discomfort in lower quadrants bilat, unable to
tolerate POs. In addition, noted muscle and back pains (thought
[**1-31**] work), non productive cough. Noted fever of 100-101 at home,
chills on arrival to ED. Denies sick contacts, never had
opportunistic infections. Stopped taking Lantus (50U HS) at that
time as he had been unable to take PO. Endorses polydipsia, but
no polyuria, no vision changes. States that he last took FS
regularly 5 days ago, and may have taken FS once two days ago
(?170s). Otherwise, denies chest pain, SOB, wheeze, joint pain,
rashes, dysuria.
.
In ED, given 3L NS, started on insulin gtt, given CTX/Flagyl for
presumed PNA (although CXR negative).
Past Medical History:
- HIV (sexually transmitted, not on [**Month/Day (2) 2775**], no opportunistic
infections)
- DM, dx 8 yrs ago, previously on orals. On 70/30 for ~4 years,
then recently changed to Lantus ~one month ago per pt.
- Corneal ulcer
- Asymmetric Pupils, L>R
Social History:
Works intermittently as caterer. On disability now, had been a
school bus driver for disabled kids previously. Denies alcohol,
tobacco, drug or IV drug use. Sexually active with male partners
too numerous to count w/o condom use.
Family History:
DM on father's side. CA on mother's side. No kidney disease
Physical Exam:
(on transfer to floor)
VS - Tm 98.1, Tc 97.5, BP 118/68, HR 82, RR 20, sats 100% on RA
FS 111
Gen: WDWN young male in NAD.
HEENT: Sclera anicteric. Irises different color (contact on R).
L pupil > R, both reactive to light. OP clear, no thrush. No
cervical LAD. MMM.
CV: RR, normal S1, S2. No m/r/g.
Lungs: CTAB, no crackles/wheezes/rhonchi.
Abd: Soft, NTND. No HSM appreciated. + BS. + costal margin
tenderness bilaterally.
Ext: 2+ radial, PT pulses bilaterally. No c/c/e.
Skin: No rashes.
Pertinent Results:
LABS on admission:
WBC 13.0, Hct 29.4, MCV 83, Plt 95
88%N, 7.0%L, 3.1%M, many smudge cells
MICRO:
[**2188-6-9**] blood cx - 4/4 bottles + for E.coli
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2188-6-9**] urine cx - 10-100,000 E.coli
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- 1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2188-6-9**] mycolytic blood cx - pending
[**2188-6-9**] blood cx - pending
[**2188-6-10**] blood cx - pending
[**2188-6-11**] urine cx - no growth
.
IMAGING:
[**2188-6-9**] CXR: The cardiac, mediastinal, and hilar contours are
within normal limits. Pulmonary vasculature is unremarkable. The
lungs appear clear. No pleural effusions or pneumothoraces are
identified. Surrounding osseous and soft tissue structures
appear unremarkable.
.
[**2188-6-9**] CXR: Increased left retrocardiac opacity with time
course favoring atelectasis, though pneumonia cannot be
excluded.
.
[**2188-6-9**] CXR:
1. Right subclavian central venous catheter tip in the mid SVC
without pneumothorax.
2. Patchy bibasilar opacities, which may represent atelectasis
or aspiration with new tiny bilateral pleural effusions.
.
[**2188-6-10**] ABD U/S:
1. No evidence of nephrolithiasis or cholelithiasis. Mild
gallbladder distention with a small amount of surrounding fluid.
If symptoms worsen, follow up is recommended.
2. Simple-appearing cyst in the left kidney.
3. Splenomegaly
.
[**2188-6-10**] CXR: Improved pulmonary edema. Increased small left
pleural effusion.
.
[**2188-6-12**] LIVER U/S: The liver is normal in contour and
echotexture without focal lesions. No evidence of intra- or
extra-hepatic ductal dilatation. The portal vein demonstrates
appropriate forward flow. The gallbladder again is slightly
distended with no evidence of wall thickening, no gallstones
present, and no demonstrable surrounding fluid. The right kidney
measures approximately 12 cm.
IMPRESSION: Unchanged slightly distended gallbladder. No
additional son[**Name (NI) 493**] evidence of cholecystitis.
Brief Hospital Course:
34yo M w/ HIV and DM type I, presents w/ DKA, ARF, and elevated
LFTs in setting of Ecoli urosepsis/bacteremia.
.
# GASTROENTERITIS: Diarrhea and nausea appear to have resolved
at this time.
-check stool studies if pt continues to have diarrhea
# DKA: Pt was seen by [**Last Name (un) **] consult who thinks he has type I DM
and DKA. His insulin gtt was stopped last night and he was
started on standing lantus. His gap is closing and his BS are
currently in the 200s and being treated with humalog.
-serum betahydroxybutyrate pending
-pt taking in POs
-appreciate Josline recs
- q 8 hour electrolyte checks, and more frequently if BS cont to
rise
- cont q hr FS while in unit and cover with humalog SS
(tightened this Am)
Resolved now. Likely due to the combination of no insulin and
urosepsis. Now on SC insulin. [**Last Name (un) **] following. Needs DM
education as pt did not know how to modify insulin w/ his
illness.
- cont lantus + HISS
- f/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] recs
- ? how to enroll pt in diabetes education
.
# ARF: Slowly resolving. Cr down to 5.0, still w/ good UOP. FeNa
suggestive of ATN, and per renal, feel that Cr will likely
improve w/ time. Most likely combination of ATN and severe
prerenal state in setting of n/v/d + DKA. Urine eos pending.
Renal had been following, signed off today.
- d/c Tums
- f/u urine eos
- f/u BUN/Cr in 1 week
- avoid nephrotoxic agents
- renally dose meds
- supportive care
.
# BACTEREMIA: Mr. [**Known lastname 32713**] likely had urosepsis, as he grew Ecoli
in [**4-1**] blood cx from [**2188-6-9**], as well as his urine cx from
[**2188-6-9**]. Blood cx since are no growth, urine is no growth. He
had originally been started on ceftriaxone and flagyl, but once
his cultures returned w/ sensistivities to CTX, his flagyl was
discontinued. Has been on ceftriaxone since [**2188-6-9**]. ? if can
switch to PO levofloxacin tomorrow.
- f/u cultures
- monitor WBC and fever curve
- switch to PO abx when able
.
# TRANSAMINITIS: LFTs are trending up. Pt c/o right sided pain
that was intially thought to be RUQ pain, but today he is c/o
rib pain. An abdominal ultrasound was done two days ago that
showed slightly edematous GB but no cholelithiasis or
choledocholithiasis.
-trend LFTs, if cont to rise could get repeat RUQ or abd CT (to
also evaluate for pyelo-but would have to be non-contrast)
Unclear etiology to his transaminitis/abnormal LFTs. ALT, alk
phos, GGT elevated, but liver U/S without evidence of
cholecystitis. ? ceftriaxone induced as abnormalities began
[**2188-6-11**], after start of abx (but no evidence of ductal
dilatation). Hep panel pending, as are hemolysis labs.
- f/u hepatitis panel
- f/u hemolysis labs
- monitor LFTs daily
.
# METABOLIC ACIDOSIS: Non-gap acidosis, secondary to etihter
renal failure, RTA, or resolving diarrhea.
- f/u urine lytes
.
# HIV: Per his PCP, [**Name10 (NameIs) 2775**] was not initiated while the patient
was hospitalized. This discussion will be deferred to the
outpatient setting.
.
# SMUDGE CELLS/SPLENOMEGALY: Concerning for a heme malignancy,
but could also be due to his acute illness. These findings
should be followed up as outpatient. Will convey this to his
PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **].
.
# THROMBOCYTOPENIA: Likely secondary to HIV/splenomegaly. Will
check platelets daily. No concern for DIC or TTP at present.
- monitor plts daily
.
# FEN: Regular [**Doctor First Name **] diet. No IVF. Check lytes daily, replete prn.
- nutrition consult given his low albumin
- sugar free shakes as supplement
.
# ACCESS: 2 peripheral IV and triple lumen SC on R
- ? can d/c R SC line today (was placed on [**6-9**])
.
# PPX: Hep SC, PPI, no bowel regimen given recent diarrhea
.
# CODE: FULL
.
# DISPO: To home, possibly tomorrow. ? outpt SW or other
services.
Discharge Medications:
1. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
Disp:*75 ML(s)* Refills:*0*
2. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous at bedtime.
3. Insulin Lispro (Human) 100 unit/mL Solution Sig: Varied units
Subcutaneous four times a day: As per sliding scale.
Disp:*qs 1 month units* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
5. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
Disp:*9 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
E.coli bacteremia
E.coli UTI
DKA
ARF
Transaminitis
.
Secondary diagnosis:
HIV
DM type I
Discharge Condition:
Good. Afebrile, VSS.
Discharge Instructions:
Please call your PCP or go to the nearest ER if you develop any
of the following symptoms: fever >101, chills, shortness of
breath, difficulty breathing, chest pain, shortness of breath,
inability to urinate, back pain, nausea, vomiting, diarrhea, or
any other worrisome symptoms.
.
Please complete the full course of your antibiotic - last dose
is [**2188-6-23**]
.
Please keep all your follow-up appointments as outlined below.
It is very important that you see Dr. [**Last Name (STitle) **] on [**Last Name (STitle) 2974**] of next
week to have your labs drawn to make sure your Creatinine and
Liver function tests are stable.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] on [**Last Name (STitle) 2974**] [**6-20**] at
10:40am.
You need to have BUN/Cr and LFTs checked in 1 week to make sure
that they have all returned to baseline. Please call
[**Telephone/Fax (1) 2776**] if you have any questions or concerns.
.
Please follow-up with [**First Name9 (NamePattern2) 32887**] [**Doctor Last Name 1726**] (Diabetes Educator) at
[**Last Name (un) **] on [**Last Name (LF) 2974**], [**6-20**], at 1pm. Please call her office at
[**Telephone/Fax (1) 2384**] if you have any questions or concerns.
|
[
"5845",
"5990",
"2875",
"2762",
"99592",
"V5867",
"2859"
] |
Admission Date: [**2122-1-15**] Discharge Date: [**2122-2-11**]
Date of Birth: [**2058-8-17**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Erythromycin Base / Dipentum / Asacol / Purinethol
/ Colazal
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
Right Internal Jugular Catheter
Right Femora Vein Catheter
Left Radial Artery Catheter
History of Present Illness:
Patient is a 63 yo female with history of severe COPD and asthma
on chronic prednisone therapy and home O2 with a poor basline
exercise tolerance with DOE walking across the room. She has
been hospitalized several times in the past ten years but has
had no prior intubations. On [**2122-1-5**] she complained of
increasing shortness of breath and went to see her PCP. [**Name10 (NameIs) **] her
PCP's office her sat's were in the 80's and she was in moderate
respiratory distress. She improved slightly with nebs and
refused hospitalization at that time. She went home and was
started on 40 mg Prednisone. She did not have a significant
improvement over the next week. On [**2122-1-12**] she became acutetly
SOB while walking to the car to go to her follow up appointment
with her PCP and instead went to the local ED in [**Location (un) 45887**] VT.
At the ED her ABG was 7.24/ CO2 79/ O2 91. She was admitted and
initially maintained on NC then bipap (which she did not
tolerate). At 1 am on [**1-14**] her blood gas was 7.11/ 113/ 85 and
she was inubated. She was placed on SIMV at 10x500 16PSV FIO2
)0.4. Her blood gas on these sttings was 7.29/64/74. She was
started on solumedrol 125mg q6 and IV aminophylline 20 mg/hr.
She was transferred to the [**Hospital Unit Name 153**] for managment of high peak
airway pressures up to the high 40's.
Past Medical History:
COPD on chronic prednisone with a baseline O2 requirment and
dyspnea with minimal exertion
Asthma
Ulcerative Colitis
Fractured L hip
Social History:
Patient lives with her husband in [**Name (NI) 45887**] VT, she works part
time as a special-ed teacher. She has a distant smoking history
and occasional EtOH.
Physical Exam:
T: 99.5 BP: 136/74 HR:122
Gen: Patient sedated but in some distress on the vent with very
strong abdominal excursions.
HEENT: PERRL [**2-4**] OU, modereate chemosis, no JVD
Chest: very distant breath sounds, expiratory wheezes throughout
CV: tachy, RRR no MRG
AB: soft during inspiration rigid during expiration, +BS
Ext: no c/c/e
Neuro: does not respond to sternal rub
Pertinent Results:
[**2122-1-15**] 08:40AM BLOOD WBC-16.6* RBC-3.79* Hgb-12.6 Hct-37.9
MCV-100* MCH-33.3* MCHC-33.3 RDW-13.5 Plt Ct-376
[**2122-1-15**] 08:40AM BLOOD Neuts-91* Bands-3 Lymphs-3* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2122-1-15**] 08:40AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-NORMAL
[**2122-1-15**] 10:00AM BLOOD PT-12.1 PTT-23.7 INR(PT)-0.9
[**2122-1-15**] 08:40AM BLOOD Plt Smr-NORMAL Plt Ct-376
[**2122-1-15**] 08:40AM BLOOD Glucose-129* UreaN-10 Creat-0.6 Na-139
K-5.5* Cl-103 HCO3-31* AnGap-11
[**2122-1-15**] 08:40AM BLOOD Calcium-7.4* Phos-2.4* Mg-2.4
[**2122-1-16**] 08:39AM BLOOD Theophy-2.5*
[**2122-1-15**] 07:45AM BLOOD Type-ART pO2-88 pCO2-81* pH-7.18*
calHCO3-32* Base XS-0
[**2122-1-15**] 07:45AM BLOOD Lactate-1.0
[**2122-1-15**] 04:29PM BLOOD K-4.7
[**2122-1-15**] 10:27AM BLOOD freeCa-1.09*
Echocardiogram ([**2122-2-5**])- Limited/poor study secondary to patient
being tachycardic. LV systolic function appears depressed with
probable
mid to distal anteroseptal hypokinesis and possible apical
hypokinesis but views are technically suboptimal for assessment
of regional wall motion.
Estimated ejection fraction ?45-50%.
Brief Hospital Course:
When the patient arrived on [**1-15**] she was awake and anxious, and
with respiratory disynchrony on SIMV mode. She was started on
Versed 4mg/hr and Fentanyl 100mcg/hr with good effect on
comfortable on the ventilator. We discontinued the Theophylline
and continued the Levoquin and Ceftriaxone that were initiated
at the OSH.
On [**1-16**] her chest exam deteriorated with very poor air movement
and wheezes. She also had very high "auto"-PEEP, as high as 25.
She was restarted on IV aminophylline and her sedation was
increased and paralysis was considered. With increased sedation
her "autt"-PEEP decreased as well as her PIPs. Auto-PEEP was an
issue daily and she required periodic removal from the
ventilator to exsuflate the auto-PEEP.
On [**1-21**] the patient became tachycardic to the 130's and
hypertensive to the 150's SBP in the setting of decreasing
sedation and vent disynchrony. She started on propofol and her
HR and BP normalized. An EKG taken at the time showed ST
depressions in leads v4-6 and t wave changes in II and III.
Cardiac enzymes were negative. Auto-PEEP continued to be an
issue in times of sedation weaning so the patient was kept fully
sedated on propofol while versed and fentanyl were slowly
weaned. In light of the fact that the main obstacle to
extubation was aggitation during weaning of sedation a
tracheostomy was thought to be of benefit because it would be
less uncomfortable. She was evaluated by IP but her anatomy was
too difficult for a percutaneous trach. Thoracic surgery was
consulted, however on the day of her procedure her PTT became
elevated into the 60's in isolation of any other coagulation
abnormality. She was given FFP and her PTT trended down
appropriately. It was therefore decided that the SC Heparin was
responsible for the elevated PTT. She received a Trach and PEG
on [**1-26**].
Weaning attempts were again initiated however the patient had
several episodes of hypertension to the 170's and tachycardia to
the 120's. She was treated with IV lopressor PRN that
transiently normalized her HR and BP. Her EKGs showed no
evidence of ischemia. On [**1-28**] she was started on an esmolol
drip for HR control. Hypotension then became an issue and the
esmolol was discontinued. Her blood pressure continued to
fluctuate and she recieved several NS boluses during hypotensive
episodes and lopressor PRN for tachy/hypertension.
She became more awake and interactive for the first time on [**1-30**]
and was following commands appropriately. Patient continued to
improve but had limited range of motion. An EMG was done which
was consistent with diffuse myopathy suggestive of ICU myopathy.
Neurology was consulted who recommended tapering steroids and
occupational and physical therapy. Steroids were tapered down
to standing dose of prednisone 5mg qd.
Patient spiked a temperature on [**2-2**] while on vancomycin.
Vancomycin was switched to linezolid and patient breifly started
on levofloxacin and aztreonam for empiric treatment of
ventilator associated pnuemonia. Patient wound swab from trach
site came back positive for VRE and MRSA. Levofloxacin and
aztreonam were discontinued after blood cultures showed no
growth and sputum clture came back positive for only MRSA.
Patient to complete 14 day course of linezolid (Day#1 was [**2-2**]).
An EKG was done on [**2122-2-4**] for concern for prolonged QT interval.
Patient's QT interval was normal however patient now had
diffuse TWI in precordial leads which were not seen on EKG on
admission. Patient had an echocardiogram done which was a
limited study but showed a LVEF of 40-50% and septal and apical
hypokinesis. However cardiac enzymes were flat. Patient was
started on beta-blocker which was titrated up as patient blood
pressure tolerated. Once patient more stable will need further
evaluation of heart function outpatient. Patient with elevated
blood sugars during admission, which was felt to be secondary to
steroids. Patient initially on insulin drip and then swtiched
to NPH and insulin sliding scale. She continued to do well on
the vent and was slowly weaned down on the vent on pressure
support.
Medications on Admission:
Theophylline 500 mg qd
Singulair 10 mg QD
Lorazepam 0.5 mg PRN
Temazepam 15mg PRN
Prednisone 3 mg QD
Albuterol MDI PRN
Atrovent 2 puffs QID
Flovent [**Hospital1 **]
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours).
5. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q2-4H (every 2 to 4 hours) as needed.
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
8. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
9. Acetaminophen 160 mg/5 mL Elixir Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
10. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed) as needed for rash.
11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
12. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral PRN (as
needed) as needed for pain rash.
13. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours).
14. Morphine Sulfate 10 mg/5 mL Solution Sig: One (1) PO Q4H
(every 4 hours) as needed.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
16. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days.
18. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
20. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
21. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
22. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QD () as
needed for anxiety.
23. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
24. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous qam.
25. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten
(10) Units Subcutaneous at bedtime.
26. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 59111**]
Discharge Diagnosis:
COPD exacerbation
Pneumonia
Cardiomyopathy
Discharge Condition:
Stable - Patient with ICU myopathy that should improve daily
with physical and occupational therapy. Patient on ventilator
however improving everyday, and continued to be weaned off.
Discharge Instructions:
Please follow up with your Primary Care doctor [**First Name (Titles) **] [**Last Name (Titles) 59112**]
of rehabilitation. During your admission your heart function
was found to be depressed. Once your condition is more improved
you should either follow up with your primary care doctor for
further evaluation of your heart function.
Followup Instructions:
Please follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 59113**] for further evaluation of your heart function, COPD
management, and workup for diabetes.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"42789",
"4019"
] |
Admission Date: [**2140-6-29**] Discharge Date: [**2140-7-12**]
Date of Birth: [**2060-12-13**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4277**]
Chief Complaint:
R calf pain
Major Surgical or Invasive Procedure:
Resection of neurofibrosarcoma R calf
History of Present Illness:
Mr. [**Known lastname 61773**] is a 79 year old gentleman with a history of
Neurofibromatosis. He presented to clinic with a painful right
calf mass. This mass was biopsied and proved to be a
neurofibrosarcoma. He underwent radiation therapy for this, but
unfortunately this did not significantly change his symptoms.
After a discussion of the risks and benefits of surgical
resection he elected to procede with surgery.
Past Medical History:
Neurofibromatosis
CAD w/CABG X2
Social History:
Lives alone.
Grandaughter in [**State 108**]
Pertinent Results:
[**2140-6-29**] 07:01PM TYPE-ART O2-100 PO2-100 PCO2-48* PH-7.36
TOTAL CO2-28 BASE XS-0 AADO2-588 REQ O2-93 COMMENTS-FACE MASK
Brief Hospital Course:
Patient was admitted through the same day surgery program. He
surgery was uneventful and he was extubated and came to PACU in
stable condition. Unfortunatlely while in pacu he began to have
respiratory difficulty and had to be intubated. He was admitted
to the ICU and a chest CT revealed a pulmonary embolus. He was
started on a heparin drip and given supportive care in the ICU.
Unfortunately he was unable to come off of the ventilator and
began to require more supportive care including pressor and
increasing ventilator support. After 13 days the granddaughter
elected to withdraw support and give comfort care only. Mr.
[**Name14 (STitle) 61774**] was extubated in the morning of [**7-12**] and expired
shortly therafter.
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulmonary Embolus following resection of Neurofibrosarcoma R
calf.
Discharge Condition:
Deceased
Completed by:[**2140-7-14**]
|
[
"486",
"2859",
"V4581"
] |
Admission Date: [**2175-6-21**] Discharge Date: [**2175-6-27**]
Date of Birth: [**2108-7-14**] Sex: F
Service: VASCULAR
CHIEF COMPLAINT: Bilateral claudication.
HISTORY OF PRESENT ILLNESS: This 66 year-old female with a
past medical history of peripheral vascular disease,
hypertension, protein C deficiency, anticoagulated and
multiple myeloma who presents with life limiting claudication
who now presents for elective peripheral revascularization.
PAST MEDICAL HISTORY:
Multiple myeloma that was diagnosed in [**2166**], history of
gastrointestinal bleed asymptomatic, history of peripheral
vascular disease. History of urinary tract infections most
recent was [**5-18**] treated. Left axillary vein thrombosis,
acquired protein C deficiency, anticoagulated.
PAST SURGICAL HISTORY: L5 disc surgery in [**2141**], appendectomy
remote, status post cervical disc in [**2155**] and back surgery in
[**2159**].
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Coumadin 3 mg q.d. last dose was [**6-16**].
2. Protonix.
3. Thatisdonide 100 mg q.d.
SOCIAL HISTORY: The patient is a former smoker of 50 pack
years. Alcohol socially.
PHYSICAL EXAMINATION: Vital signs 132/66, 76. General
appearance this is a pleasant white female in no acute
distress. HEENT examination there were no carotid bruits or
JVD. Lungs are clear to auscultation bilaterally. Heart is
a regular rate and rhythm with a normal S1 and S2. Abdominal
examination was unremarkable. Extremities feet are cool.
There are no ulcerations. There is dependent rubor of the
left foot. There is diminished sensation of the left foot.
The femoral pulses are on the right are palpable, on the left
dopplerable signal. Posterior tibial pulses are palpable
bilaterally. Dorsalis pedis pulses are absent bilaterally.
PREOPERATIVE LABORATORIES: CBC white blood cell count 3.5,
hematocrit 32.0, platelets 150K, INR 1.7, BUN 19, creatinine
1.7, K 5.0, ALT and AST were normal. Alkaline phosphatase
was normal. Total bilirubin was normal. Chest x-ray was
unremarkable. Electrocardiogram was sinus bradycardia with
left ventricular hypertrophy by voltage criteria, lateral ST
wave changes secondary to repolarization, nonspecific poor R
wave progression. Probable left atrial enlargement.
HOSPITAL COURSE: The patient was admitted to the
preoperative holding area. On 8/60/03 she underwent
aortobifemoral bypass with Dacron. Intraoperatively she had
episodes of bradycardia hypotension requiring a few chest
compressions at the beginning of the case. Otherwise the
patient did hemodynamically well. Thereafter she required 4
units of packed red blood cells intraoperatively. She was
transferred to the PACU in stable condition. Postoperative
hematocrit was 37.6. She continued to do well and was
transferred to the VICU for continued monitoring and care.
Total CK initial was 55, troponin .01. Perioperative Kefzol
was begun. Postoperative day one there were no overnight
events. Her cardiac index was 3.2, SVR was 1045, CVP 7, PA
60/21. Hematocrit remained stable at 36, BUN 6, creatinine
1.2, K 3.9 repleted. Nasogastric was discontinued. The
patient remained on heparin subQ t.i.d., intravenous fluids
at 200 cc per hour. This was adjusted to LR 150 cc per hour.
She was begun on her Coumadin. She remained in the VICU.
The patient remained in the CICU postoperative day two. She
was extubated. Vital signs remained stable. Hematocrit
remained stable. BUN and creatinine remained stable. She
had a triphasic dorsalis pedis pulse and posterior tibial
pulse bilaterally. Feet were warm. Her morphine sulfate PCA
was converted to po. Analgesics Hydralazine for systolic
hypertension as needed. Physical therapy was to see the
patient. She remained lined and was transferred to the VICU
for continued monitoring and care.
Postoperative day three she was afebrile. She was delined
and transferred to the regular nursing floor. Right IJ was
changed to triple lumen. Chest x-ray was not obtained.
Physical therapy saw the patient and felt that she would be
able to go home after several sessions with physical therapy.
Postoperative day four INR was 3.1. Her Coumadin dosing was
adjusted. Hematocrit remained stable. Platelet count was
90K. Heparin was discontinued. Diet was advanced as
tolerated. Foley was discontinued. She voided without
difficulty. She continued to remain afebrile. Hematocrit
remained stable at 31.2, BUN 23, creatinine 1.4 and stable.
Her physical examination remained unchanged. The patient had
some loose stools, C-diff stool culture was sent and Flagyl
was started empirically. The patient remained on her home
dose of Coumadin. Heparin was discontinued. The Pepcid was
discontinued and we will await rehab screening for [**Hospital 46**]
Rehab. The remaining hospital course was unremarkable.
DISCHARGE MEDICATIONS:
1. Nicotine patch 21 mg q.d. for total of 31 days and then
she should follow up with her primary care physician
regarding graduating her dosages.
2. Insulin sliding scale. Sliding scale was q 6 hours,
glucoses less then 120 no insulin, 121 to 160 2 units, 161 to
200 4 units, 201 to 240 6 units, 241 to 280 8 units, 281 to
320 10 units, greater then 300 12 units.
3. Acetaminophen 325 to 650 mg q 4 to 6 hours prn.
4. Thalidomide 100 mg q.d.
5. Metoprolol 25 mg b.i.d. hold for systolic blood pressure
less then 110, heart rate less then 55.
6. Warfarin 3 mg at h.s.
7. Oxycodone acetaminophen tablets one to two q 4 to 6 hours
prn for pain.
8. Flagyl 500 mg t.i.d.
DISCHARGE DIAGNOSES:
1. Aortoiliac disease status post aortobifemoral.
2. Smoking dependency started on nicotine patch.
3. Hypotension secondary to hypovolemia requiring fluid
boluses and transfusion.
4. Bradycardia secondary to anesthesia corrected.
5. Blood loss anemia corrected.
FOLLOW UP: The patient should follow up with Dr. [**Last Name (STitle) **]
in two weeks time. Skin clips will remain in place until
seen in follow up. The patient may take showers, no tub
baths. No heavy lifting. They should call the office if
they have a temperature of greater then 101.5 or if there is
redness, swelling, drainage from the skin wounds.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2175-6-26**] 12:06
T: [**2175-6-26**] 12:18
JOB#: [**Job Number 101671**]
|
[
"2851",
"3051",
"V5861",
"4019",
"42789"
] |
Admission Date: [**2188-4-2**] Discharge Date: [**2188-4-5**]
Date of Birth: [**2119-12-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fatigue/PAF
Major Surgical or Invasive Procedure:
[**2188-4-3**] - Bilateral mini thoracotomies with MAZE Procedure and
Left Atrial Appendage Ligation.
[**2188-4-2**] - Cardiac Catheterization
History of Present Illness:
68 y/o male with paroxysmal atrial fibrillation and worsening
fatigue. As this continues despite optimal medical management,
he is admitted for a MAZE procedure and left atrial appendage
ligation.
Past Medical History:
PAF
Stroke
HTN
Sleep apnea
Social History:
Land developer. Lives with wife. Past [**Name2 (NI) 1818**] with 24 pyh. [**12-25**]
drinks per night.
Family History:
Noncontributory.
Physical Exam:
GEN: NAD
LUNGS: CTA
HEART: RRR
ABD: Benign
EXT: No edema, 2+ pulses.
NEURO: A+Ox3. Left facial droop.
Pertinent Results:
[**2188-4-2**] 09:15AM PT-14.5* PTT-28.6 INR(PT)-1.3*
[**2188-4-2**] 09:15AM PLT COUNT-272
[**2188-4-2**] 09:15AM WBC-5.7 RBC-4.96 HGB-16.0 HCT-48.3 MCV-98
MCH-32.3* MCHC-33.2 RDW-15.1
[**2188-4-2**] 09:15AM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2188-4-2**] 09:15AM ALT(SGPT)-86* AST(SGOT)-60* ALK PHOS-58
AMYLASE-77 TOT BILI-0.3 DIR BILI-0.1 INDIR BIL-0.2
[**2188-4-2**] 09:15AM GLUCOSE-99 UREA N-19 CREAT-1.2 SODIUM-140
POTASSIUM-5.0 CHLORIDE-106 TOTAL CO2-27 ANION GAP-12
[**2188-4-2**] 04:45PM PT-13.7* PTT-27.3 INR(PT)-1.2*
[**2188-4-2**] - Carotid Duplex Ultrasound
1. Less than 40% stenosis of the internal carotid arteries
bilaterally.
2. No evidence of significant peripheral vascular disease on
both legs at rest and post-exercise.
[**2188-4-2**] - Cardiac Catheterization
1. Selective coronary angiography of this right dominant system
revealed
no evidence of coronary artery disease. The LMCA, LAD, LCx, and
RCA were
all widely patent.
2. Limited resting hemodynamics revealed an opening aortic
pressure of
138/65mmHg.
3. Left ventriculography was deferred.
[**2188-4-3**] ECHO
1. The left atrium is moderately dilated. Mild spontaneous echo
contrast is present in the left atrial appendage. A left atrial
appendage thrombus cannot be excluded.
2. A small secundum atrial septal defect is present in the
membranous portion.
3. Overall left ventricular systolic function is normal
(LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
6. The mitral valve leaflets are structurally normal. Mild (1+)
mitral
regurgitation is seen.
7. There is no pericardial effusion.
8. Simple atheroma noted in the descending thoracic aorta
9. LAA ligated by surgeons - visualized obliteration of LAA
cavity and
maintained patency of L circ. All walls moving normally s/p
ligation
Brief Hospital Course:
Mr. [**Known lastname 20692**] was admitted to the [**Hospital1 18**] on [**2188-4-2**] for surgical
management of his paroxysmal atrial fibrillation. A cardiac
catheterization and echocardiogram was performed in prepartion
for surgery, both of which were normal. Please see reports for
details. Heparin was started as he had been off his coumadin for
five days. On [**2188-4-3**], he was taken to the operating room where
he underwent bilateral mini thoracotomies with a MAZE procedure
and left atrial appendage ligation. Postoperatively he was taken
to the cardiac surgical intensive care unit for monitoring. By
postoperative day one, he was extubated and neurologically
intact. He was then transferred to the step down unit for
further recovery. Amiodarone and coumadin were restarted.
On POD#2, he was cleared by physical therapy to go home. His
subcutaneous pain medication pumps were discontinued. He felt
well and was able to care for himself. He is to follow up in
clinic with Dr. [**Last Name (STitle) 914**].
Medications on Admission:
Amiodarone
Toprol
Coumadin
Spiriva
Aspirin
Viagra
Multivitamins
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: Take while on narcotic medication.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
allcare vna
Discharge Diagnosis:
PAF
Stroke
HTN
Sleep Apnea
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. No bathing or swimming
for 1 month. Use sunscreen on incision if exposed to sun.
5)No lifting greater then 10 pounds for 10 weeks.
6)No driving for 1 month.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 1504**] in 1 month.
Follow-up with Dr. [**First Name (STitle) 216**] in [**1-27**] weeks. ([**Telephone/Fax (1) 1300**]
Please call for all appointments.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2188-7-16**] 12:40
Provider: [**Name10 (NameIs) 2841**] LABORATORY Date/Time:[**2188-5-6**] 2:30
Provider: [**Name10 (NameIs) **] AWAKE [**Name10 (NameIs) **] LAB - [**Hospital Ward Name **] 5 Date/Time:[**2188-5-6**] 1:00
Completed by:[**2188-4-5**]
|
[
"42731",
"4019",
"32723"
] |
Admission Date: [**2132-1-16**] Discharge Date: [**2132-1-21**]
Date of Birth: [**2132-1-16**] Sex: M
Service: NB
HISTORY: Baby boy [**Known lastname 6431**] is the 3.55 kg product of a term
gestation born to a 38-year-old G6, P2, now 3 mother. This
pregnancy was apparently uncomplicated.
Prenatal screens notable for hepatitis surface antigen
negative, RPR nonreactive, GBS negative, O positive, antibody
negative, rubella non-immune, no sepsis risk factors noted.
FAMILY HISTORY: Notable for positive PPD. Mother is non-
English speaking. The infant delivered via spontaneous
vaginal delivery with precipitous vaginal delivery with thin
meconium stained amniotic fluid. The infant was vigorous at
delivery. No intubation needed. Apgars were 8 and 9.
In the newborn nursery, the infant noted to have periodic
breathing prompting transfer to the newborn intensive care
unit. Of mother received [**Name (NI) **] approximately 45 minutes
prior to delivery.
PHYSICAL EXAMINATION: The infant was quiet, nondysmorphic
infant with occasional periodic breathing. Skin without
lesions except for facial bruising. HEAD, EARS, EYES, NOSE
AND THROAT: Normal with the exception of conjunctival
hemorrhages with normal retina. CARDIOVASCULAR: Normal S1 and
S2 without murmurs. LUNGS: Clear. ABDOMEN: Benign. GENITALIA:
Normal male. Anus patent. SPINE: Intact. HIPS: Normal.
NEUROLOGIC: Notable for slightly decreased activity and
decreased tone, symmetric moving all extremities. Episodes of
clonic movements of lower extremities noted with agitation
and stimulation.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: [**Doctor First Name **]
has been stable in room air with the exception of occasional
apneic episodes on admission. These resolved within the first
12 hours of life and have been stable since that time.
CARDIOVASCULAR: The infant has had no cardiovascular
concerns.
FLUIDS AND ELECTROLYTES: Birth weight was 3.555 kg. Discharge
weight is 3445 gram. The infant was initially started on 60 cc
per kg per day of D10W. Enteral feedings were initiated on day of
life 1. The infant continues to ad lib breast feed or
supplement with Similac 20 calorie.
GASTROINTESTINAL: Bilirubin on day of life No. 4 was
10.8/0.3.
HEMATOLOGY: Hematocrit on admission was 48.7.
INFECTIOUS DISEASE: CBC and blood culture obtained on
admission. CBC was benign and blood cultures grew back
positive for 2 species of staph epidermidis at which time
ampicillin and gentamycin were discontinued as it was felt to
be contaminant.
NEUROLOGIC: Due to concerning clinical picture for potential
seizures, a CT scan was performed and was read as within
normal limits.
An EEG was performed and was read as negative.
Electrolytes were obtained at the time of concern which were
within normal limits with a sodium of 138, potassium of 4.2,
chloride of 104, and total CO2 of 26. Serum calcium of 9.1,
magnesium of 2.2, and phos of 5.8. Those were all drawn on
[**1-16**] on admission. The infant has transitioned through his
concerning neuro presentation and it is now likely thought to be
a transitional issue related to his delivery with [**Month (only) **] prior to
delivery and the precipitous delivery with meconium.
SENSORY: Hearing screen was performed automated auditory
brain stem responses and the infant passed.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **]. Telephone No.: [**Telephone/Fax (1) 71639**].
CARE RECOMMENDATIONS:
1. Feeds at discharge: Continue ad lib breast feeding with
Similac 20 calories.
2. Medications: None.
3. Car seat position screening: not applicable.
4. State newborn screens were sent on [**2132-1-19**].
5. Immunizations received: The infant received Hepatitis B
vaccine on [**2132-1-20**].
DISCHARGE DIAGNOSES: 1)Apnea secondary to late transition.
2)Rule out sepsis with antibiotics.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 66930**]
MEDQUIST36
D: [**2132-1-20**] 23:21:06
T: [**2132-1-21**] 01:03:56
Job#: [**Job Number 71640**]
|
[
"V290",
"V053"
] |
Admission Date: [**2159-7-30**] Discharge Date: [**2159-8-13**]
Date of Birth: [**2130-2-24**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 562**]
Chief Complaint:
Fever, cough and progressive SOB x 2weeks
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
29yo male with hx of childhood asthma presents reports that
approximatley 2 weeks ago he began noticing a productive cough.
Spiked fever to 103F @ home. Went to see PCP, [**Name10 (NameIs) **] was late and
told that he would have to come back. Patient continued to feel
fatigued, and began noticing some difficulty catching his
breath. Returned to PCPs office and found to be tachypneic,
tachycardic, with sats of low 80% on 2liters nasal cannula.
Transported via EMS to ED for further eval and treatment.
Received 1 gram ceftriaxone and 500mg Levaquin in ED with total
of 4mg of morphine. CXR showed LLL pna. Evaled by MICU and
admitted for pulmonary monitoring/treatment. No acute episodes
in MICU, sating in high 90% on Nonrebreather mask. Called out
for transfer to CC7 floor bed. [**7-31**] onset of non-bloody
diarrhea, ova/parasites sent along with urine legionel antigen.
Patient sating well on floor. Desats to 90-92% on room air, and
to 85% with any ambulation so MICU called to evaluate. ABG was
7.47/40/47
Past Medical History:
1.Asthma (as a child, no episodes in past 2-3years, no prior
intubations or hospitilizations for attacks)
Pertinent Results:
[**2159-7-30**] 06:15PM LACTATE-1.2
[**2159-7-30**] 04:08PM LACTATE-2.9*
[**2159-7-30**] 03:20PM GLUCOSE-97 UREA N-11 CREAT-0.8 SODIUM-139
POTASSIUM-4.3 CHLORIDE-99 TOTAL CO2-28 ANION GAP-16
[**2159-7-30**] 03:20PM ALT(SGPT)-52* AST(SGOT)-60* CK(CPK)-49 ALK
PHOS-148* TOT BILI-0.5
[**2159-7-30**] 03:20PM WBC-10.0 RBC-5.13 HGB-15.0 HCT-43.1 MCV-84
MCH-29.2 MCHC-34.8 RDW-11.9
[**2159-7-30**] 03:20PM NEUTS-77.5* LYMPHS-16.4* MONOS-5.8 EOS-0.2
BASOS-0.2
[**2159-7-30**] 03:20PM PLT COUNT-338
Liver:
[**2159-8-5**] 04:15AM BLOOD ALT-132* AST-118* LD(LDH)-774*
AlkPhos-264* TotBili-0.3
[**2159-8-5**] 04:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE HAV Ab-POSITIVE
[**2159-8-5**] 04:15AM BLOOD HCV Ab-NEGATIVE
On Discharge:
[**2159-8-13**] 11:03AM BLOOD WBC-7.5 RBC-4.24* Hgb-12.1* Hct-36.8*
MCV-87 MCH-28.6 MCHC-32.9 RDW-13.1 Plt Ct-366
[**2159-8-7**] 03:40AM BLOOD Neuts-89.5* Lymphs-6.8* Monos-3.1 Eos-0.4
Baso-0.2
[**2159-8-13**] 11:03AM BLOOD Glucose-126* UreaN-22* Creat-1.0 Na-136
K-4.2 Cl-100 HCO3-26 AnGap-14
[**2159-8-13**] 11:03AM BLOOD Calcium-8.8 Phos-5.2*# Mg-1.7
Brief Hospital Course:
[**Hospital Unit Name 153**] course:
Patient transfered from floor to [**Hospital Unit Name 153**] on [**8-1**] secondary to
decreased O2 sat despite NRB mask. A CT scan was done on [**8-1**]
which showed bilateral pneumonia left > right. Patient also had
serial CXRs which showed minimally improving left lower lobe
PNA. Patient refused HIV testing but a CD4 count that was drawn
came back as 60. Patient was continued on treatment for
hospital acquired PNA with vancomycin, azithromycin, and
ceftriaxone which was later switched to just azithro and
caftriaxone for CAP. Since patient had low CD4 count was
started on treatment for PCP PNA with prednisone and bactrim (21
day treatment). Induced sputum was done which confirmed PCP.
[**Name10 (NameIs) **] also with thrush so started on nystatin. During [**Hospital Unit Name 153**]
stay he had a run of [**Last Name (LF) 6059**], [**First Name3 (LF) **] cardiology consulted. A TTE was
ordered to rule out seeding of heart valve; there were no masses
or vegetations seen. He did not have another episode of [**First Name3 (LF) 6059**].
He also had a complaint of headache "the worst headache he has
ever had" so LP and CT head were done which both came back
negative. Patient continued to remain stable and slowly improve
in [**Hospital Unit Name 153**] so was transferred to floor on NRB mask on [**8-5**]
On Floor
1) PNA - Continued Bactrim 400mg IV q8 (eventually switched to
PO Bactrim DS 2tabs q8) and prednisone. Prednisone was tapered
from 80mg after 5 days to 40mg for 5 days and then 20mg for
remaining 11 days. Patient for first few days on floor remained
on NRB mask but slowly improved and gradually tansitioned to
nasal cannula with weaning of oxygen as tolerated. Patient
remianed afebrile on floor and WBC remained within normal
limits. He will be discharge with another 8 days of Bactrim and
prednisone to complete 21 day courses, along with home oxygen
for ambulation.
2) Oral Thrush - Continued nystatin swish and swallow, gradually
improved while on floor.
3) Low back pain - Patient complaining of low back pain while on
floor. Initially treated with IV morphine, ibuprofen and
oxycodone, then transitioned to flexerol and ibuprofen with
oxycodone for breakthrough. Patient never had any symptoms of
weakness or numbness in his lower extremeties. No gait
disturbances.
4) HIV testing - While on floor patient asked again by
Housestaff about being tested for HIV, patient continued to
refuse. However with continued discussion with attendings
patient stated willing to follow up outpatient.
Medications on Admission:
none
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day): Swish and spit for thrush in your mouth.
Disp:*40 mL* Refills:*2*
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Two (2)
Tablet PO Q8H (every 8 hours) for 8 days.
Disp:*24 Tablet(s)* Refills:*0*
3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
4. Ventolin 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 canister* Refills:*2*
5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
6. Cyclobenzaprine HCl 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical
Discharge Diagnosis:
Pneumocystis carninii pneumonia
Community acquired pneumonia
Thrush
Discharge Condition:
Good, stable.
Discharge Instructions:
Call Dr. [**Last Name (STitle) **] if you experience a fever, increased shortness
of breath, develop a cough, or feel worse.
Drink plenty of fluids.
Try to rest, walking slowly, stopping if you feel short of
breath.
Follow up with your PCP in two days.
Followup Instructions:
Follow up appointment with Dr. [**Last Name (STitle) **] on [**8-15**] at 11:20.
|
[
"486",
"42789"
] |
Admission Date: [**2201-4-24**] Discharge Date: [**2201-5-2**]
Date of Birth: [**2137-6-18**] Sex: M
Service: MEDICINE
Allergies:
Quinolones
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
1. arterial line placed
2. bronchoscopy
History of Present Illness:
63 yo M h/o HLD, BPH, ETOH abuse, has had dry cough for several
months. Seen by ENT at [**Hospital **] and dx with atrophic
rhinitis. Saw pcp [**4-6**] who ordered chest xray. CXR suggestive of
RML PNA and possible post obstructive PNA. Patient was scheduled
to have repeat imaging following the weekend however wife was
concerned and brought him to ED for evaluation. Repeat CXR today
showed persistant RML opacity, c/f underlying mass. CT Scan
showed 3.6 cm in lungs and liver and osseus mets.
In the ED, initial vs were: T98.8 P85 BP179/89 R18 O2 sat100%.
Patient was given CTX and levo for post obstructive PNA. Seen by
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] in ED who informed patient and wife of possible cancer
dx. Patient was admitted to floor where he complained of RUE
pain before having a [**12-28**] minute tonic/clonic seizure witness by
his wife. A code Blue was called. He did not recieve ativan or
other anti-epiletics. His seizure resolved spontaneously. He was
intubated for airway protection and taken for emergent head CT.
.
Per report from his wife his [**Name2 (NI) **] pressure has been creeping up
all day to the 160's sytolic. No reports of HA, dizzyness or
other focal neurologic disorders. No nausea or vommiting.
Past Medical History:
Right kidney cysts
Nephrolithiasis
Social History:
- Tobacco: former smoker
- Alcohol: history of EToh use. No recent use
- Illicits: unknown
Family History:
His twin brother died of a coronary occlusion and his older
brother died at age 38 of AIDS. His father died of coronary
disease at age 58 and mother of breast cancer at age 84.
Physical Exam:
ADMISSION:
Initial ICU admission physical exam:
Intubated, sedated.
BP 116/66 HR 93 RR 18 99% O2 sat on PSV 10/5 FIo2 0.5
Lungs clear anteriorly
CV RRR distinct S1 and S2
Abdomen soft, nontender
Extremities warm
Neuro exam not noted
Discharge physical exam
VSS
Lungs clear
CV RRR
No pronator drift
Ataxic gait
Mental status close to baseline.
Pertinent Results:
ADMISSION LABS:
[**2201-4-24**] 06:55PM GLUCOSE-94 UREA N-22* CREAT-0.9 SODIUM-140
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
[**2201-4-24**] 06:55PM WBC-9.4 RBC-4.51* HGB-13.1* HCT-37.7* MCV-84
MCH-29.1 MCHC-34.9 RDW-13.0
[**2201-4-24**] 06:55PM NEUTS-62.0 LYMPHS-20.1 MONOS-8.6 EOS-8.3*
BASOS-0.9
[**2201-4-24**] 06:55PM PLT COUNT-197
.
DISCHARGE LABS:
[**2201-5-1**] 12:56PM [**Year/Month/Day 3143**] WBC-19.2* RBC-4.71 Hgb-13.8* Hct-40.1
MCV-85 MCH-29.3 MCHC-34.4 RDW-13.3 Plt Ct-175
[**2201-5-1**] 12:56PM [**Year/Month/Day 3143**] Plt Ct-175
[**2201-5-1**] 12:56PM [**Year/Month/Day 3143**] Glucose-145* UreaN-27* Creat-1.1 Na-139
K-3.9 Cl-103 HCO3-25 AnGap-15
[**2201-5-1**] 12:56PM [**Year/Month/Day 3143**] ALT-44* AST-19 AlkPhos-154* TotBili-0.5
.
STUDIES:
.
CXR [**4-24**]:
IMPRESSION: Persistent right middle lobe opacities. Although the
patient has not undergone interval treatment for pneumonia, per
discussion with the referring physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26216**],
there is concern for underlying mass lesion. Recommend CT for
further evaluation.
.
CT CHEST [**4-24**]:
IMPRESSION:
1. Obstructing right middle lobe mass, with post-obstructive
pneumonia and
ipsilateral bronchovascular spread.
2. Innumerable hepatic and osseous metastases.
3. Suspicious 1.2-cm soft tissue nodule in the right upper renal
pole.
This constellation of findings is highly suggestive of stage IV
metastatic
lung cancer.
.
CTAP [**4-24**]:
IMPRESSION:
1. Obstructing right middle lobe mass, with post-obstructive
pneumonia and
ipsilateral bronchovascular spread.
2. Innumerable hepatic and osseous metastases.
3. Suspicious 1.2-cm soft tissue nodule in the right upper renal
pole.
.
MRI [**4-25**]:
IMPRESSION: Findings are consistent with multiple brain
metastases in the
supra- and infratentorial region. Mild surrounding edema seen.
No midline
shift or hydrocephalus.
.
Bone scan [**5-1**]:
Multiple increased areas of uptake in the spine, left shoulder,
ribs and pelvis consistent with metastatic disease.
.
Pathology:
Liver biopsy [**4-27**]: Needle biopsy of liver: Hepatic parenchyma
only. No metastatic carcinoma seen.
Liver biopsy [**4-28**]: Needle biopsy of liver: Metastatic
adenocarcinoma. Tumor cells stain strongly and diffusely for CK7
and TTF1, very focally for CK20, and do not stain for CK5/6. The
findings are consistent with a tumor of lung origin.
Also [**4-28**]:
FNA, and touch prep of core, liver:
POSITIVE FOR MALIGNANT CELLS, CONSISTENT WITH CARCINOMA.
Note: This is a non-small ccell carcinoma. The site of
origin cannot be determined based on cytomorphology. See
core biopsy S11-[**Numeric Identifier 26217**] for further discussion.
.
EEGS:
[**4-25**]: This is an abnormal continuous EEG due to the presence of
a
burst suppression pattern where the bursts consist of a mixed
alpha/beta
frequency activity seen with an anterior predominance. This
pattern is
suggestive of a spindle coma which may be secondary to
medication
effects (most commonly benzodiazepines, barbiturates, or
tricyclics).
Alternatively, if seen after diffuse hypoxic injury, it portends
an
extremely poor prognosis. There were no focal abnormalities or
epileptiform features seen.
.
[**4-26**]:This is an abnormal continuous EEG due to the presence of
prolonged periods of generalized, mixed theta and delta
frequency
slowing interrupted by occasional periods of alpha frequency
activity
with an anterior predominance. This pattern is suggestive of a
moderate
to severe diffuse encephalopathy commonly seen with medication
effect,
metabolic disturbance, or infection. Compared to the previous
tracing,
the periods of mixed theta and delta slowing are more prolonged
and
frequent possibly consistent with a lightening of sedation
effect.
There are no focal abnormalities or epileptiform features seen.
.
[**4-27**]: This is an abnormal 24-hour video EEG due to the slow and
disorganized background of [**4-1**] Hz with bursts of generalized
delta
frequency slowing, indicative of a moderate encephalopathy.
Again seen
were periods of generalized mixed alpha and beta frequency
activity,
which were far less prolonged and noticeable than the previous
day's
recording. These findings represent an improvement in the
background
compared to the previous day's recording. However, rare
generalized
sharp and slow wave discharges were seen and indicate
generalized
cortical irritability. No clear electrographic seizures were
seen.
.
[**4-28**]: This is an abnormal EEG telemetry due to the presence of a
disorganized, mixed alpha and theta frequency background,
alternating
with periods of [**12-28**] Hz frontally predominant generalized detla
slowing.
This pattern is indicative of a moderate encephalopathy,
commonly seen
with medication effect, metabolic disturbance, or infection. In
addition, the frequent periods of generalized rhythmic delta
activity
with embedded sharp waves are suggestive of a diffuse cortical
irritability, these were less prominent than the previous day's
recording. There were no definite electrographic seizures seen.
.
MICRO:
Bcx: negative
BAL:
[**2201-4-25**] 12:21 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2201-4-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2201-4-27**]): NO GROWTH, <1000
CFU/ml.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2201-4-27**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
.
Sputum [**4-28**]:
GRAM STAIN (Final [**2201-4-27**]):
[**10-20**] PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2201-4-29**]):
SPARSE GROWTH Commensal Respiratory Flora.
.
Pending tests:
ACID FAST CULTURE (Preliminary): pending
Dilantin level [**5-1**]
Brief Hospital Course:
HOSPITAL COURSE:
Mr. [**Known lastname **] is a 63 yo man with prior history of etoh abuse and
smoking, transferred from ICU after admission to the medical
service with pneumonia, and found to have a post obstructive
pneumonia with a lung mass. CT also showed liver and osseous
metastases. Course complicated by a seizure on the floor, for
which he was intubated for airway protection and transferred to
the MICU. Brain MRI showed brain metastases. He was loaded
with phenytoin, as well as keppra and decadron. His course was
also notable for an acute delirium, subsequently resolved.
While hospitalized, he was seen by neurology, neuro-oncology,
radiation oncology, and medical oncology. He was started on
brain XRT and will follow up with oncology for chemotherapy
initiation and discussion of further steps after discharge.
.
Hospital course by problem:
.
# Metastatic lung cancer: Pt had mets suggested by CTAP to liver
& bone, and mets in brain by MRI. Liver biopsy was performed
twice, with the second biopsy revealing metastatic lung cancer.
Bone scan revealed multiple areas of ossesous metastatic
disease, including ribs, left shoulder, bilateral pelvis and
spine. Oncology was consulted and he will follow up with them
as an outpatient (appt still pending) to discuss chemotherapy
after his brain radiation is completed. Neuro-Oncology was
involved by Neuro and he will have repeat MRI and neurology
follow up in 1 month.
.
# Seizure with brain metastases: He had a seizure shortly after
presentation, and was seen by neurology. It was attributed to
metastatic disease and lowered seizure threshhold due to
florquinolone usage. He was treated with AED's, and neurology
was consulted. Pt had CT head demonstrating vasogenic edema. MRI
brain showed brain metastases. He appeared to be seizing on
Keppra on HOD#1. Keppra was increased; he was loaded with
Dilantin & started on Decadron for edema. An EEG was placed and
showed high cortical irritability but no further seizures. Pt
was weaned off propofol and maintained on antiepileptics. After
discharge from the ICU, he had no further seizure activity. He
was seen by radiation oncology and underwent whole brain
radiation starting on [**4-30**] without complications. He will have a
total of 10 treatments. Given prolonged decadron treatment, he
was started on a PPI, bactrim TIW, calcium and vitamin D. He
was discharged on keppra 1500 mg po bid
.
# Acute respiratory distress: Intubated for airway protection in
setting of seizures. Vent was kept overnight given need to
ensure adequate antiepileptic coverage prior to discontinuation
of propofol. Pt was extubated on [**4-26**] without complication.
.
# Post obstructive Pneumonia: As suggested by CT. Pt with recent
reported fevers, but only low grade temps in MICU. He was placed
on Vanc/Zosyn for coverage. He was treated for 8 days, with no
fevers. Cultures were negative.
.
# Acute delirium. While in the ICU, he developed an acute
delirium after extubation. He slowly cleared and returned to
his baseline. The cause was likely multifactorial with
infection, steroids, and ICU-related.
.
# Lactic acidosis: Most likley etiology is [**1-28**] to seizure. As
above, possibly also related to lung source; however lactate
quickly came down once AEDs started and treated with IVF's. Pt
was ruled-out for MI with serial cardiac enzymes. Lactic
acidosis resolved.
.
# Steroid induced hyperglycemia: HE was started on ISS as on
decadron, and then transitioned to po glipizide, with glucometer
monitoring. He will have VNA teaching regarding glucose testing
in the next 2 days.
.
Outstanding tests at discharge:
dilantin level pending
AFB culture pending
.
Transitional issues:
1. Oncology follow up: He will need oncology follow up in the
next 2 weeks after completing radiation.
2. Home services: HE will have home PT as well as home nursing
services.
Medications on Admission:
Lipitor 10mg
Flomax
Discharge Medications:
1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*30 Tablet(s)* Refills:*1*
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*0*
5. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*1*
6. levetiracetam 750 mg Tablet Sig: Two (2) Tablet PO twice a
day.
Disp:*120 Tablet(s)* Refills:*1*
7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
10. glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*1*
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
13. Glucometer
Check [**Month/Day (2) **] sugar twice daily, first thing in the morning and
then before dinner.
Dispense #1
No refills.
14. Lancets
Use as directed to test sugar.
Dispense: 1 month's supply
1 Refill
15. Test strips
Use as directed, twice daily.
Dispense #100
1 refill
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Seizure
Post obstructive pneumonia
Metastatic lung cancer
Acute delirium
Gait instability
Discharge Condition:
Ataxic gait, some slowed responses, requires walker for
ambulation
Discharge Instructions:
You were admitted with a cough, and then subsequently had a
seizure. The evaluation that we did found metastatic cancer
originating in your lungs, and also in your bones, liver and
brain. You started on radiation therapy for your brain
metastases, and will follow up with the oncologists in the next
few weeks to discuss chemotherapy. As your gait remains
unsteady, you should have someone within you whenever possible,
and use a walker to walk with.
.
Your [**Location (un) **] sugar is high due to the steroids. You should check
your [**Location (un) **] sugar twice a day and keep track. The visiting nurses
will teach you how to use the glucometer machine. Do not worry
about it until tomorrow.
.
New medications:
Start DECADRON 4 mg po every 6 hours (brain swelling)
Start KEPPRA 1500 mg twice daily (seizures)
Start PHENYTOIN 100 mg three times daily (SEIZURES)
Start Sulfameth/Trimethoprim DS 1 TAB 3X/WEEK (MO,WE,FR)
(INFECTION REDUCTION)
Start Calcium Carbonate 500 mg PO/NG TID (BONES)
Start Vitamin D 800 UNIT PO/NG DAILY (BONES)
Start PRILOSEC 20 mg po daily (ULCER PREVENTION)
Start TRAZODONE 50 MG po qhs (SLEEP)
Start GLYBURIDE 2.5 mg po twice daily. (HIGH SUGARS)
Start TYLENOL 500 mg 1-2 tabs, up to 4 tablets per day, for pain
Followup Instructions:
Radiation therapy - Monday, 9AM
.
Department: INTERNAL MEDICINE
When: MONDAY [**2201-5-11**] at 9:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], MD [**Telephone/Fax (1) 142**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Location: [**Hospital1 18**]-DIVISION OF HEMATOLOGY/ONCOLOGY
Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**0-0-**]
We are working on a follow up appointment with
Hematology/Omcology within 1 week. You will be called at home
with the appointment. If you have not heard from the office
within 2 days or have any questions, please call the number
above.
Department: RADIOLOGY
When: MONDAY [**2201-6-8**] at 1:55 PM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: MONDAY [**2201-6-8**] at 3:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"486",
"2762",
"2724",
"2859"
] |
Admission Date: [**2132-1-9**] Discharge Date: [**2132-1-22**]
Date of Birth: [**2082-11-22**] Sex: M
Service: GENERAL SURGERY
COMPLICATIONS: Myocardial infarction and death.
HISTORY OF PRESENT ILLNESS: This patient is a 49 year-old
male who had no significant past medical history except for
chronic renal insufficiency and hypertension who was
transferred from an outside hospital after sustaining a
hemorrhagic stroke in the left basal ganglia causing symptoms
of right hemiplegia on [**2132-1-9**]. He was admitted to
the Neurology Service for management of his hemorrhagic
stroke. Subsequently his renal insufficiency worsened and he
subsequently went into renal failure, which required
hemodialysis. Over the following week and a half he was
managed on multiple antihypertensive regimens in the
Intensive Care Unit and was stabilized and transferred to the
floor on [**1-18**]. He was receiving prophylaxis, stress
peptic ulcer prophylaxis on Protonix. On [**1-19**], the
patient complained of acute abdominal pain during dialysis
and an upright chest x-ray was obtained. He was noted to
have free air and was brought to the Operating Room
emergently. He was found on exploration to have a perforated
sigmoid colon secondary to diverticulitis with an abscess.
The patient was resected and immediately after his resection
he suffered a cardiac arrest and developed PEA on the
Operating Room table. His abdomen was closed rapidly without
maturation of his colostomy and he was brought to the
Intensive Care Unit on pressors for resuscitation.
He ruled in for a massive myocardial infarction with peak
troponins over 5 and CKMBs over 1000. The plan had been to
return him to the Operating Room for completion of his
colostomy, however, given that his cardiac status was so
severe after consultation with cardiology consult we decided
to wait until the following day before taking him back to the
Operating Room given the stress to his heart. However, on
postop day number three the day we had planned on returning
him to the Operating Room for his colostomy, he suffered
another cardiac arrest. He was given multiple intravenous
medications and ACLS protocol was initiated. He was coded
for approximately thirty minutes before expiring.
Autopsy revealed death caused by acute myocardial infarction.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Name8 (MD) 38545**]
MEDQUIST36
D: [**2132-2-1**] 17:04
T: [**2132-2-4**] 11:45
JOB#: [**Job Number 38546**]
|
[
"9971",
"4280",
"40391",
"5845"
] |
Admission Date: [**2208-1-21**] Discharge Date: [**2208-2-5**]
Date of Birth: [**2137-3-18**] Sex: F
Service: SURGERY
Allergies:
Plavix / Sulfur, Elemental / Penicillins / Iodine-Iodine
Containing / Enalapril / Hydralazine And Derivatives / IV Dye,
Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
[**2208-1-21**]: Sigmoidectomy with colostomy (Hartmann's procedure).
History of Present Illness:
70F w/ hx of RCC metastatic to lung, pancreas, bone with
completion of XRT and cycle 20 day 15 of Avastin who presented
to the ED after a fall around midnight with head strike. LOC
uncertain. She lives alone and was down for about 8 hours. She
reports being fine yeserday after her chemotherapy, but has
since the fall felt lightheaded. In the ED, CT revealed
perforated sigmoid diverticulitis and 5cm abscess.
Past Medical History:
PMH: metastatic RCC s/p nephrectomy ([**2198**]), R VATS wedge for
mets ([**2201**]) now on chemo (Avastin - last [**1-20**]), HTN, CAD s/p
PCI/LAD stent ([**2198**]), Hyperkalemia, Hypercholesterolemia, Hx
postop PE [**2182**] (on coumadin s/p IVCF), Hx [**Doctor First Name **] s/p treatment x
18months ([**2201**]), SLE, Antiphospholipid syndrome, Osteoporosis
.
PSH: L radical nephrectomy/adrenalectomy w periaortic
lymphadenectomy ([**2198**]), RLL/RML VATS wedge rsxn x 2 for
metastatic RCC ([**Doctor Last Name **]-[**2201**]), R eye cataract procedure
[**2203**]), L eye cataract ([**2204**]), Excision of right thigh lesion for
atypical squamous proliferation ([**Doctor Last Name 519**]-[**2205**]), L cephalic v
portacath ([**Doctor Last Name 519**]-[**3-/2207**])
Social History:
SOCH: Widow. Lives alone. 3 children/5 grandchildren. Daughters
live nearby and help out with shopping and chores around the
house. Tobacco: 15 pack yr hx - quit [**2166**]; EtOH: Denies
Family History:
FAMH: Two paternal aunts had cancer, and the patient is not sure
what type. One paternal aunt had a colon cancer, a maternal
aunt had stomach cancer. The patient's father had prostate
cancer and her sister may have had a GYN cancer.
Physical Exam:
Physical Exam on admission:
Vitals: HR 102 BP: 101/78 RR 34 SaO2 100%NC
Gen: WD, obese, elderly F; anxious-appearing.
HEENT: anicteric, EOMI
CV: RRR, I/VI murmur along left sternal border
P: CTAB
Abd: soft, Diffusely tender to light palpation, distended
EXT: WWP
NEURO: A&Ox3, non-focal
Pertinent Results:
[**2208-1-21**] 10:25AM BLOOD WBC-2.8*# RBC-4.55# Hgb-11.6* Hct-38.1#
MCV-84 MCH-25.4* MCHC-30.3* RDW-16.6* Plt Ct-362
[**2208-2-1**] 03:39AM BLOOD WBC-5.6 RBC-3.23* Hgb-8.6* Hct-27.5*
MCV-85 MCH-26.7* MCHC-31.5 RDW-20.0* Plt Ct-180
[**2208-2-1**] 03:39AM BLOOD Plt Ct-180
[**2208-1-21**] 04:30PM BLOOD Fibrino-214
[**2208-1-29**] 02:15AM BLOOD ESR-68*
[**2208-2-1**] 03:39AM BLOOD Glucose-166* UreaN-39* Creat-0.9 Na-141
K-4.4 Cl-110* HCO3-22 AnGap-13
[**2208-2-1**] 03:39AM BLOOD cTropnT-<0.01 proBNP-[**Numeric Identifier 20645**]*
[**2208-1-29**] 02:15AM BLOOD ALT-30 AST-27 LD(LDH)-469* AlkPhos-188*
TotBili-1.9* DirBili-1.2* IndBili-0.7
[**2208-2-1**] 08:49AM BLOOD Glucose-138* Lactate-2.3*
Brief Hospital Course:
The patient presented to the [**Hospital1 18**] ED [**2208-1-21**] after being found
by family members s/p fall. On arrival to the ED patient was
manifesting septic physiology with concerning abdominal exam.
CT abd/pelvis was obtained which showed perforated sigmoid
diverticulitis and large pelvic abscess. Central access was
obtained in the ED and resuscitation was initiated with several
liters crystalloid fluid. Patient also found to have INR: 2.5
in setting coumadin use for hx PE. Four units FFP given to
correct coagulopathy. Patient was then taken to the operating
room for exploratory laparotomy with Hartmann's procedure.
Intraoperatively, patient required levo/vaso pressor support and
was transfused 4pRBC and 2FFP. Patient tolerated procedure and
was subsequently transferred to the TSICU for further management
under the ACS service. At time of transfer patient had ETT,
OGT, abdominal JP, colostomy, [**Known lastname **], radial a-line and R IJ CVL.
After a brief uneventful stay in the ICU, she was transferred to
the floor. Given failure to thrive post operatively, her family
elected to make her comfort measures only. She was placed on a
morphone dropp and she passed away at 10:40am [**2209-2-5**].
Medications on Admission:
[**Last Name (un) 1724**]: ALBUTEROL SULFATE 90mcg INH Q4-6H prn, AMLODIPINE 5',
BEVACIZUMAB (last [**1-20**]), DEXAMETHASONE 4'', FLUTICASONE 50/Spray
[**2-15**]', ADVAIR DISKUS 250-50', LORAZEPAM 0.5', METOPROLOL XL 100',
NITROGLYCERIN 0.4', OMEPRAZOLE 20', ONDANSETRON 4 Q8H prn,
OXYCONTIN 20 QAM, 10QPM, PREDNISONE 10', WARFARIN 4 6d/wk, 5
1d/wk, ACETAMINOPHEN 500 Q6H prn, ASA 81', CALCIUM CARBONATE-VIT
D3-MIN 600(1,500)400'', DOCUSATE SODIUM 100'', LOPERAMIDE 2'
prn, SENNOSIDES 8.6'' prn
Discharge Medications:
Patient expired in hospital.
Discharge Disposition:
Expired
Discharge Diagnosis:
Perforated diverticulitis
Discharge Condition:
Expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2208-3-23**]
|
[
"0389",
"78552",
"5849",
"496",
"2875",
"99592",
"4019",
"V4582",
"V5861"
] |
Admission Date: [**2170-8-4**] Discharge Date: [**2170-8-10**]
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
1) Upper GI bleed
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Pt is a [**Age over 90 **] yo female who was transferred to the [**Hospital1 18**] for
treatment of a upper GI bleed from a mass like lesion in her
stomach. On [**7-25**] she was admitted to [**Hospital3 8544**] with a
right lower quadrant pneumonia. Five days before that, she was
seen at the [**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **] for asthmatic bronchitis, and she was
treated with prednisone. The [**Hospital 228**] hospital course
apparently proceeded without complication until the day prior to
when she was supposed to be discharged [**7-31**] when she vomited
bright red blood and melena (INR 3.1). An EGD was done on [**8-1**]
which revealed a large clot on the fundus. Cardiac enzymes were
negative. CT was negative for splenic vein thrombosis, or liver
disease, but was positive for a 3 cm round lesion in the
pancreatic head. Repeat EGD on [**2170-8-3**] showed a lobulated mass
in the fundus that was quite soft. EGD on [**8-4**] showed a
submucosal vascular appearing mass overlying the cardiac border
with feeding vessels but no active bleeding. The patient
subsequently received 6 units of RBC and 3 units of FFP and 3 mg
Vit K which raised the Hct to 30.4 before transfer from the OSH
to [**Hospital1 18**] for further evaluation. Just before transfer, however,
the patient had another episode of hematemesis (200mL BRB) along
with grossly melanotic stools and tachycardia/afib. Her HCT
decreased from 32.7 to 28.4 and increased to 29.7 with 2 units
PRBCs. She was intubated for airway protection. On admission
to the [**Hospital1 18**], the patient received 1 unit of RBC. Her Hct was
30.9. Hct on [**8-4**] was 28.4 from 32 and then increased to 29.7
with 1 unit of PRBCs. No bleeding was seen at the [**Hospital1 18**]. She
did not have any GI complaints, h/o HIV, chest pain, liver
disease, or a history of GI bleeds.
Past Medical History:
1) AF on coumadin
2) hypothyroid
3) constipation
4) THR
5) TAH/BSO
Social History:
1) lives with her daughter
Family History:
NC
Physical Exam:
On admission to the [**Hospital1 18**] ICU:
Vitals - 97.4 96/36 70-85 97%RA
GEN: no acute distress
HEENT: anicteric
COR: S1/S2 nl, irregular, no murmurs
THORAX: R lung base coarse rales. L few basilar crackles
ABD: no tenderness, distended, bowel sounds normal
EXT: chronic venous stasis with edema
NEURO: alert and oriented x 3. MAE x 4
Pertinent Results:
[**2170-8-9**] 07:15AM BLOOD WBC-8.4 RBC-3.97* Hgb-12.6 Hct-36.0
MCV-91 MCH-31.6 MCHC-34.9 RDW-15.1 Plt Ct-152
[**2170-8-6**] 12:12AM BLOOD Neuts-84.5* Lymphs-12.2* Monos-2.6
Eos-0.4 Baso-0.3
[**2170-8-9**] 07:15AM BLOOD Plt Ct-152
[**2170-8-9**] 07:15AM BLOOD Glucose-101 UreaN-12 Creat-0.8 Na-143
K-3.5 Cl-109* HCO3-25 AnGap-13
[**2170-8-9**] 07:15AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.8
Brief Hospital Course:
1) Upper GI bleed: In the ICU, the patient's soft vascular mass
was considered to be gastroesophageal varices. Other
possibilities in the differential were leiomyoma, lipoma, or
malignancy. It was generally felt that whatever the precise
character, the mass was still oozing blood insofar as the three
units that she received at the outside hospital did not
significantly increase her Hct. The ICU team set a goal of Hct
> 30 given her age and potential rapidity of rebleeding. On ICU
day 2, the patient was transfused 1 unit PRBC to reach a Hct of
32.1, but she continued to have no episodes of hematemesis or
melena. RUQ ultrasound was negative for signs of liver disease.
A repeat EGD was also performed which revealed 1. a normal
celiac axis. 2. pancreatic body and the PD within it were
normal. 3. in the proximal stomach, the protruding mass was
identified and endosonographically was both hypoechoic and
vascularly consistent with gastric varices. Unfortunately, it
remained difficult to determine the cause of the most latter
finding. On [**8-8**], the patient was transferred from the ICU to
the floor for further care under the medicine service. At this
point, the GI team saw her and recommended nadolol to help
decrease portal pressures. Anticoagulation remained
discontinued, and the patient's femoral line was discontinued.
A PPI was started to decrease gastric distress and the patient's
diet was advanced to a soft, low salt diet. Potassium was
repleted as necessary. The patient did not experience any
repeat episodes of hematemesis or melena. All stools were
guaiac negative. At discharge, the patient's Hct was 36.0.
Throughout the hospital course within the ICU and on the floor,
the patient's family was kept well-informed of all medical
decisions. Some clarification will be required regarding her
code status as it is relatively unclear. At the moment, she is
full code, but her son has expressed a desire not to have "my
mother on any machines." The patient's daughter, her health
care proxy wishes to have "aggressive but not extraordinary"
routes of treatment pursued.
2) Cardiac: With respect to atrial fibrillation, The patient
was rate controlled on digoxin and discontinued from
anticoagulation in light of her upper GI bleed. Heart rate
remained stable at <100. Cardiac ECHO was performed on [**8-8**]
which showed the following: 1. Overall left ventricular
systolic function is normal (LVEF>55%). 2. no free wall motion
abnormalities. 3. Moderate (2+) mitral regurgitation is seen.
4. Moderate [2+] tricuspid regurgitation is seen. 5.
Significant pulmonic regurgitation is seen.
3) Activity: Physical therapy was consulted and the patient was
found to demonstrate safe and independent functional mobility
with a cane. It was recommended that she be discharged home
with home safety evaluation and home PT. The patient's family,
however, refused to take the patient home and the patient was
screened for transfer to a lower level rehab facility.
4) Hypothyroid: the patient was continued on levothyroxine
5)Code Status: The patient was admitted with a code status of
DNR but full intubation. However, upon further discussion, her
code status changed to full code. This topic will need to be
discussed in more detail at a later date.
Medications on Admission:
1) digoxin .125 once a day
2) coumadin 3 once a day
3) levoxyl 50 once a day
4) protonix iv 40 once a day
5) digoxin .125 once a day
6) ceftriaxone 1 once a day
Discharge Disposition:
Extended Care
Facility:
Maples Nursing & Retirement Center - [**Location (un) 6151**]
Discharge Diagnosis:
1) upper GI bleed 2) gastroesophageal varices 3) atrial
fibrillation 4) hypothyroidism 5) pneumonia 6) GERD
Discharge Condition:
good
Discharge Instructions:
1) Please follow up with your PCP regarding this hospital
admission. She has been contact[**Name (NI) **] via phone and mail.
2) Please discuss your advanced directives with your family so
that your doctors [**Name5 (PTitle) **] help [**Name5 (PTitle) **] most accordingly to your wishes.
3) Please seek medical attention if you experience any or all of
the following: vomiting blood, blood in your stool, blood from
your rectum, lightheadedness, chest pain, palpitations,
shortness of breath, swelling in your extremities, sudden
weakness
4) You have slight thrombocytopenia at discharge. Please follow
up on your Platelet count and Hematocrit in a few days.
5) Please have a repeat CBC and Electrolytes analysis in a few
days.
Followup Instructions:
1) Please follow up with your PCP regarding this hospital
admission. She has been contact[**Name (NI) **] via phone and mail.
2) Please discuss your advanced directives with your family so
that your doctors [**Name5 (PTitle) **] help [**Name5 (PTitle) **] most accordingly to your wishes.
3) Please seek medical attention if you experience any or all of
the following: vomiting blood, blood in your stool, blood from
your rectum, lightheadedness, chest pain, palpitations,
shortness of breath, swelling in your extremities, sudden
weakness
|
[
"42731",
"486",
"4240",
"4280",
"V5861"
] |
Admission Date: [**2178-9-12**] Discharge Date: [**2178-9-18**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87-year-old diabetic male with diastolic dysfunction,
hypertrophic cardiomyopathy, atrial fibrillation & tachybrady
syndrome - recently hospitalized in [**2178-3-21**] for TEE
cardioversion and DDDR (dual chamber paced, dual chamber sensed,
dual response, rate modulated) placement, who is admitted to the
CCU with CHF decompensation.
.
According to patient's son-in-law, patient was in his usual
state of health until about 1 week ago when he began complaining
of worsening fatigue and shortness of breath, but he refused
hospitalization until the night of admission. With the
assistance of a Russian translator, the patient denies
orthopnea, PND, or significant dependent edema; also denies CP,
palpitations, nausea, and vomiting. Per his family, he did not
have any fevers or cough; there were apparent no changes in diet
or other precipitating events 1 week ago.
.
According to the [**2178-4-21**] EP letter, his functional status
improved markedly after his [**2178-3-21**] hospitalization. At the
time of the note, he was able to ambulate from bed to the
bathroom and back before becoming short of breath, suggestive of
class II-III heart failure; prior to this, he could only move
from bed to a chair before becoming short of breath.
.
Most recent TTE showed [**2-/2178**]:
The left atrium is elongated. There is asymmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with distal septal, anterior, and lateral severe
hypokinesis/akinesis. Overall left ventricular systolic function
is normal (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The right ventricular free wall is
hypertrophied. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
.
IMPRESSION: Suboptimal image quality. Asymmetric left
ventricular hypertrophy consistent with hypertrophic
cardiomyopathy. Mild regional left ventricular systolic
dysfunction with overall normal function.
.
Most recent Cath showed [**2-/2174**]:
COMMENTS:
1. Selective coronary angiography in this right dominant
circulation
demonstrated only mild non-obstructive CAD. The LMCA was free of
any
angiographically apparent flow limiting disease. The LAD was
free of
flow limiting disease. The D1 was of moderate size and had a
40-50%
stenosis in the proximal segment. The LCx had a 40% stenosis
after the takeoff of the OM2. The OM1 was a large vessel, but
OM2 was a moderate size vessel. The L-PL was also moderate size.
Neither had flow limiting disease. The RCA was a large vessel
and gave rise to the a moderate size R-PDA and small R-PL. There
were no flow limiting lesions in these vessels.
2. Limited resting hemodynamics from left heart catheterization
demonstrated moderately elevated LVEDP (20mmHg). There was no
transarotic pressure gradient upon catheter pullback.
3. Left ventriculography demonstrated normal systolic LV
function. The calculated EF was 54%. There was no mitral
regurgitation appreciated.
.
FINAL DIAGNOSIS:
1. Mild non-obstructive coronary artery disease.
2. Normal ventricular systolic function.
3. Mild to moderate LV diastolic dysfunction.
.
In the ED, initial vitals were: T 98.0 HR 100, 100/72, RR: 35,
96% on RA. He recieved 60mg of IV lasix (put out ~600cc) and
full ASA. CXR showed increased congestion suggestive of CHF
decompensatoin.
.
On arrival to the CCU, vitals were: T 96.3 HR 100, 115/73, RR:
29, 95% BiPAP of [**8-25**] with ABG 7.49/38/118/28. He was diuresed
with Lasix, rate controlled with metoprolol 5mg IV x 2, and
transitioned to 100% rebreather.
.
Past Medical History:
1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia, (+)
Hypertension
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS: cath in [**2173**]; 1. Mild
non-obstructive coronary artery disease. 2. Normal ventricular
systolic function. 3. Mild to moderate LV diastolic dysfunction.
-PACING/ICD: h/o atrial fib with tachy/brady syndrome s/p dual
chamber pacemaker on [**2178-3-23**] and TEE cardioversion
3. OTHER PAST MEDICAL HISTORY:
Atrial Fibrillation
Tachy/brady syndrome s/p pacemaker placed [**2178-3-23**]
HTN
Prostate CA s/p resection [**2165**]
S/p cataract surgery
Post-pneumonia myocarditis at 24yo
Chronic diastolic dysfunction
Hypertrophic Cardiomyopathy
Social History:
practiced primary care for 50 years, moved to [**Location (un) 86**] 9 years
ago. Married. From [**Hospital 100**] Rehab.
-Tobacco history: none, none prior
-ETOH: none
-Illicit drugs: none
Family History:
Mother died of stroke.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission Exam
GENERAL: Elderly well nourished male. CPAP. 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 elevated in ED, but deferred on the floor with
CPAP.
CARDIAC: PMI non-displaced. RR, normal S1, S2. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: Bibasilar fine wet crackles. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2178-9-12**] 06:30PM PT-38.0* PTT-46.5* INR(PT)-4.0*
[**2178-9-12**] 06:30PM NEUTS-75* BANDS-0 LYMPHS-6* MONOS-15* EOS-4
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2178-9-12**] 06:30PM WBC-13.8* RBC-4.45* HGB-12.9* HCT-38.1*
MCV-86 MCH-29.0 MCHC-33.8 RDW-15.7*
[**2178-9-12**] 06:30PM proBNP-2302*
[**2178-9-12**] 06:30PM cTropnT-0.01
[**2178-9-12**] 06:52PM LACTATE-1.7
Micro:
[**9-12**] Urine and Blood cx negative
ECG [**9-13**]:
Atrial tachycardia with varying block is noted. Right
bundle-branch block with left anterior hemiblock. Left
ventricular hypertrophy and secondary
repolarization changes are seen. Since the previous tracing
variable
conduction is now noted.
CXR: [**9-12**]:
FINDINGS: Portable AP view of the chest is obtained. Dual-lead
pacer device is again noted with proximal lead in the expected
location of the right atrium and distal lead in the expected
location of the right ventricle. Cardiomegaly is stable. There
is mild pulmonary vascular congestion. No definite pleural
effusion or pneumothorax seen. Aorta is unfolded and partially
calcified.
Bony structures are intact.
IMPRESSION: Cardiomegaly with mild pulmonary vascular
congestion.
Labs on Discharge:
[**2178-9-18**] 06:00AM BLOOD WBC-12.1* RBC-4.28* Hgb-12.3* Hct-36.1*
MCV-84 MCH-28.8 MCHC-34.2 RDW-15.3 Plt Ct-278
[**2178-9-18**] 06:00AM BLOOD Glucose-139* UreaN-34* Creat-1.2 Na-138
K-4.1 Cl-100 HCO3-30 AnGap-12
[**2178-9-18**] 06:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.2
Brief Hospital Course:
87-year-old diabetic male with diastolic dysfunction,
hypertrophic cardiomyopathy, atrial fibrillation & tachybrady
syndrome s/p TEE cardioversion & DDDR, who is admitted to the
CCU with CHF decompensation.
.
# DIASTOLIC CHF DECOMPENSATION: Pt initially appeared clincally
hypervolemic with BNP elevated (2,000s) from baseline. Pt
initially placed on CPAP and then weaned off to nasal canula
oxygen. Pt was diuresed with IV lasix which improved SOB and
showed improvement on CXR. EKG with no acute changes. Pt's CHF
exacerbation attributed to underlying A. fib. Pt was tachcardic
in the 100s on admission and metoprolol increased from 50mg [**Hospital1 **]
to 100mg [**Hospital1 **]. Calcium Channel blocker was not introduced but
would be the next [**Doctor Last Name 360**] to add if pt continues to have A. fib
with HR>100s. Pt's outpatient cardiologist might consider adding
a CCB if he continues to be tachycardic.
.
# HYPERTENSION: Continued Lisinopril 5mg and increased
metoprolol 50mg [**Hospital1 **]-->100mg [**Hospital1 **].
.
# AF s/p TEE cardioversion: CHADS2 = 3 (High Risk). Pt was in A.
fib during hosptialization with rate as high as 100. Held
coumadin since initially elevated INR (3.7). Coumadin
re-introduced as INR trended down. Decision was made to change
couamdin dose from 3mg daily to 2mg daily since he appeared to
have supratherapeutic INR on 3mg. Rate controled with metoprolol
100mg [**Hospital1 **]. Discharge INR was 3.1 on [**2178-9-18**].
.
# DM 2: Held home hypoglycemics and continued insulin Sliding
scale. Pt can restart home regimen after discharge.
.
# HYPERLIPIDEMIA: Continued home simvastatin 20mg
.
# INSOMNIA: Continued home trazodone 25mg QHS
.
# GUAIAC-POSITIVE STOOL: One stool was guiaic positive. No
evidence of significant GI bleed. The patient has no record of
colonoscopy in the [**Hospital1 **] records. His
outpatient providers should continue to follow this.
Medications on Admission:
Lisinopril 5 mg Daily
Metoprolol Succinate 100 mg daily
Amlodipine 2.5 daily
Simvastatin 20 daily
Warfarin 3 mg daily
Isosorbide Dinitrate 5 mg [**Hospital1 **]
Lasix 20 mg daily
.
Ipratropium Bromide 0.02 % Solution inh q6h
Glipizide 2.5 mg daily
Insulin Lispro 100 unit/mL sliding scale
.
Trazodone 25 QHS
Cyanocobalamin 100 mcg daily
Docusate Sodium 100 mg [**Hospital1 **]
Senna 8.6 mg QHS
Cholecalciferol 800 daily
Calcium Carbonate 500 mg (1,250 mg) TID
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
6. Senna Laxative 8.6 mg Tablet Sig: One (1) Tablet PO at
bedtime.
7. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
three times a day: with meals.
8. ipratropium bromide 0.02 % Solution Sig: One (1) vial
Inhalation Q6H (every 6 hours) as needed for wheeze/sob.
9. glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO DAILY (Daily).
10. warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
11. Outpatient Lab Work
Please check INR on [**2178-9-19**], goal INR 2.0-3.0
12. Oxygen
Please give 2L osygen continuous
13. metoprolol succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Hold
HR < 55, SBP < 95.
14. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. insulin lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous three times a day: check FS before meals,
give Humalog 15 min before meals. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Acute on Chronic Diastolic congestive Heart Failure
Atrial Fibrillation with rapid ventricular response
Diabetes Mellitus Type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had an acute exacerbation of your congestive heart failure
that caused you to have trouble breathing. We believe this was
because your heart rate was too high so we adjusted your
medicines to keep your heart rate lower.
Medication changes:
1. Increase the Metoprolol to 200 mg daily
2. Stop Amlodipine, Trazadone and isosorbide dinitrate
3. Decrease Warfarin to 2 mg on [**2178-9-18**], please check your INR
on Saturday [**9-19**].
.
Weigh yourself every morning, call Dr. [**First Name (STitle) 437**] if weight goes up
more than 3 lbs in 1 day or 6 pounds in 3 days.
You had small amounts of microscopic blood found in your stool.
It is important to follow this up with your primary care doctor.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2178-10-27**] at 3:00 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2178-10-27**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2178-12-16**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: Monday [**10-19**] at 9:00AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: Primary Care
[**9-23**] at 9:45am
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3357**]
Phone: [**Telephone/Fax (1) 4606**]
|
[
"4280",
"42731",
"25000"
] |
Admission Date: [**2151-2-28**] Discharge Date: [**2151-3-20**]
Date of Birth: [**2078-10-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
Enterocutaneous Fistulae
Major Surgical or Invasive Procedure:
Exploratory Lapartomy
Lysis of Adhesions
Takedown of enterocutaneous fistulae
G-tube exchange
small bowel resection with anastomosis
History of Present Illness:
72M with h/o sigmoid colectomy in [**2147**] for diverticulitis. He
underwent an exploratory laparotomy x 2 in [**5-/2150**] for SBO
complicated by multiple enterotomies that were combined and
converted to a proximal end-jejunostomy further complicated by
an enterocutaneous fistula. Presents for enterocutaneous
fistula repair and takedown of ostomy.
Past Medical History:
PMH:
COPD
Prostate Cancer
Meningitis as child
Diverticulitis
PSH:
Appendectomy [**2108**]
Left Inguinal Hernia Repair [**2142**]
Radical Prostatectomy [**2141**]
Sigmoid Colectomy [**2147**]
Ex-Lap, LOA, end ileostomy with GJ tube placement [**2-12**] SBO [**5-16**]
Social History:
Married with 3 children, ETOH 10 years ago, 25 ppy Tobacco 15
years ago. Retired federal government.
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam [**2151-2-28**]
99.5 94 132/90 18 93%RA
NAD
NCAT, PERRL, EOMI, CNII-XII grossly intact
neck supple, no cervical lymphadenopathy
lungs clear
heart RRR
Abd soft, NT, ND, BS+, end ileostomy, GJ tube present
Ext: 1+ ankle edema, no cyanosis or clubbing
Pertinent Results:
Admission Labs
[**2151-2-28**] 06:00PM BLOOD WBC-9.3 RBC-3.03* Hgb-9.5* Hct-29.1*
MCV-96 MCH-31.4 MCHC-32.6 RDW-14.2 Plt Ct-452*
[**2151-2-28**] 06:00PM BLOOD PT-11.9 PTT-26.1 INR(PT)-1.0
[**2151-2-28**] 06:00PM BLOOD Glucose-82 UreaN-21* Creat-0.8 Na-141
K-3.0* Cl-102 HCO3-30 AnGap-12
[**2151-2-28**] 06:00PM BLOOD ALT-16 AST-17 AlkPhos-82 Amylase-65
TotBili-0.3 DirBili-0.1 IndBili-0.2
[**2151-2-28**] 06:00PM BLOOD Albumin-3.2* Calcium-8.9 Phos-2.5*#
Mg-2.0 Iron-36*
[**2151-2-28**] 06:00PM BLOOD calTIBC-302 Ferritn-91 TRF-232
[**2151-2-28**] 01:44PM BLOOD Type-ART Temp-38.1 pO2-74* pCO2-44
pH-7.44 calTCO2-31* Base XS-4 Intubat-NOT INTUBA Comment-ROOM
AIR
Discharge Labs
OPERATIVE REPORT
PREOPERATIVE DIAGNOSIS: Enterocutaneous fistula.
POSTOPERATIVE DIAGNOSIS: Difficult abdomen enterocutaneous
fistula. Multiple adhesions and multiple enterocutaneous
fistulas.
INDICATIONS FOR SURGERY: I heard from a hospital in [**State **] in which he had undergone surgery for
intestinal obstruction. Apparently the procedure was
extraordinarily difficult and after a number of hours there
were multiple enterotomies which could not be dealt with. At
least 3 loops of bowel, according to my findings today, were
brought out through an incision and the incision was closed
thus giving him loss of domain and incisional hernia. At that
point the operation was terminated and he was later referred
to me with a wide open central abdominal wound with multiple
loops of bowel on the surface and an abdominal fistula. The
nutritionalist assisted the patient including 3 days
preparation in which he had a quick burst of around-the-clock
enteral nutrition to increase his transferrin to 231 from the
situation in which he previously had a transferrin down
around 110. He had lost about 30 of 40 pounds. The following
procedure was carried out.
PROCEDURE IN DETAIL: Under satisfactory general anesthesia
the patient was placed supine and prepped and draped in the
usual manner. Before draping the incision, the old
gastrostomy tube was removed and a new fresh sterile
gastrostomy tube was calibrated at the appropriate level and
sewn in with some FiberWire.
We began the operation by extending the incision cephalad and
inferiorly and it was a relatively small incision through
which it would have been difficult to do the operation. As it
turned out we used the entire length of the midline incision
in the abdomen. We began the incision superiorly entering the
abdomen above the liver without making any enterotomies and
without making any holes in the liver. The bowel, as one
would expect, was intimately associated with the abdomen. We
isolated the small bowel loops after very strenuous
dissection and very difficult with the bowels. The bowel
really matted to each other. We were able to get him back to
having one afferent limb and one efferent limb which we then
placed [**Doctor Last Name **] Kochers and then resected the bowel. The
mesentery, which was a single mesentery across these loops,
had approximately 15 inches to 18 inches of bowel attached to
it, but he had ample bowel remaining so that nutrition
__________. with 4-0 and 2-0 silk, mostly 2-0, until we had
gotten the loops of small bowel, 1 proximal and 1 distal,
immediately adjacent to each other. There was a slight
difference in caliber because the top part of the anastomosis
had had some food passed through it in the past and the
distal had not had any food for approximately about 10 months
and so there was complete diversion. As a matter of fact in
the colon, there was some stool balls in the right colon and
they had probably been there for 10 months. We had tried to
enematize them prior to the operation without success.
After this we carried out a two-layer silk, 4-0 silk
anastomosis in end-to-end and had ligated the mesentery and
sutured the mesentery before we had put these 2 loops of
bowel together. The blood supply was excellent and we were
very happy with the anastomosis. The fistula which has a lot
of skin attached had also been resected prior to doing this
and this was satisfactory as well.
It then became time to mobilize the abdominal wall widely to
repair his incisional hernia which was brought about by the
previous operation carried out elsewhere. This was done with
immobilization of the entire area and was extensive enough to
require #19 [**Doctor Last Name 406**] drains in the subcutaneous area.
Gloves, gowns and drapes were then changed. The wound was
closed in layers with #1 Prolene in running fashion on the
fascia, 3-0 Vicryl as the subcutaneous closure. This was
difficult in the area below the umbilicus but this was
successfully carried out with interrupted vertical mattress
of 3-0 nylon. The superior portion was closed with 4-0
Monocryl and 3-0 Vicryl. Estimated blood loss was 150 cc. The
patient tolerated the procedure well. Two sponge counts,
needle counts and instrument counts were reported as correct
by the nurse in charge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 26005**]
Dictated By:[**Last Name (NamePattern1) 63863**]
Brief Hospital Course:
[**Known firstname **] [**Known lastname **] was admitted to [**Hospital1 18**] on [**2151-2-28**] under the care of
Dr. [**Last Name (STitle) 957**]. TPN was continued. Preoperative labs showed TRF
135; Albumin 3.3; Baseline pCO2 44. Preoperatively Hibiclens
washes were provided and he was given a prep of
Neomycin/Erythromycin. He was taken to the operating room on
[**3-4**] where he underwent an exploratory laparotomy; lysis of
adhesions; gastrostomy tube change; enterocutaneous fistula
resection; primary anastomosis; w/ repair of incisional hernia.
He tolerated the procedure well and was taken to the ICU
postoperatively for closer monitoring. Pain was controlled via
epidural and PCA. At POD 1 he was afebrile and with good urine
output. Hct was 26. He was transferred to the floor. At POD 3 he
received 1 unit PRBCs for a Hct of 24.0. The narcotic component
of the epidural as discontinued. We continued to await bowel
function. At POD 4 Reglan was started. He was afebrile and
ambulating. At POD 6 he was febrile to 101.5. The epidural was
removed. CXR showed LLL PNA. He was (+) flatus. He was
tolerating clear liquids. The incision site, particularly
around the G-tube, had a moderate amount of erythema/purulent
drainage. Vancomycin/Cefepime/Flagyl were started for empiric
coverage. Blood/Urine cultures were negative for growth.
Incisional drainage was (+) for yeast; enterococcus; MRSA.
Fluconazole was added. At POD 10 he continued to have an
elevated WBC count at 17.2. Incisional cellulitis and drainage
was resolving. Repeat CXR showed continued LLL PNA and right
middle lobe opacities. At POD 11 he was tolerating a regular
diet. WBC count was 16.6. Chest CT was completed which showed
small bilateral effusions and severe emphysema. At POD 12 he
was somnolent. ABG was obtained which showed pCO2 of 69; PH
7.35; PO2 80. Albuterol/Atrovent were provided with good
response. Narcotics were discontinued. TPN was discontinued. At
POD 14 he was afebrile and with good bowel function. WBC count
was 11.8. Repeat ABG showed PCO2 at 50. Megace and zinc were
started for poor appetite. Calorie counts showed 29g protein;
998 kcal. At POD 16, pt discharged to home with services. At
this point, pt is tolerating a regular diet and PO intakes have
significantly improved since he was first discontinued from TPN.
He will continue to take IV Vancomycin and PO Cipro, Flagyl and
Fluconazole at home for additional 1 wk.
Medications on Admission:
Diltiazem 120mg qd
Atrovent 4 puffs QID
Albuterol 2 puffs q3h prn
Temazepam 30mg qhs prn
Ativan 0.5mg [**Hospital1 **] prn
Paroxetine 20mg qd
Protonix 40
Oxycodone 10mg q12h
Darvocet q4H prn
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Enterocutaneous Fistulae
Emphysema
Post-op pneumonia
Post-op anemia
Post-op wound infection
Discharge Condition:
Good
Discharge Instructions:
Please return or contact for:
* Fever (>101 F) or chills
* Abdominal Pain
* Nausea or Vomiting
* Increased Shortness of breath or chest pain
* Redness or drainage from incision site
* Increased swelling or redness of extremities
* Inability to pass gas or stool
* Any other concerns
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 957**] in 2 weeks. Please call for
an appointment
Completed by:[**2151-3-22**]
|
[
"486",
"2851"
] |
Admission Date: [**2112-10-15**] Discharge Date: [**2112-10-24**]
Service: [**Location (un) **]
This patient is an 80-year-old male with a past medical
history significant for end-stage renal disease on
hemodialysis, coronary artery disease status post myocardial
infarction, ischemic cardiomyopathy with an ejection fraction
of 40%, and status post recent pneumonia who presents to the
Emergency Department from hemodialysis with hypotension
(blood pressure 60/palp).
The patient is status post a recent hospital admission at
outside hospital for a pneumonia and treated with Vancomycin.
Patient at hemodialysis on the day of admission, where he
received only 22 minutes of hemodialysis with 250 cc fluid
removed when he was found to have a blood pressure of
60/palp, asymptomatic. The patient was sent to the Emergency
Department at [**Hospital1 69**], where he
was reportedly alert, awake, oriented.
Patient denied fever, chills, abdominal pain, nausea,
shortness of breath, chest pain, palpitations. Patient is
aneuric and denies diarrhea and constipation.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis 3x a week
(anuric).
2. History of nonsustained ventricular tachycardia previously
treated with amiodarone (recently discontinued).
3. Spinal stenosis.
4. Parkinson's disease.
5. Coronary artery disease status post myocardial infarction
with ischemic cardiomyopathy and ejection fraction of 40%.
6. Status post cataract surgery.
7. Hypertension.
8. Amiodarone pulmonary toxicity with restrictive pulmonary
function tests.
9. Status post recent pneumonia.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Nephrocaps one tablet q day.
2. Sinemet 25 mg/250 mg po tid.
3. Vancomycin 1 gram 3x a week (dose at dialysis).
4. Vitamin C 500 mg [**Hospital1 **].
5. Zinc 220 mg q day.
6. Ativan 0.5 mg po q hs.
7. Colace 100 mg po bid.
8. Renagel 400 mg po tid with meals.
9. Aspirin 81 mg po q day.
10. Proscar 90 mg po q day.
11. Zestril 5 mg po q day.
12. Imdur 60 mg po q day.
SOCIAL HISTORY: Patient is married and lives with his wife
of 50 years. Denies tobacco, alcohol, as well as intravenous
drug use.
FAMILY HISTORY: Noncontributory.
EXAMINATION ON ADMISSION: Temperature 95.9, blood pressure
102/53, heart rate 90, respiratory rate 26, and oxygen
saturation 99% on 100% nonrebreather. In general, the
patient is found lying still, with flat facies, in no acute
distress. HEENT examination: Normocephalic, atraumatic,
surgical pupils. Extraocular movements are intact
bilaterally. Anicteric sclerae. Clear oropharynx. Poor
dentition. Moist mucous membranes. Neck exam: Decreased
mobility secondary to spinal pain, supple, no jugular venous
distention, no lymphadenopathy. Cardiovascular examination:
regular, rate, and rhythm, normal S1, S2, no murmurs, rubs,
or gallops. Pulmonary examination: Scattered end
inspiratory rales throughout, no wheezes or rhonchi
appreciated. Abdominal examination: Decreased abdominal
sounds, soft, nontender, and nondistended, no
hepatosplenomegaly. Extremities are warm and well perfused
with no clubbing, cyanosis, or edema. Neurologic
examination: Drowsy, but oriented to person, place, and
time, conversant, and appropriate, bradykinesic, increased
tone throughout, with symmetric motor strength and sensation
intact to light touch. Skin examination: Multiple
ecchymoses throughout the upper extremities, no rash.
Rectal: Heme positive black stool.
LABORATORIES AND STUDIES ON ADMISSION: Complete blood count
with a white blood cell count of 15.2, hematocrit 28.4
(previously 36.1 in [**2112-9-6**]), MCV 103, platelets 270
with white blood cell differential of 77% polys, 18%
lymphocytes, 3% monocytes. Chem-7 with a sodium of 135,
potassium 4.7, chloride 94, bicarb 31, BUN 41, creatinine
5.1, and glucose 106. Coag studies with a PT of 13.9, INR
1.3, and PTT of 28.4. Calcium 7.9, magnesium 2.0, and
phosphate 5.5.
Electrocardiogram on admission: Normal sinus tachycardia at
107, with right bundle branch block, and ST depressions in V3
through V5 (new) with left atrial dilatation.
Chest x-ray on admission with slight increased chronic
opacities at the bases right greater than left, no edema,
right pleural effusion. Abdominal CT scan was notable for
right lung base consolidation, diffuse vascular
calcification, perinephric fat, no abdominal aortic aneurysm,
spinal degenerative joint disease, no evidence of
retroperitoneal bleed.
HOSPITAL COURSE: In the Emergency Department, the patient
was found with a temperature of 95.9, blood pressure 60/43,
respiratory rate 36, heart rate 113 with an oxygen saturation
of 100% nonrebreather. The patient received intravenous
fluids, levofloxacin, and dopamine for presumed sepsis. The
patient's initial laboratory work was notable for a
hematocrit of 28.4, previously 36 one month prior with
hemoccult positive rectal examination.
The patient's abdominal CT scan was without evidence of
abdominal aortic aneurysm or retroperitoneal bleed. The
patient's electrocardiogram demonstrated a right bundle
branch block and new ST depressions in leads V3 through V5.
The patient's blood pressure responded to dopamine and
intravenous fluids, and the patient was admitted to the
Medical Intensive Care Unit for further management.
REMAINDER OF THE HOSPITALIZATION BY SYSTEMS:
1. Hematology: The patient was transfused a total of 5 units
of packed red blood cells from [**10-15**] for
a hematocrit less than 30. After the second unit of packed
red blood cells, the patient was weaned off dopamine and
maintained adequate blood pressure. The patient was followed
with serial hematocrits q8h with persistent requirement of
transfusion for persistent gastrointestinal bleed.
Following a definitive endoscopic procedure, the patient's
hematocrit stabilized and the patient was transferred out of
the Medical Intensive Care Unit and maintained a stable
hematocrit greater than 30, without evidence of bleeding.
The patient developed thrombocytopenia while in the Medical
Intensive Care Unit with a drop in platelets from 270-97 from
[**10-15**] to [**10-17**]. The patient's medications
were reviewed and Heparin was subsequently discontinued with
concern for Heparin-induced thrombocytopenia. The patient's
platelet count stabilized above 100 for the remainder of the
hospitalization without signs of bleeding. The patient was
continued off of Heparin and the subsequent Heparin-induced
thrombocytopenic antibody was negative. The etiology of the
thrombocytopenia is unclear. However, potentially type I
HITT.
2. Gastrointestinal: The patient developed melena while in
the Medical Intensive Care Unit, and a subsequent nasogastric
lavage was significant for 1 liter of coffee-ground emesis.
The patient's melena persisted and on hospital day #2, the
patient underwent an upper endoscopy with evidence of
multiple pyloric and duodenal ulcers, with the stigmata of
recent bleeding. The patient underwent BICAP electrocautery
without further evidence of bleeding.
The patient was tested for H. pylori (negative) and gastrin
(pending at time of dictation). The patient was started on
high dosed intravenous Protonix, now oral. The patient is
now eight days status post electrocautery without further
evidence of bleeding.
3. Renal: The patient is anuric, end-stage renal disease,
and continued on his previously scheduled 3x a week
hemodialysis throughout the hospitalization. The patient had
on average 1.5-2 liters of fluid removed at each dialysis,
well tolerated. The patient was restarted on Nephrocaps and
Renagel following the stabilization of the gastrointestinal
bleed.
4. Infectious Disease: On admission, the patient was found
to be relatively hypothermic and hypotensive with concern for
sepsis, status post a recent pneumonia. Blood cultures on
admission grew coag-negative Staph in [**1-11**] bottles. Given the
patient's recent pneumonia and clinical picture, the patient
was started on empiric Vancomycin and continued on a 14-day
course for coag-negative Staph bacteremia. Follow up blood
cultures on [**10-21**] are no growth to date. The patient
will be continued on Vancomycin to complete a 14 day course
(last day [**10-31**]).
The patient remained afebrile for the remainder of the
hospitalization without further signs of infection.
5. Cardiovascular: The patient's hypotension on admission
resolved with intravenous fluids and packed red blood cells.
The patient was maintained on dopamine initially with
concerns for sepsis. The patient's initial electrocardiogram
demonstrated new ST depressions in leads V3 through V5. The
patient ruled out for myocardial infarction by three sets of
enzymes with a peak troponin-I of 1.7. The patient was
placed on Telemetry which demonstrated multiple premature
ventricular contractions and occasional nonsustained V-tach.
The patient has a known history of nonsustained V-tach
previously treated with amiodarone, which was recently
discontinued for amiodarone induced pulmonary toxicity. On
admission, the patient was restarted on a low dose of
amiodarone, however, this was discontinued secondary to
concern for worsened pulmonary injury.
The patient underwent a transthoracic echocardiogram which
demonstrated diffuse left ventricular hypokinesis with
akinesis of the inferior half of the basilar wall as well as
inferolateral wall akinesis, symmetric left ventricular
hypertrophy, ejection fraction of 35-45%, moderate mitral
regurgitation, mild pulmonary hypertension.
The patient was restarted on a low dose of Zestril, well
tolerated, and subsequently started on a low dose of
Lopressor at 12.5 mg [**Hospital1 **]. At the time of dictation, the
patient is tolerating blood pressure management well with
planned resumption of the previous outpatient dose of
Zestril.
6. Pulmonary: The patient has a history of restrictive lung
disease secondary to amiodarone toxicity. The patient was
rapidly weaned off of oxygen while in the Medical Intensive
Care Unit and has maintained adequate oxygen saturations on
room air.
7. Nutrition: The patient was maintained without oral intake
on intravenous fluids while in the Intensive Care Unit. The
patient's diet was advanced following the stabilization of
the gastrointestinal bleed. The patient underwent a
swallowing study with evidence of fatigability and trace
aspiration on liquids and soft solids.
The patient underwent a video swallow study and was
subsequently approved for a soft-solid diet. The patient
tolerated this soft-solid diet without difficulty.
8. Musculoskeletal/Neuro: The patient has a known diagnosis
of Parkinson's disease and is now status post two prolonged
hospitalizations with significant debilitation. The patient
underwent physical therapy evaluation with recommendation to
pursue rehabilitation-level care. However, given the patient
and the patient's family's wishes to return home, the patient
will return to home with home physical therapy.
CONDITION ON DISCHARGE: Good.
MEDICATIONS ON DISCHARGE:
1. Lopressor 12.5 mg po bid.
2. Zestril 2.5 mg po q day.
3. Colace 100 mg po bid.
4. Senna two tablets po bid prn constipation.
5. Vancomycin (dose by level at hemodialysis).
6. Sinemet CR one pill po q am.
7. Methadone 5 mg po q am.
8. Protonix 40 mg po bid.
9. Ativan 0.5 mg po q hs prn.
INSTRUCTIONS ON DISCHARGE: The patient is to be discharged
to home with instructions to followup with his primary care
physician in one week postdischarge. The patient is to
continue on his previously scheduled 3x a week hemodialysis
where he will continue his Vancomycin dosing. The patient is
scheduled to followup with cardiologist, Dr. [**Last Name (STitle) **] on
[**11-2**] at 12 noon in the [**Hospital Ward Name 23**] Building. The
patient will be provided with home physical therapy as well
as CNA services.
DIAGNOSES ON DISCHARGE:
1. End-stage renal disease on hemodialysis 3x a week.
2. Upper gastrointestinal bleed (ulcers) status post
electrocautery.
3. History of nonsustained ventricular tachycardia.
4. Amiodarone pulmonary toxicity.
5. Spinal stenosis.
6. Parkinson's disease.
7. Coronary artery disease status post myocardial infarction.
8. Ischemic cardiomyopathy.
9. Status post cataract surgery.
10. Hypertension.
11. Status post pneumonia.
12. Coag-negative Staphylococcus bacteremia.
Of note, the patient maintained a code status of DNR/DNI.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D. [**MD Number(1) 3475**]
Dictated By:[**Name8 (MD) 4935**]
MEDQUIST36
D: [**2112-10-22**] 19:03
T: [**2112-10-22**] 19:05
JOB#: [**Job Number 9360**]
|
[
"2875",
"4240",
"4168",
"4019"
] |
Admission Date: [**2146-8-30**] Discharge Date: [**2146-9-9**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Ischemic ulcer of the right foot
Major Surgical or Invasive Procedure:
[**8-30**]: Rt CFA-Peroneal with NRSVG, profunda/SFA EA
[**9-5**]: Cardiac catheterization with bare metal stent to the RCA
complicated by L groin hematoma
[**9-5**]: Ex1. Left groin exploration.
2. Repair of left iliac vein bleed and left external iliac
artery bleed.
3. Evacuation of retroperitoneal hematoma.
History of Present Illness:
The patient is an 89-year-old gentleman has severe ischemic rest
pain and nonhealing ischemic ulcers of his right foot.
Arteriography showed him to be a poor candidate for endovascular
treatment; his common femoral artery was heavily
calcified with a high-grade calcific plaque at the origin of the
profunda femoris artery and essential total occlusion of all
vessels down to the level of the mid peroneal artery which was
his best runoff vessel distally. For these reasons he was
admitted to [**Hospital1 18**] with planned bypass graft in the right leg.
Past Medical History:
PVD with non-healing ulcers of R foot
HTN
Colon CA s/p colectomy
Carotid stenosis-chronic 100% occlusion L carotid
AFib
CRI with baseline creatinine 2.0
Chronic macrocytic anemia
[**Male First Name (un) 4746**] disease by CT
PSH: TURBT, s/p R CEA
Social History:
Lives alone, his wife died a few years ago. Served in WWII.
Has family nearby.
Family History:
N/C
Physical Exam:
Upon discharge
A and O NAD
VSS
PERRL, moist mucus membranes, no JVD
RRR + systolic murmur nl S1 S2
CTAB
soft slight TTP at L inguinal region
extensive ecchymoses at R and L flanks
abdominal staples along LLQ; incision c/d/i
R groin incision c/d/i
R LE + pitting edema, + incision c/d/i; open staples at proximal
thigh
L LE no c/c/e
Pulses: L DP neither palpable nor dopplerable, L PT
dopplerable; R DP and PT dopplerable
Pertinent Results:
[**2146-9-8**] 05:10PM BLOOD Hct-32.0*
[**2146-9-7**] 10:49AM BLOOD WBC-11.4* RBC-3.16* Hgb-10.1* Hct-28.2*
MCV-89 MCH-32.0 MCHC-35.9* RDW-14.6 Plt Ct-224
[**2146-9-1**] 06:00AM BLOOD WBC-13.5* RBC-2.61* Hgb-8.6* Hct-25.4*
MCV-97 MCH-33.1* MCHC-34.0 RDW-13.4 Plt Ct-296
[**2146-8-30**] 02:05PM BLOOD WBC-12.4* RBC-2.69* Hgb-8.7* Hct-25.7*
MCV-96 MCH-32.5* MCHC-34.1 RDW-13.1 Plt Ct-323
[**2146-9-7**] 10:49AM BLOOD Glucose-124* UreaN-25* Creat-1.2 Na-141
K-3.9 Cl-109* HCO3-27 AnGap-9
[**2146-8-30**] 02:05PM BLOOD Glucose-127* UreaN-26* Creat-1.5* Na-143
K-5.1 Cl-114* HCO3-21* AnGap-13
[**2146-9-7**] 10:49AM BLOOD Calcium-7.4* Phos-2.4* Mg-2.0
Brief Hospital Course:
The patient is an 89 yo male who was admitted for scheduled
angiography and intervention. The patient was admitted to
Vascular surgery/Dr. [**Last Name (STitle) **] on [**2146-8-30**], taken to angio suite
and inderwent successful Rt CFA-Peroneal with NRSVG,
profunda/SFA EA. The patient recovered in PACU then transferred
to [**Hospital Ward Name 121**] 5 for further observation. On routine post-op check
patient was noted to have cold L lower
extremity(non-intervention leg) and no DP pulse, but no
complaints of pain.
POD1 [**2146-8-31**] No acute events, L foot is now warm with [**Last Name (un) **] DP
pulse. Routine nursing care, lines discontinued. LENI- showed
significant L iliac, SFA and tibial disease.
POD2 [**2146-9-1**] Patient complained of chest pain, EKG was done that
showed ST depression throughout the precordium. Cardiac enzymes
were cycled, initial Troponin .04; repeat 0.15. His hct was
noted to be 25.4, down from 28.2 on admission. The patient most
likely suffered demand ischemia in setting of postoperative
acute blood loss anemia, with his symptoms, ECG changes, and
enzyme changes consistent with NSTEMI. Transfused with 2 units
PRBC's with Lasix in between. Cardiology consulted.
POD3 [**2146-9-2**]: cardiac Echo: Efx 55%, elongated LA, dilated RA,
mild regional systolic LV dysfunction, mild-moderate MR,
thickened Ao, Mitral, TC valve leaflets. Cards plan for cardiac
cath on Monday [**2146-9-5**], to give Mucomyst night prior to
procedure.
POD4 [**2146-9-3**] Transfused with 1 unit PRBC.
POD5 [**2146-9-4**] Pre-oped for cardiac cath.
POD6 [**2146-9-5**] Cardiac catheterization: The patient successfully
underwent cardiac catheterization, which revealed 90% occlusion
in RCA s/p bare metal stent, 70% occlusion in distal left main,
no intervention done.
Left groin hematoma s/p exploration, evacuation, left external
iliac arteriotomy and L iliac venotomy: Unfortunately the
patient became hypotensive to SBP 60s and a large groin hematoma
was noted while the groin sheath was being pulled by cardiology
in the catherization area. The patient was intermittently
placed on dopamine, then vascular surgery was called, and the
patient was given IVF, and 2 units of packed RBC with pressure
held to the groin with his SBP returning to the 150s.
His blood pressure began to drop again, however, to the 70s
systolic, and so he was taken emergently to the operating room
on [**9-5**] under general anesthesia for L groin exploration that
revealed a bleeding L external iliac artery, L iliac vein, both
of which were sutured. The hematoma was evacuated. A JP drain
was left in place and the patient was extubated and returned to
the CCU, and then to the floor. He did receive 2 units of blood
intraoperatively and then 1 unit following the surgery, but his
hematocrit remained stable at 28-29. He remained
hemodynamically stable postoperatively and thereafter.
A Foley catheter was placed on [**9-5**] when the patient returned to
the operating room.
Two staples were removed in the upper thigh on the right with
concern for infection but there was no drainage. The slight
redness is thought to be secondary to scrotal irritation.
The patient was then seen by physical therapy, who recommended
short term rehab.
The remainder of his stay was uneventful, and he is being
discharged today in stable condition.
Medications on Admission:
LISINOPRIL 10', LOVASTATIN 20', METOPROLOL TARTRATE 50',
NIFEDICAL XL 60', QUININE SULFATE 324', TRIAZOLAM .25', ASA 81'
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
9. Triazolam 0.25 mg Tablet Sig: One (1) Tablet PO qhs () as
needed.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Nifedipine 60 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
PVD with non-healing ulcers of R foot, ischemic L leg
HTN
Carotid stenosis-chronic 100% occlusion L carotid
AFib
CRI with baseline creatinine 2.0
Chronic macrocytic anemia
[**Male First Name (un) 4746**] disease by CT
PSH: TURBT, s/p R CEA, Colon CA s/p colectomy
Discharge Condition:
Weak but stable
Discharge Instructions:
1. The upper thigh wound may be covered with a dry sterile
gauze as needed
2. The patient is being discharged with a leg bag and Foley
catheter. He is s/p TURP and you may attempt to d/c the Foley
again. He needs follow up with his primary care physician.
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-13**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
1. Follow up with your cardiologist, Dr. [**Last Name (STitle) **]: Phone:([**Telephone/Fax (1) 30479**] 3:30 pm [**9-21**]
2. Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 79097**] This is
very important because you need follow up for your prostate and
difficulties urinating as well as your other medical problems.
3. Follow up with Dr [**Last Name (STitle) **] on [**2146-9-22**] 12:50 pm and
[**2146-9-26**] at 11:10 am; phone: [**Telephone/Fax (1) 1237**] for your vascular
surgery.
Completed by:[**2146-9-9**]
|
[
"41071",
"2851",
"41401",
"40390",
"5859",
"42731"
] |
Admission Date: [**2119-9-22**] Discharge Date: [**2119-10-1**]
Date of Birth: [**2055-4-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Readmitt for fever and chills
Major Surgical or Invasive Procedure:
Diagnostic thoracentesis.
Intubation
History of Present Illness:
Mr. [**Known lastname 72100**] presents with fever and respiratory failure with
undiagnosed right-sided pleural effusion.
Past Medical History:
Esophageal Cancer s/p Transthoracic esophagectomy
Hypertension
Hypercholesterolemia
Myocardial Infarction [**2109**]
Chronic Right Shoulder Pain
Social History:
He is married. He has four children in their 20s. He lives in
[**Location 5110**] with his wife. [**Name (NI) **] is retired from the meat cutting
industry. He does not smoke cigarettes nor has he in the past.
He drinks alcohol rarely about a six-pack per summer.
Family History:
His mother is alive at age 88 with breathing difficulties and
memory loss and heart problems.
His father is alive at age [**Age over 90 **] and was just recently diagnosed
with gastric
cancer.
He has a sister who died at age 61 of pancreatic cancer and a
sister who is alive at age 54.
There is no other family history of breast, ovarian, uterine, or
colon cancer.
Physical Exam:
General: 64 y.o. male in no added distress
HEENT: normocephalic, mucusmembranes moist
Neck: supple no lymphadenopathy
Card: RRR, normal S1,S2 no mumur/gallop or rub
Resp: decreased breath sounds with faint crackles
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm no edema
Skin: neck incision well healed, mid-abdominal incision well
healed
J-tube site clean, no dishcarge, mild skin thickening around
J-tube site
Neuro: non-focal
Pertinent Results:
[**2119-9-23**]: Pleural fluid (right): Mesothelial cells, histiocytes
and mixed inflammatory cells.
[**2119-9-26**] Esophogram: 1. Collection of contrast at approximate
level of the anastomosis may represent a folded loop versus
contained anastomotic leak. Correlation with the type of
anastomosis performed is suggested.
2. No evidence of stricture.
[**2120-9-25**] Echocardiogram:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function
are normal (LVEF >55%) Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is a small circumferential pericardial
effusion without echocardiographic signs of tamponade.
IMPRESSION: Preserved biventricular systolic function. Small
pericardial
effusion without echocardiographic signs of tamponade. Mild
aortic
regurgitation.
[**2119-9-25**] Chest CT:
1. No evidence of pulmonary embolism.
2. Subcutaneous soft tissue air anterior to the trachea, of
uncertain clinical significance. In consultation with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], this air along the anterior neck is secondary to a
recent procedure in this region.
3. Loculated pleural effusions and atelectasis.
4. Small pericardial effusion.
5. Cholelithiasis without evidence of cholecystitis.
Brief Hospital Course:
Patient was admitted for fever of unknown origin. He was
admitted for further work-up. All blood cultures and urine
cultures were negative. However, he developed respiratory
distress and was intubated for a question of aspiration. He was
taken to the ICU. A CT scan showed no frank evidence of leak at
the anastamosis site and pleural effusions. However, he had
thoracentesis which drained 400 cc of serous fluid which did not
grow anything on subsequent culture. His BAL while in the ICU
likewise showed no growth. He was extubated and transferred to
the floor in stable condition. Tube feeds were restarted and a
barium swallow was performed which showed no leak. After this,
the patient was started on a soft mechanical diet and tolerated
it without difficulty. He worked with physical therapy and they
believed that he would be able to go home with [**Last Name (NamePattern1) 269**] and continued
PT. He was discharged afebrile and in stable condition.
Medications on Admission:
Lipitor 20', Metoprolol XL 50', Lisinopril 10'
Discharge Medications:
1. Megestrol 40 mg/mL Suspension [**Last Name (NamePattern1) **]: One (1) PO DAILY (Daily).
Disp:*30 * Refills:*2*
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
[**Last Name (NamePattern1) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Heparin Lock Flush (Porcine) 10 unit/mL Solution [**Last Name (STitle) **]: One (1)
ML Intravenous DAILY (Daily) as needed.
5. Roxicet 5-325 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO every six (6)
hours as needed for pain for 7 days.
Disp:*30 5ml* Refills:*0*
6. Lipitor 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
7. Lisinopril 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Partners [**Name (NI) 269**]
Discharge Diagnosis:
Esophageal Cancer s/p Transthoracic esophagectomy
Hypertension
Hypercholestolemia
Myocardial Infarction [**2109**]
Chronic Right Shoulder Pain
Discharge Condition:
Deconditioned
Discharge Instructions:
Call Dr.[**Last Name (STitle) 28484**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101
-Increased shortness of breath, cough or sputum production
-Chest pain
Tube feeds site: keep clean and dry. Flush every 8 hrs with
water
Should it become clogged instill warm water or coke
If your feeding tube sutures become loose or break, please tape
securely and call the office [**Telephone/Fax (1) 170**].
Should the feeding tube fall out, call the office immediately it
will need to be replaced in a timely manner so the tract will
not close.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **]. Please call [**Telephone/Fax (1) 170**] for an
appointment at the [**Hospital Ward Name 517**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 8939**]
Report to the [**Location (un) **] radiology department for a chest x-ray
45 minutes before your appointment
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7047**] [**Telephone/Fax (1) 3183**]
|
[
"5119",
"4241",
"4019",
"2720",
"412"
] |
Admission Date: [**2117-2-14**] Discharge Date: [**2117-2-17**]
Date of Birth: [**2052-6-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest pain and diaphoresis
Major Surgical or Invasive Procedure:
Cardiac Cath with stents to LAD (2 stents) and LPDA (1 stent)
History of Present Illness:
64 yo Indian male experiencing substernal chest pain yesterday,
[**5-11**], non-radiating, associated with diaphoresis but not SOB.
Pain awoke pt from sleep. After persisting for 30 minutes, pt
went to [**Hospital3 **] where an EKG showed 1mm ST elevations in
I and aVL with reciprocal changes in II and aVF. Pt was started
on heparin, aspirin, and a beta-blocker. Pt was transferred to
[**Hospital1 18**] this morning for cardiac cath.
Past Medical History:
None
Social History:
Lives with wife. Retired 2 years ago as plant manager. Little
physical exercise and abundant fatty foods. No smoking.
Occassional alcohol.
Family History:
Brother had an MI and CABG at age 52. He is still alive.
Physical Exam:
Most notably, Mr. [**Known lastname **] is a well-nourished Indian male with a
7cm JVP, clear lungs, regular rate without murmurs, rubs, or
gallops, benign abdomen, and 2+ dorsalis pedis pulses
bilaterally without edema.
Pertinent Results:
[**2117-2-16**] 05:55AM BLOOD WBC-7.8 RBC-4.53* Hgb-13.6* Hct-38.6*
MCV-85 MCH-30.0 MCHC-35.2* RDW-12.5 Plt Ct-170
[**2117-2-16**] 05:55AM BLOOD Plt Ct-170
[**2117-2-16**] 05:55AM BLOOD Glucose-88 UreaN-9 Creat-0.9 Na-138 K-4.2
Cl-103 HCO3-30* AnGap-9
[**2117-2-15**] 04:18AM BLOOD ALT-41* AST-159* LD(LDH)-432*
CK(CPK)-1482* AlkPhos-71 TotBili-0.7
[**2117-2-17**] 10:30AM BLOOD CK(CPK)-197*
[**2117-2-15**] 03:24PM BLOOD CK-MB-116* MB Indx-10.1* cTropnT-2.46*
[**2117-2-17**] 10:30AM BLOOD CK-MB-6 cTropnT-1.64*
[**2117-2-15**] 04:18AM BLOOD Triglyc-108 HDL-34 CHOL/HD-4.4 LDLcalc-92
EKG:
Sinus bradycardia. Modest lateral ST segment elevation with what
appears to be slight ST segment depression in lead III (although
unstable baseline makes the latter difficult to assess) - could
be in part, early repolarization pattern but consider also,
lateral injury/ischemia. Clinical correlation is suggested. No
previous tracing available for comparison.
Cath:
1. Coronary angiography of this left dominant circulation
demonstrated
two vessel coronary artery disease. The LMCA was patent. LAD
had
proximal calcification with 90% serial lesions. There was a
tubular 70%
lesion in the mid vessel. Two diagonal vessels were small with
proximal
80% lesions. LCX was a large dominant vessel with an ulcerated
hazy 80%
lesion in the LPDA. OM1 had a proximal 50% lesion. RCA was a
non-dominant vessel with 40% stensis in the mid vessel.
2. Left ventriculography was not performed.
3. Limited resting hemodynamics post angiography demonstrated
elevated
right and left sided filling pressures with a mRA of 20 mmHg and
mPCWP
of 23 mmHg. PA pressures were mildly elevated at systolic PAP
of 40
mmHg. Central aortic pressure was normal. The Fick calculated
CO and
CI were mildly reduced at 4.7 L/min and 2.2 L/min/M2,
respectively.
4. Successful placement of 3.0 x 18 mm Cypher drug-eluting stent
in the
L-PDA. Final angiography demonstrated no residual stenosis, no
angiographically apparent dissection, and normal flow (See PTCA
Comments).
5. Successful placement of two overlapping Cypher drug-eluting
stents
(2.5 x 28 mm distally and 2.5 x 18 mm proximally) in the
proximal to
mid-LAD postdilated with a 3.0 mm balloon. Final angiography
demonstrated no residual stenosis, no angiographically apparent
dissection, and normal flow (See PTCA Comments).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Elevated left and right sided filling pressures.
3. Mildly reduced cardiac index.
4. Successful placement of drug-eluting stent in L-PDA.
5. Successful placement of drug-eluting stent in LAD.
ECHO:
EF = 60%. Preserved global and regional biventricular systolic
function. Trace AR. Mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**]. Trivial MR.
Brief Hospital Course:
Mr. [**Known lastname **] is a 64 yo male admitted with an STEMI due an 80% LAD
and an 80% LPDA lesions. He underwent PTCI with two Cypher
stents placed to his LAD lesion, and one to his LPDA. His LVEDP
was elevated during the procedure after receiving 3 liters of
IVFs, and he was subsequently admitted to the CCU for post-cath
management and diruresis. Pt was started on aspirin and plavix.
He was maintained on Integrilling for 18 hours post-cath. He
readily diuresed with 20mg of Lasix IV and remained euvolemic.
A beta-blocker and an ACE inhibitor were added and well
tolerated. Lipitor was also added. A post-cath ECHO showed a
normal EF (60%) with preserved left ventricular function. Mr.
[**Known lastname **] was counselled on lifestyle modification, including diet
and excercise. He will follow up with Dr. [**Last Name (STitle) **] in [**3-5**] weeks.
FULL CODE
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Nitroglycerin 3 mg Tablet Sustained Release Sig: One (1)
Buccal q5mins as needed for chest pain for 3 doses: Dissolve one
tablet under your tongue if you experience chest pain. .
Disp:*10 tabs* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
STEMI s/p cardiac cath and stents to LAD and LPDA
Discharge Condition:
Pt was in good condition with stable vital signs.
Discharge Instructions:
Continue taking your medications as prescribed. Minimize your
salt and fatty food intake. Exercise for at least 30 minutes
five days per week.
Call Dr. [**Last Name (STitle) **], Cardiology, for a follow up appointment in [**3-5**]
weeks.
Return to the hospital or call your doctor if you experience
chest pain, shortness of breath, change in mental status, or
weakness.
Followup Instructions:
Call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 62**]) for a follow-up cardiology
appointment in 1 month.
Provider: [**Name10 (NameIs) **] care physician Appointment should be in [**7-11**]
days
|
[
"41071",
"41401"
] |
Admission Date: [**2135-1-18**] Discharge Date: [**2135-4-5**]
Date of Birth: [**2072-6-18**] Sex: F
Service: MEDICINE
Allergies:
Percocet / Reglan / Fentanyl / Compazine / Levaquin
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Elective admit for MEC and DLI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
62-year-old female with secondary AML with deletion 7 chromosome
abnormality who is s/p matched related reduced intensity
allogeneic transplant in [**8-/2133**] with conditioning regimen of
fludarabine, busulfan and ATG with recurrent disease who is
being admitted for further treatment with MEC in hopes of
getting her disease in better control prior to another DLI.
Following her recurrence of AML, Ms. [**Known lastname **] has had treatment with
low dose of cytarabine in [**2-/2134**] followed by her 1st DLI on
[**2134-3-26**], complicated by acute GVHD of the liver. Her AML has
persisted and she is s/p 6 total cycles of Decitabine last given
on [**2134-11-25**] with a 2nd DLI given after her 4th cycle. She
received a 3rd DLI on [**2134-12-14**]. Ms. [**Known lastname **] has remained
pancytopenic requiring transfusion support and has required
periodic admissions with fever and infections. Most recently,
she was noted for acute increased pain and swelling around her
left eye with fevers and she was admitted on [**2134-11-13**].
Clinical picture was initially concerning for orbital cellultis,
which was ruled out by CT sinus imaging, showing only
preseptal/periorbital involvement. She was treated with
Zosyn/Vancomycin for six days while hospitalized and her
cellulitis markedly improved. Wound swab of the left eye grew
rare pseudomonas aeruginosa and sparse staph coagulase negative
bacteria. Ms. [**Known lastname **] was discharged to home to complete a total 2
week course of Zosyn. She received her 6th cycle of Decitabine
as planned on [**2134-11-25**] and her 3rd DLI on [**2134-12-14**]. She more
recently has had episodes of stool incontinence which has mainly
occurred at night. She underwent MRI imaging without contrast
which did not show anything concerning outside of degenerative
disc disease. She had an LP done on [**2134-12-28**] which was
negative for CNS involvement of AML. These episodes have
stopped. Her peripheral blast count has been increasing and she
underwent bone marrow aspirate and biopsy on [**2135-1-10**] which
unfortunately showed increasing blasts in the biopsy. After
further discussion of treatment options, the decision was made
to [**Year (4 digits) 10836**] froward with more intensive chemotherapy with MEC in
hopes of getting her leukemia in better control and then move
forward with another DLI.
On the floor she reports progressive malaise over the past few
weeks leading up to discovering her disease progression. She was
very distressed to learn the result of her BMBx on [**1-10**]. She was
hoping that the blasts would be better controlled by her past
treatements and DLI. She also has been having mild bone pain of
the legs for the past few weeks similar to past bone pain, but
less severe. She has no other complaints and no recent
illnesses.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies myalgias. Denies
rashes or skin breakdown. No numbness/tingling in extremities.
No feelings of depression or anxiety. All other review of
systems negative.
Past Medical History:
1. Pancreatic neuroendocrine tumor - s/p partial
pancreatectomy/splenectomy in [**2126**], with recurrence in
pancreatic tail in [**2129**] treated with octreotide then
bevacizumab/Temodar until cycle 15, day 15 on [**2131-7-18**]; liver
metastasis in [**2130**] treated with chemoembolization 9/[**2130**]. Follow
up CT scans that have showed some persistent lesions in the
liver, but no clear evidence of growth of her neuroendocrine
tumor. Last scan was on [**2134-12-23**].
2. End of [**Month (only) 958**]/beginning of [**2133-3-17**], ongoing workup for
weakness and confusion at OSH, and noted to have low blood
counts including anemia and thrombocytopenia. She was admitted
to [**Hospital1 18**] and she underwent a bone marrow aspirate and biopsy on
[**2133-4-28**], which revealed involvement by acute myeloid leukemia
with monoblasts and monocytes accounting for 29% of the aspirate
differential, categorized as AML, FAB subtype M5B. Cytogenetics
revealed deletion 7 abnormality.
3. Treated with induction chemnotherpy on [**2133-5-5**] and
achieved complete remission; subsequently received two cycles of
high-dose ARA-C with continued remission.
4. Treatment course complicated by an episode of acute
appendicitis with E. coli bacteremia and s/p appendectomy.
5. Neurologic workup during her admission to evaluate her
symptoms of transient weakness, shakiness, and headaches were
felt consistent with conversion disorder. MRI of the brain was
negative, LP was negative, EEG results were negative for any
seizures and her symptoms resolved during the course of her
initial hospitalization.
6. Matched sibling reduced intensity allogeneic transplant with
Fludarabine, Busulfan and ATG on [**2133-9-16**]. Her initial post
transplant course was essentially uneventful.
7. CMV viremia in [**10/2133**], treated with Valcyte. Switched back
to Acyclovir as of [**2133-11-24**].
8. Bone marrow aspirate and biopsy on [**2133-12-11**], due to
persistent low counts and increased monocytes on her peripheral
blood did not show any evidence for leukemia although with
possible dysplastic changes.
9. Admitted on [**2134-1-31**] due to worsening upper respiratory
symptoms with temperature to 100.2, increased congestion/sinus
pain and cough. Nasal washings were positive for parainfluenza
with no pneumonia. She completed a 10 day course of Tamiflu and
5 day course of Zithromax.
10. In [**1-/2134**], platelet count continued to decrease and repeat
bone marrow aspirate and biopsy on [**2134-2-18**] did not show any
evidence for recurrent leukemia but was noted for Trisomy 8.
Because of persistent drop in her neutrophil count and platelet
count, she underwent repeat bone marrow aspirate and biopsy on
[**2134-3-4**] which showed increased blasts with CD34-blasts
comprising 10-15% of marrow cellularity. Trisomy 8 was evident
and she was now 85% donor.
11. Ms. [**Known lastname **] received modified cytarabine therapy from
[**Date range (2) 44392**] followed by her DLI on [**2134-3-26**]. Noted for
increased liver function transaminases and bilirubin with acute
GVHD, Grade III. Treated with high dose steroids with
resolution. 12. Admitted on [**2134-3-27**] with fevers and right
hand cellulits and sinus infection with conjunctivitis.
Prolonged admission with IV antibiotics. Discharged on
[**2134-5-15**].
13. AML persisted despite the GVHD and with improvement of her
liver function tests, Ms. [**Known lastname **] received 1st cycle Decitabine at
20mg/m2 for 5 days starting on [**2134-5-7**].
14. Bone marrow aspirate and biopsy on [**2134-5-27**] showed no
increased blasts in the marrow but with continued evidence for
Trisomy 8 chromosome abnormality. Chimerism showed her to be
55% donor, increased from 20% in [**3-18**] cycle of Decitabine
on [**2134-5-31**] with the plan to move forward with a second DLI.
15. Admitted on [**2134-6-9**] for fevers with pneumonia. Treated
with IV antibiotics. She remained profoundly neutropenic, but
because she was otherwise feeling well with no ongoing fevers,
she was discharged home on [**2134-7-7**] to complete a course of
Zosyn.
16. 2nd DLI on [**2134-6-23**]. Repeat BM biopsy on [**2134-6-30**] showed
a markedly hypocellular marrow (5% cellularity) with erythroid
dominant hematopoiesis with mild erythroid dyspoiesis.
Diagnostic morphologic features of involvement by acute leukemia
are not seen.
17. Readmitted on [**2134-7-15**], due to infected left toe in the
setting of neutropenia. Received IV Vancomycin along with IV
Zosyn. Podiatry removed part of the toenail and she was
discharged home.
18. Repeat bone marrow biopsy on [**2134-7-15**] showed an erythroid
dominant marrow with myloid hyperplasia and left shift.
CD34/CD117 staining represent 5 - 10% of core cellularity.
Chimerism showed that she was 55% donor. Repeat bone marrow
biopsy on [**2134-8-9**] due to increasing circulating blasts showed
increasing blast count. Her chimerism showed that she was 35%
donor.
19. 3rd cycle of Decitabine on [**2134-9-2**], followed by a 4th
cycle on [**2134-9-30**] as her overall peripheral blast count had
markedly improved.
20. Bone marrow biopsy on [**2134-10-21**] showed residual blasts with
same phenotype as seen before, both in peripheral blood (1%) and
marrow (4-6%). By immunohistochemistry, CD34 highlights blasts
which are 3-5% of marrow cellularity. CD117 enumerates immature
myeloid precursors at 5-10% of marrow cellularity. Continues
with Trisomy 8 abnormality. 5th cycle of Dacogen which was
given on [**2134-10-28**].
21. Admitted on [**2134-11-13**] with periorbital cellulitis. Treated
with IV Zosyn with resolution.
22. 6th cycle of Decitabine on [**2134-11-25**].
23. 3rd DLI on [**2134-12-14**].
24. Increasing peripheral blast count with repeat bone marrow
biopsy on [**2135-1-10**] shows a marrow cellularity of 20%. There is
an interstitial infiltrate of immature cells consistent with
blasts occurring in small clusters and in sheets occupying
60-70% of marrow cellularity.
.
Other Past Medical History
1. AML FAB subtype M5B, outlined above
2. Pancreatic neuroendocrine tumor status post partial
pancreatectomy/splenectomy in [**2126**] with recurrence in the
pancreatic tail in [**2129**] treated initially with octreotide then
bevacizumab/Temodar until cycle 15 and day 15 on [**2131-7-18**] and
was stopped due to decrease of tumor burden. She was then noted
to have liver metastasis treated with chemoembolization in
09/[**2130**]. Her primary oncologist is Dr. [**First Name (STitle) **] [**Name (STitle) **].
3. Appendectomy on [**2133-5-15**].
4. Status post open cholecystectomy [**31**]/[**2131**].
5. Insulin-dependent diabetes due to pancreatectomy.
6. Stress related migraines.
7. Restless legs syndrome.
8. Hypertension.
9. Depression.
10. Two benign breast cysts surgically removed.
11. Status post tonsillectomy.
12. History of fractured skull at age 3.
13. Carpal tunnel syndrome.
14. E. coli bacteremia.
15. Acute GVHD of the liver with increased bilirubin.
Social History:
Ms. [**Known lastname **] is divorced and has two children. She shares a house
in [**Location (un) 5450**], [**Location (un) 3844**] with her friend [**Name (NI) 553**] who is her
healthcare proxy. She was the principal of a high school until
[**2129**] when she went on disability and retired permanently in
[**2130**]. She does not drink alcohol and is a nonsmoker.
Family History:
Notable for history of pancreatic cancer and history of gastric
cancer. There is coronary artery disease and diabetes mellitus
in the family.
Physical Exam:
GEN: NAD, pleasant
VS: 96.7 126/90 86 16 98% on RA
HEENT: MMM, pale mucosae, neck is supple, no cervical,
supraclavicular, or axillary LAD
CV: RR, NL S1, loud S2, no S3S4 MRG
PULM: CTAB with bibasilar crackles
ABD: BS+, NTND, no masses or hepatomegaly
LIMBS: No LE edema, no tremors or asterixis
SKIN: No rashes, skin breakdown, or petechiae
NEURO: PERRLA, EOMI, CN II-XII WNL, strength is diffusely 4+/5
on the R and 4-/5 on the L, toes are down bilaterally, gait is
normal, no evidence of dysdiadokinesis of the upper or lower
extremities
Pertinent Results:
Admission labs:
5.5>26.4<64
N10, L59, M13, E0, Atyp5, Blast 12, NRBC4
PT 11.8, PTT 25.4, INR 1.0
141/4.6/106/30/18/0.8<295
ALT 60, AST 44, LDH 448, AlkPhos 161, TB 0.3
Alb 3.9, Ca 8.4, Phos 3.8, Mg 2.1, UA 4.7
TSH 2.4
T4 6.2
CXR [**1-18**]
Tip of the left PIC catheter ends in the region of the superior
cavoatrial
junction. No pneumothorax, pleural effusion or mediastinal
widening. Lungs
are grossly clear, heart size top normal.
CXR [**1-22**]
Changed position of the right-sided PICC line. Unchanged size of
the cardiac silhouette. Minimal increase in diameter of the
pulmonary
vessels, potentially reflecting early overhydration. No
interstitial
markings, no focal parenchymal opacities suggesting pneumonia.
No pleural
effusions.
CT neck [**1-27**]: Mild inflammatory changes and reactive nodes in
right anterior neck. Given history of severe neutropenia,
infection is a strong possibility. No drainable fluid
collections.
CT neck [**2-16**]: 1. No CT evidence of sialadenitis. However,
prominent lymph node anterior to the right submandibular gland
measures 13 x 8 mm, and in a patient with neutropenia, could
reflect underlying infection.
2. No other acute abnormality compared to the prior study.
Abdominal U/S [**2-21**] : 1. Status post splenectomy, as seen on prior
CT examination. Small regenerative splenules are not visualized
on this study, likely obscured by overlapping loops of bowel.
2. No mass is seen at the splenectomy bed.
CT neck [**2-26**]: Unchanged CT examination of the neck compared to
[**2135-2-15**]. No abscess or fluid collection is identified. No
significant inflammatory change. A single prominent lymph node
anterior to the right submandibular gland is unchanged in size
and appearance.
Bone marrow biopsy/cytogenetics [**2-27**]: ****
CT Abd/Pelvis [**2-28**]: 1. No acute process identified with no
evidence of hematoma. 2. Known liver lesions not appreciated on
this non-contrast examination.
CT L-Spine [**2-28**]: Mild-to-moderate degenerative disease within
the lumbar spine, most pronounced at L4-5 and L5-S1, without
significant spinal canal stenosis or neural foraminal narrowing.
No clear radiographic explanation for clinical presentation.
Micro:
[**1-25**] URINE CULTURE: ESCHERICHIA COLI. 10,000-100,000
ORGANISMS/ML.
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Ms [**Known lastname **] was admitted for elective MEC followed by DLI for
progression of disease on bone marrow biopsy on [**2135-1-10**] and
progressive malaise and mild bone pain over the several weeks
prior to admission. MEC treatment was initiated on [**2135-1-18**] and
DLI was initiated on [**2135-2-17**]. Following her admission, she
developed fevers for which she was started on broad spectrum
antibiotics. She complained of neck and jaw pain for which she
underwent a CT revealed stranding/lymphadenopathy concerning for
infection in the neck. Her symptoms improved on these
antibiotics and she remained afebrile. Her symptoms recurred
again in [**Month (only) 958**], with continued blasts on peripheral smear after
MEC and 1 week post-DLI with extreme fatigue and gum pain felt
to be related to recurrent leukemia. Bone marrow biopsy was
repeated on [**2-27**], revealing persistent involvement of her AML.
She was started on a mylotarg/azacitadine regimen on [**3-3**], but
was transferred to the [**Hospital Unit Name 153**] for fevers and hypotension later
that night. Her chemotherapy was continued through her [**Hospital Unit Name 153**]
stay and she completed her mylotarg/azacitadine course. Back on
the floor, her ANC remained low (<100) throughout [**Month (only) 958**] and
early [**Month (only) 547**]. Her fevers continued since her transfer from the
ICU and a PICC line which was noted to be ~ 1 yr old was pulled,
cultured, and a new PICC was placed. She had been on a PO
antibiotics regimen and she was converted back to an IV regimen.
Her fevers persisted through vancomycin + cefepime, although
she did remain normotensive. Her neck and jaw pain were
significantly improved although she did continue to complain of
abdominal discomfort after eating. Fungal coverage was added
with voriconazole in addition to flagyl but her fevers
persisted. Repeated blood cultures revealed no infection; 1
urine culture from [**3-20**] showed < 10,000 colonies of Enterococcus
resistant to vancomycin. She was initiated on daptomycin, and
repeated urine cultures were negative. Ms [**Known lastname **] continued to
have peripheral blasts (between [**1-22**] on peripheral diff); given
continued blasts, decitabine was initiated on [**3-24**]. She
tolerated decitabine therapy well. Her ANC continued to be <
100. Following completion of daptomycin course for 10 days, her
fevers resolved and she was afebrile for 5 days prior to
discharge. Her flagyl was discontinued and her cefepime was
transitioned to PO cefpodoxime. After discontinuation of dapto
and conversion to PO regimen of cefpodoxime, Ms [**Known lastname **] continued
to be afebrile > 72 hours. She was discharged with close
follow-up with Dr [**Last Name (STitle) **]. She was neutropenic at time of
discharge, but afebrile. She was able to ambulate around the
room with mild fatigue but no other complaints. Her energy was
significantly improved. She was set up with an appointment for
inhaled pentamidine, [**Hospital1 **]-weekly transfusions, and follow up with
Hematology.
Medications on Admission:
- Lorazepam 0.5-1 mg PO Q4H:PRN
- Acyclovir 400 mg PO Q8H
- Mirtazapine 15 mg PO HS
- Allopurinol 300 mg PO DAILY
- Nystatin Oral Suspension 5 mL PO QID:PRN
- Clonazepam 0.5 to 1 mg PO QHS:PRN
- Docusate Sodium 100 mg PO TID
- Oxycodone SR (OxyconTIN) 60 mg PO Q8AM
- Oxycodone SR (OxyconTIN) 20 mg PO Q2PM
- Oxycodone SR (OxyconTIN) 60 mg PO Q8PM
- FoLIC Acid 1 mg PO DAILY
- Esomeprazole 40 mg PO Q24H
- Posaconazole Suspension 200 mg PO TID
- HYDROmorphone (Dilaudid) 2-4 mg PO Q3H
- Polyethylene Glycol 17 g PO/NG DAILY:PRN
- Insulin SC Sliding Scale & Fixed Dose Levimir 20units HS
Allergies:
Percocet, although she is able to take oxycodone and Tylenol,
Reglan, fentanyl, and Compazine. Intolerance to Levaquin.
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for nausea/anxiety/insomnia.
Disp:*30 Tablet(s)* Refills:*0*
2. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for mouth sores.
6. Clonazepam 0.5 mg Tablet Sig: 1-2 Tablets PO QHS (once a day
(at bedtime)) as needed for insomnia.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
11. Posaconazole 200 mg/5 mL (40 mg/mL) Suspension Sig: Five (5)
mL PO TID (3 times a day).
12. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
pkt PO DAILY (Daily) as needed for constipation.
13. Insulin
continue your home insulin sliding scale and fixed dose Levimir
20 units at night
14. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO qAM: at 8 AM.
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
15. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO qPM: (at 8 pm).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*2*
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Breakthrough pain.
Disp:*30 Tablet(s)* Refills:*0*
17. Saliva Substitution Combo No.2 Solution Sig: One (1) ML
Mucous membrane TID (3 times a day).
Disp:*90 ML(s)* Refills:*2*
18. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
Disp:*30 Tablet(s)* Refills:*0*
19. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO q afternoon: 2 PM.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary:
- Acute myeloid leukemia
- Neutropenia
Secondary:
- Diabetes mellitus
- Depression
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Dear Ms [**Known lastname **],
You were admitted to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for
chemotherapy and donor lymphocyte infusion. You first received
the MEC regimen (mitoxantrone, etoposide, and cytarabine) and
donor lymphocyte infusions. Following these treatments, we
waited for your bone marrow to recover, however you had
continued numbers of blasts in your blood, suggesting that your
AML needed further treatment.
You also did develop a jaw infection and a low blood pressure
with fevers for which we kept you on several antibiotics and
briefly admitted you to the intensive care unit. Your blood
pressure improved with antibiotics and we decided to start
treating your AML again given continued blasts. Following a
second round of chemotherapy with azacitadine/mylotarg, your
blast count improved somewhat, however we did a third round with
decitabine to keep your blast count low. You continued to have
fevers which required us to keep you on antibiotics for several
weeks. The source of your fevers may have been a urinary tract
infection, which cleared with the antibiotics. At time of
discharge, you had repeatedly clear blood and urine cultures
with no fevers for five days prior to your discharge.
.
The medication changes we made during this hospitalization were:
(1) Please discontinue dilaudid.
(2) We decreased your morning oxycontin dose to 40 mg and we
decreased your evening oxycontin dose to 40 mg. You should
continue the 20 mg afternoon oxycontin.
(3) We are giving you oxycodone for breakthrough pain - you can
take [**12-18**] pills as needed every six hours.
(4) You can apply caphasol gel to the mouth ulcers that you get
to help decrease pain and irritation.
(5) You can take Ativan as needed for nausea.
(6) Please continue to take cefpodoxime twice a day for the next
15 days until Dr [**Last Name (STitle) **] indicates otherwise. You should
continue your other antibiotics as usual (posaconazole and
acyclovir).
(7) You will need to get pentamidine administered on Thursday
prior to your appointment with Dr [**Last Name (STitle) **] on Thursday (at 10:00
AM).
Followup Instructions:
You have a follow up appointment scheduled with Dr [**Last Name (STitle) **] at 130
PM on Thursday, [**4-7**]. Prior to this you will get a
pentamidine treatment at 10:00 AM on the [**Hospital Ward Name **] ([**Location (un) 19201**], rm 116).
|
[
"4019",
"311",
"V5867"
] |
Admission Date: [**2116-12-3**] Discharge Date: [**2116-12-13**]
Date of Birth: [**2041-5-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Melena and anemia
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
HPI: Mr. [**Known lastname 7457**] is a 75 year old man with history of Atrail
Fibrillation on Coumadin and transfusion-dependent MDS (baseline
Hct 25-28) who presented to [**Hospital1 18**] from his hematologist's office
when he was discovered to have a history of [**2-24**] days of melena
and associated anemia. He describes having dark bowel movements
once daily for the past 4-5 days; his last dark BM was on the
day prior to admission. (At baseline he has one well-formed BM
daily.) He describes feeling fatigued and very short of breath
for two days prior to admission, with dyspnea with "any
movement," relieved by lying still. He denies experiencing chest
pain, palpitations, headache, lightheadedness, n/v, diaphoresis,
abdominal pain or abdominal cramping, dyspepsia, or fever during
this time period. He denies NSAID use. His appetite has been
stable. He has no prior history of melena, BRBPR, or
hematemesis, but notes that he has 1-2 episodes per week of
coughing blood related to his postnasal drip. On presentation
to his hematologist's office on the day of admission, his
hematocrit was found to be 18.7 and he was transfered to [**Hospital1 18**].
In the ED he received 4 units PRBC, 4 units FFP, and Vit. K and
transferred to the MICU. On the following day ([**12-4**]) he
underwent EGD where he had multiple findings (see below)
including a single linear ulcer at gastroesophageal junction
with stigmata of recent bleeding but no active bleeding, as well
as 2 AVMs in the stomach fundus. He has no previous history of
PUD or gastritis. He does report a past history of acid reflux
at night, which he has not experienced since he stopped eating
late-night meals 2 years ago.
Past Medical History:
1. Atrial Fibrillaion on coumadin diagnosed [**5-26**]
2. Left Atrium appendageal thrombus seen on TEE [**2116-11-24**]
3. Myelodysplastic Syndrome - thrombocytosis and
transfusion-dependent anemia with associated hepatosplenomegaly;
diagnosed approx. 2 y.a.
4. Pulmonary hypertension and RHF
5. CAD s/p PCI ([**9-23**])
6. Recent abrupt "muscle wasting" in extremities and trunk 6
months ago
7. Lower extremity and scrotal edema, treated with Lasix
8. Hypertension
9. Basal Cell Carcinoma
10. Prostate CA
[**21**]. Diverticular disease
12. Hemorrhoids
13. Eczema
Social History:
No EtOH, 40 pack-years tobacco (quit [**2090**]'s), no IVDU. Lives
with wife, performs own ADLs at baseline .
Family History:
Brother died of leukemia, s/p liver transplant
Physical Exam:
Physical Exam:
.
VS: ED-> T 96.5, HR 95, BP 75/45, RR 18 O2sat 95%RA
VS upon transfer: T 99.5, HR 92, BP 106/68, RR 18 O2sat 96%RA
GEN: Comfortable-appearing elderly man in NAD
HEENT: PERRL, EOMI, Sclera anicteric, OP clear and
non-erythematous, moist MM, hearing intact to finger rub
bilaterally
NECK: supple, no JVD, no LAD, no thyromegaly
CARDIO-Irregular RR, [**1-25**] SM best heard at apex
PULM-Decreased BS at L base, Faint crackles in R base
ABD-soft, NT, ND, Normal BS, liver easily palable at 10cm
inferior to costal margin, 6cm diameter ventral hernia
demarcated by 3cm well-healed scar
EXT-BLE with 2+ pitting edema. No venous stasis changes, DP 2+
bilaterally.
SKIN-WWP, multiple diffuse 2-3mm telangiectasias
NEURO-A&O to person/place/date, CNs [**1-3**] intact, Strength and
sensation to light touch intact in upper and lower extremities.
Marked muscle atrophy of limbs and shoulders.
Pertinent Results:
Studies:
.
EGD #1 [**2116-12-4**]: Esophagus: Excavated Lesions- A single
non-bleeding linear erosion was noted in the lower third of the
esophagus with overlying mucus. A single nonbleeding linear
ulcer was found in the gastroesophageal junction. There was
stigmata of recent bleeding but no active bleeding.
Stomach: Two small angioectasias non-bleeding were seen in the
fundus. No thermal therapy was applied due to high INR. Normal
duodenum. Impression: Erosion in the lower third of the
esophagus. Ulcer in the gastroesophageal junction. Angioectasia
in the fundus
.
EGD #2 [**2116-12-8**]: Normal esophagus. The stomach was difficult to
insuffulate due to what appeared to be an extrinsic compression.
A few medium localized angioectasias that were not bleeding were
seen in the fundus and stomach body. [**Hospital1 **]-CAP Electrocautery was
applied for hemostasis successfully. Normal duodenum.
Impression: Extrinsic impression of the stomach Angioectasias in
the fundus and stomach body Otherwise normal egd to second part
of the duodenum Recommendations: Continue PPI [**Hospital1 **]
Follow Hct CT scan abdomen to evaluate for extrinsic compression
of the stomach.
.
CT ABDOMEN/PELVIS [**2116-12-9**]: CT ABDOMEN FINDINGS: Images of the
lower thorax demonstrate a right pleural effusion. There is
uniform hepatomegaly. There is no biliary dilatation. There is
splenomegaly. There is compression of the stomach between these
two organs. There is cholelithiasis. The right kidney is grossly
normal except for the presence of a large upper pole simple
cyst, which measures 6.5 x 9.0 cm in AP and transverse
dimensions. The left kidney also demonstrates two large simple
cysts in the upper pole. Also, present in the left kidney are
two nonobstructing calculi, one measures 1.2 cm in length and
the other measures 0.8 cm in length, the width of each of these
calculi is approximately 4-6 mm. Between the tail of the
pancreas and the spleen, there is a 2.0 x 3.3 cm cystic lesion.
It is not clear if this arises from the pancreatic tail or the
spleen. There is no pancreatic duct dilatation, however. There
are no dilated bowel loops. Contrast passes from the stomach
into the small bowel and colon. The splenic vein is enlarged and
tortuous. There is a small amount of ascites.
CT PELVIS FINDINGS: There are numerous diverticula involving the
colon. There is a small to moderate amount of pelvic free fluid.
There is no
lymphadenopathy. Bone windows demonstrate no lytic or blastic
lesions. Well-circumscribed lucencies are present in the right
ilium which could be related to a bone marrow biopsy or
osteopenia. Degenerative changes are present throughout the
spine.
IMPRESSION:
1. Hepatosplenomegaly with compression of the stomach. This
compression
may be the cause of the mass effect seen in the recent EGD.
There is no bowel or gastric outlet obstruction, however.
2. Dilated splenic vein and ascites are suggestive of portal
hypertension.
3. Cystic structure in the region of the pancreatic tail and
spleen. Further characterization is not possible on this study.
When the patient is over his acute illness, consider further
evaluation with MRI.
4. Nonobstructing left renal calculi.
6. Diffuse atherosclerosis.
6. Small right pleural effusion.
.
CXR [**2116-12-4**]: FINDINGS: Minor area of increased opacity above the
mid portion of the left mid diaphragm likley to represent some
left basilar atelectasis. No pneumothorax or effusion
demonstrated. No gross pulmonary edema. Heart size at the upper
limits of normal.
.
CXR [**2116-12-8**]: FINDINGS: Cardiac silhouette remains slightly
enlarged. In addition to the left basilar atelectasis seen on
the prior examination, there is slightly increasing opacity,
consistent with effusion. Superimposed infection cannot be
excluded in this region. No other focal pulmonary opacities or
evidence of pneumothorax. Osseous structures appear
unremarkable. IMPRESSION: Left basilar atelectasis with
component of effusion. Infection is not excluded.
.
LABS:
[**2116-12-3**] 11:20AM WBC-22.5 RBC-1.76 HGB-5.6 HCT-16.3 MCV-93
MCH-31.8 MCHC-34.2 RDW-20.0
PT-25.8 PTT-35.9 INR(PT)-4.9
GLUCOSE-153 UREA N-78 CREAT-1.6 SODIUM-137 POTASSIUM-4.6
CHLORIDE-104 TOTAL CO2-22 ANION GAP-16
CALCIUM-8.0 PHOSPHATE-3.3 MAGNESIUM-2.6
Brief Hospital Course:
Assessment: 75 year old man with history of Atrail Fibrillation
and left sided thrombus on Coumadin with 4-5 days of melena and
associated anemia determined to be secondary to gastric AVMs
successfully cauderized.
.
1) GI BLEED: After presenting to the ED with 4-5 days of melena
and HCT 16.3 in the setting of INR of 4.9, Mr. [**Known lastname 7458**]
anticoagulation was discontinued and he was given 4 units PRBC,
4 units FFP, SC Vit. K, and transferred to the MICU. His HCT
stabilized and INR decreased to 1.9. Diltiazem, Losartan and
furosemide were held for volume depletion. On [**12-4**], he underwent
EGD and was found to have ulcer at the GE junction with stigmata
of recent bleeding but no active bleeding. EGD also identifed a
non-bleeding erosion in the lower esophagus and two small
non-bleeding angioectasias in the fundus. After EGD and
stabilization of vital signs, Mr. [**Known lastname 7457**] was transferred to the
floor, where he was monitored for recurrent GI bleed with vital
signs, serial HCT checks, serial abdominal exams, and stool
collection. His INR was followed and he was treated with
Protonix. Coumadin was at first held due to risk of re-bleed,
then restarted with a heparin bridge on [**12-6**] in consulation with
GI. After restarting Coumadin and heparin it was noted that the
patient's HCT had not elevated appropriately after a transfusion
of 1 unit PRBC given for his MDS. He was transfused a second
unit overnight, and the following day, he was noted to have
melena. Nasogastric lavage was performed to assess whether the
previously identified esophageal ulcer was bleeding; no blood
was seen on NGL. Given that he appeared to be having a repeat
bleed in the setting of restarting his anticoagulation, the
patient's coumadin, heparin, aspirin, and antihypertensives were
held. He was transfused an additional 2 units of PRBC and a
repeat EGD was performed on [**12-8**]. On repeat EGD there were no
ulcers seen in the esophagus. Two angioectasias seen in the
fundus were cauterized. After the second EGD, the patient
remained stable with no signs of recurrent bleeding: HCT and
vital signs remained stable, and the patient's bowel movements
were non-bloody and non-melenous. Anticoagulation with Coumadin
and heparin was started again on [**12-10**], and for the duration of
his hospitalization the patient remained hemodynamically stable
and without signs of GI bleeding. Diltiazem, Losartan and
furosemide were restarted prior to discharge. Aspirin was held
and the patient was instructed to restart as an outpatient in
consultation with his PCP.
.
2) Atrial fibrillation and left atrium thrombus: The patient
has A Fib and a known left atrial thrombus normally treated with
Coumadin 5mg daily. The patient's GI bleed on admission occurred
in the setting of a supratherapeutic INR of 4.9, so coumadin was
held and anticoagulation was reversed in the ED with 4 units
Fresh Frozen Plasma and Vitamin K. Given his known left atrial
thrombus and associated increased risk of stroke, it was
recommended by cardiology that he restart Coumadin as soon as
the GI team considered his GI bleed stable. Therefore,
anticoagulation with Coumadin and heparin bridge was started on
[**12-6**]. After the patient's recurrent GI bleed, anticoagulation
was again stopped, then restarted on [**12-10**]. He was kept on his
digoxin throughout the hospitalization. Diltiazem was initially
held because his BP remained in the 90's and 100's systolic, but
resumed once BP stabilized. The addition of a beta blocker to
his medication regimen was considered, but it was decided that
it would be best to start this as an outpatient, in consultation
with his cardiologist. By the day of discharge, the patient's
INR was therapeutic at 2.1 and he was discharged home on
coumadin 5mg daily.
.
3) Dyspnea: For two days prior to admission the patient
experienced shortness of breath with minimal exertion, likely
related to his severe anemia. He continued to experience
intermittent milder dyspnea on hospital day 2, and O2 sat of 91%
on RA was recorded. The patient was placed on 2L oxygen via
nasal cannula, and EKG was obtained to rule-out cardiac ischemia
EKG was unchanged from prior. CXR was obtained which showed a
small opacity in the L lower lobe which was consistent with
pneumonia. A 10-day course of Levofloxacin was started. By
discharge, the patient no longer had an oxygen requirement, and
only noted mild dyspnea while in certain positions, which he
attributed to his enlarged liver exerting pressure on his lungs.
.
4) Edema: The patient has a history of lower extremity edema and
scrotal anasarca for which he takes furosemide 80mg daily. His
furosemide was initally held because of low BP, then later
re-started when he noted scrotal anasarca. His volume status
was closely monitored while on furosemide. By discharge, there
was moderate resolution of scrotal swelling, but the patient's
lower extremitity edema had not resolved.
.
5) Myelodysplastic Syndrome: Heme was consulted and felt that
there was no acute process at this time. Given that the patient
is known to have thrombocytosis and transfusion-dependent
anemia, his blood counts were closely followed. He was continued
on his anagrelide, but thalidomide was held due to hospital
regulations. The patient was advised to follow-up with his
outpatient hematologist upon discharge and continue medications
as prescribed.
.
6) CAD s/p PCI: The patient's CAD remained stable throughout
his hospitalization. He was monitored for signs of cardiac
ischemia, especially in the setting of his GI bleed and low HCT,
and remained without signs of active ischemia. He was continued
on statin therapy throughout his hospitalization. Diltiazem and
Losartan were initially held, then resumed once the patient was
stable and it appeared that his blood pressure could tolerate
them. The addition of a beta blocker to his medication regimen
was considered, but it was decided that this could be started as
an outpatient. Aspirin was held, and the patient should restart
it as an outpatient, in consultation with his PCP or
cardiologist. The patient was maintained on a cardiac diet while
hospitalized.
.
7) Findings on CT scan: The patient had multiple significant
findings on abdominal/pelvic CT obtained on [**12-9**]:
- Dilated splenic vein and ascites, indicative of portal
hypertension
- 2.0 x 3.3 cm cystic lesion between the tail of the pancreas
and the spleen; it is not clear if this arises from the
pancreatic tail or the spleen.
Outpatient work-up of portal hypertension is recommended. It is
also recommended that the patient undergo MRI for follow-up of
the cystic lesion in the area of the pancreatic tail. This can
also be done as an outpatient.
Medications on Admission:
Coumadin 5mg
Anagrelide 1mg [**Hospital1 **]
Thalidomide 50mg daily
Cyanocobalamin daily
Losartan 50mg daily
Digoxin 0.125mg daily
ASA 81mg daily
Diltiazem 240mg daily
Lovastatin 20mg daily
Lasix 80mg daily
Discharge Medications:
1. Anagrelide 0.5 mg Capsule Sig: Two (2) Capsule PO bid ().
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
4. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
8. Thalidomide 50 mg Capsule Sig: One (1) Capsule PO once a day.
9. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed in the setting of high INR, Anemia
Discharge Condition:
Mr. [**Known lastname 7458**] GI bleeding and shortness of breath have resolved.
His Coumadin has been restarted, INR is Hematocrit is stable
at >30.
Discharge Instructions:
1) Please call your doctor or return to the Emergency Department
if you experience recurrence of blood in your bowel movements or
dark bowel movements, or any of the following: chest pain,
shortness of breath, dizzyness, fevers, chills, weakness,
fatigue.
2) Please keep your appointment on Monday with your hematologist
Dr. [**Last Name (STitle) 7459**].
3) Please discuss with Dr. [**Last Name (STitle) 7459**] or your PCP before
restarting your daily Aspirin
4) Continue to take all other medications as prescribed
Followup Instructions:
1) Please follow-up this week with Dr. [**Last Name (STitle) 7459**]
2) Please have your INR checked every 2 weeks, or as recommended
by Dr. [**Last Name (STitle) 7459**]
3) Please call this week to make an appointment to see your PCP
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7460**]
|
[
"486",
"42731",
"4280",
"V5861",
"4168",
"4019",
"V4582",
"41401"
] |
Admission Date: [**2172-7-10**] Discharge Date: [**2172-7-12**]
Date of Birth: [**2115-4-30**] Sex: M
Service: CU
HISTORY OF PRESENT ILLNESS: This is a 57-year-old male with
known CAD, coronary artery disease who is status post PTCA/MI
in [**2165**] who was doing well until he presented to an outside
hospital with substernal chest pain, which had awoken him
from sleep. It was nonradiating. The patient complained of
associated weakness, dizziness, diaphoresis and some
shortness of breath. However, there was no nausea or
vomiting. He also complained of a pain in his back. An EKG
revealed ST elevation in leads II, III and aVF. The patient
was started on heparin and a lidocaine drip, P and K at half
the dose and a 2B3A inhibitor, a baby aspirin and Lopressor
25 mg and was transferred to [**Hospital1 188**] for cardiac catheterization. When he arrived at [**Hospital1 1444**] he did have a sudden onset of
SVT, supraventricular tachycardia, for which he was given
lidocaine. The patient arrived to the [**Hospital1 190**] catheterization laboratory at 6 in the
morning. His chest pain had resolved and he was
hemodynamically stable.
MEDICATIONS ON ADMISSION: He was on Lopressor 25 mg p.o.
b.i.d. He was started on Lopressor on [**7-10**] after the
MI. On [**7-11**] an ACE inhibitor, lisinopril was added at
5 mg q.d. The dose was titrated up on the 2nd to 10 mg q.d.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: CAD status post MI in [**2165**] and
hyperlipidemia.
FAMILY HISTORY: Not significant.
SOCIAL HISTORY: No alcohol. The patient reports having quit
smoking and no IV or street drug abuse.
PHYSICAL EXAMINATION ON ADMISSION: Blood pressure 110/60,
heart rate 78, respiratory rate 16. General: Alert and
oriented, lying flat in bed, in no apparent distress. HEENT:
Sclerae were anicteric, mucous membranes were moist. There
was no JVD or JVP appreciated. Cardiovascular: Regular rate
and rhythm. Normal S1 and S2. No murmurs, rubs or gallops.
Respiratory: Clear to auscultation bilaterally without
crackles. Abdomen: Soft. Nontender. Nondistended.
Extremities: Warm. His hands were cool without edema. His
pulses radial and DP were 2+ bilaterally. The right cardiac
catheterization site, there was a small, soft hematoma. No
bruit was heard.
LABORATORY DATA: Significant laboratory from the outside
hospital revealed his hematocrit was 35.1. Electrolytes were
fine. CPK 176, MB 4.9, troponin I 0.37.
The catheterization at [**Hospital1 69**]
on the first showed 60% mid LAD lesion, 70% at the origin of
LAD. The left circumflex had mild, diffuse disease. The RCA
had 90% mid, 70% distal stenosis. Hepacoat stents were
placed in the proximal, mid and distal RCA. Wedge pressure
was 16. His RA pressure was 12. An LV ventriculogram showed
60% with normal systolic function.
HOSPITAL COURSE: The patient was admitted to the CCU.
Cardiac wise he was continued on the aspirin, Plavix,
Lopressor 25 b.i.d. CKs were serially checked and they began
to trend down. On the day of discharge his CK was 648. The
patient had no further episodes of chest pain or EKG changes
during his hospital course. He was on telemetry and
throughout his hospital stay he was in normal sinus rhythm.
There were no other ectopies. The patient's LV function was
60%. The LV had a 60% ejection fraction. He was continued
on IV fluids at 150 cc per hour to maintain his preload,
given his territory of his myocardial infarction.
For his right groin hematoma, the Integrilin was stopped at
1800 hours on [**7-11**]. The patient showed no further
signs of bleeding. The right groin hematoma was serially
followed. It was stable throughout his hospital course and
was beginning to decrease. There were no bruits auscultated
throughout his hospital course.
Hyperlipidemia. He was started on Lipitor 20 mg q.d. On
discharge he was given a prescription for Lescol XL 80 mg
q.d. The patient was noted to have an elevated LDL during
his hospital course.
The patient was seen by physical therapy and they recommended
that he have outpatient cardiac rehabilitation for a week
post MI.
DISCHARGE INSTRUCTIONS: The patient was discharged home on
[**7-12**] with the following instructions. If you
experience any chest pain, nausea, vomiting or shortness of
breath, please [**Name8 (MD) 138**] M.D. or return to the ER. Take all
medications as instructed. Do not continue Plavix unless
instructed by a cardiologist.
FINAL DIAGNOSES:
1. Myocardial infarction, non ST elevation myocardial
infarction, status post cardiac catheterization.
2. Coronary artery disease, status post myocardial infarction
in [**2165**] and [**2171**].
3. Hyperlipidemia.
RECOMMENDED FOLLOWUP: He is to follow up with his PCP, [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within the next week. He is to be referred to a
cardiologist per Dr. [**Last Name (STitle) **] and he can schedule. If he does
not follow up with his cardiologist, he should schedule an
appointment with Dr. [**Last Name (STitle) **], cardiology at [**Hospital1 346**] as necessary. He is to follow up
and have an outpatient PMIBI to evaluate his 60% LAD stenosis
and see if there is reversible ischemia.
MAJOR SURGICAL OR INVASIVE PROCEDURES DURING THE HOSPITAL
COURSE: Cardiac catheterization.
DISCHARGE CONDITION: Stable.
DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d., Clopidagrel
75 mg p.o. q.d., metoprolol 25 mg p.o. b.i.d., Lescol XL 80
mg p.o. q.d., lisinopril 10 mg p.o. q.d.
The patient is also to follow up with physical therapy for
outpatient cardiac rehabilitation in four weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 5211**]
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2172-7-12**] 12:30
T: [**2172-7-19**] 11:36
JOB#: [**Job Number 51316**]
cc:[**Last Name (NamePattern4) 51317**]
|
[
"41401",
"4019",
"2724",
"412",
"V4582"
] |
Admission Date: [**2171-3-2**] Discharge Date: [**2171-3-7**]
Date of Birth: [**2121-7-21**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p Pedestrian struck by auto
Major Surgical or Invasive Procedure:
[**2171-3-2**] Pelvic Angiography
History of Present Illness:
40F pedestrian vs auto w/ ?LOC GCS 14 on arrival with mild
confusion. Transported to [**Hospital1 18**] for further care.
Past Medical History:
HTN
Family History:
Noncontributory
Physical Exam:
Upon exam:
O: T:97.2 BP: 168/107 HR:98 R20 O2Sats100%ra
Gen: WD/WN, comfortable, NAD, sedated-given fentanyl recently
for
fx's
HEENT: Pupils: perrl, pinpoint bilat. EOMs intact bilat
Neck: Supple. c collar in place
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake, cooperative with exam, sedated
Orientation: Oriented to person, place, and date.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
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 [**6-5**] throughout. LUE hard to examine
given deformity and pain. No pronator drift
Sensation: Intact to light touch
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2171-3-2**] 11:35PM GLUCOSE-125* UREA N-11 CREAT-0.5 SODIUM-137
POTASSIUM-5.7* CHLORIDE-103 TOTAL CO2-20* ANION GAP-20
[**2171-3-2**] 11:35PM ALT(SGPT)-163* AST(SGOT)-222* LD(LDH)-1121*
[**2171-3-2**] 04:35PM WBC-17.1* RBC-4.20 HGB-13.2 HCT-36.9 MCV-88
MCH-31.6 MCHC-35.9* RDW-12.7
[**2171-3-2**] 04:35PM PLT COUNT-312
[**2171-3-2**] 04:35PM PT-11.4 PTT-24.2 INR(PT)-0.9
[**2171-3-2**] 04:35PM FIBRINOGE-232
IMAGING:
[**3-2**] CXR Mid humerus fracture
[**3-2**] CT Head Left SDH with 7mm midline shift to right
[**2171-3-2**] CT C-spine Negative
[**2171-3-2**] Torso Pelvic fracture through left pubic symphysis ?
[**3-2**] angio: no evidence of extrav. No embo done
[**3-3**] head CT: stable
[**3-4**] CT Head: Unchanged hemorrhagic contusions in the bilateral
inferior frontal and left temporal lobes, Stable small left
subdural hematoma, diffuse mild cerebral edema with mild
rightward shift and possible early left uncal herniation.
.
Brief Hospital Course:
She was admitted to the Trauma service. Neurosurgery and
Orthopedics were consulted given her injuries. Serial head CT
scans were done and remained stable. She is receiving Dilantin
and dosages have been adjusted; her last Dilantin level was 16.4
on [**2171-3-7**]. Neurology has also followed along during her course
related to her decreased level of consciousness and concern for
seizure related activity. An EEG was done which did not show any
electrograph ic seizures and her Dilantin was recommended to be
continued. Her mental status has slowly improved so that she is
more responsive and alert with periods of drowsiness. She will
follow up in [**Hospital 878**] clinic in [**5-9**] weeks and with Neurosurgery
in 4 weeks for a repeat head CT scan.
Her humerus fracture was managed non operatively and per
Orthopedics [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8688**] brace was ordered. She will need to
follow up in [**3-7**] weeks with Dr. [**Last Name (STitle) **] for this.
She was evaluated by Physical and Occupational therapy and is
being recommended for short term rehab.
Medications on Admission:
unknown BP med
Discharge Medications:
1. Phenytoin 125 mg/5 mL Suspension Sig: One [**Age over 90 **]y Five
(125) MG PO Q8H (every 8 hours).
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every [**5-7**]
hours as needed for pain.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. Dulcolax 10 mg Suppository Sig: One (1) supp Rectal once a
day as needed for constipation.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
10. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
s/p Pedestrian struck by auto
Subdural hematoma
Intraparenchymal left temporal hematoma
Scalp hematoma
Left humerus fracture
Rib fracture - 8th left
Secondary diagnosis:
Seizure disorder
Discharge Condition:
Level of Consciousness:Lethargic but arousable
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
*
Followup Instructions:
Follow up in 4 weeks with Dr. [**First Name (STitle) **], Neurosurgery. Call
[**Telephone/Fax (1) 1669**] for an appointment. Inform the office that you will
need a repeat head CT scan for this appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) **], Orthopedics for your
humerus fracture. call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in [**5-9**] weeks with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Neurology; call
[**Telephone/Fax (1) 541**] for an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2171-5-15**]
|
[
"4019"
] |
Admission Date: [**2168-4-2**] Discharge Date: [**2168-4-11**]
Date of Birth: [**2110-11-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion.
Major Surgical or Invasive Procedure:
Emergency evacuation of pericardial tamponade.
History of Present Illness:
56 year old gentleman who was found to have a systolic murmur in
[**2166-8-23**]. He was sent for an echocardiogram which revealed
aortic insufficiency and an aortic aneurysm. Repeat
echocardiogram this [**2167-6-23**] showed that the aneurysm had
increased to 5.3cm and his aortic insufficiency on cardiac
catheterization was now 3+. He complains of dyspnea on exertion
and pain in his chest with minimal activity. These symptoms
developed immediately following a motor vehicle accident in
[**2165**]. He was referred for surgical evaluation in [**Month (only) 205**] however
has been delaying his surgery. He presents on [**2168-3-21**] for
elective Bentall procedure. He was discharged to home on [**2168-3-27**].
he prsented to LGH ER w/ vague complaints of not feeling well
denies fever, chills, N/V/D/C. Per ER PA- slightly depressed
(has history of depression).
Arrived to [**Hospital1 18**] in SR 80's BP 120/70 w/ c/o left shoulder pain.
Turned on right side and became diaphoretic, hypotensive and
developed rapid afib. Volume resusitated to SBP 120/88. Emergent
echo w/ tamponade and RV collapse. Dr. [**First Name (STitle) **] called and
requested OR team to be called in.
Past Medical History:
Aortic insufficiency and ascending aortic aneurysm
Hypertension
Depression
Obesity
Sternal fracture [**12-29**] from fall
MVA [**2165**]
PTSD
Obstructive sleep apnea
Vitamin D defficiency
Impaired fasting glucose
Left Le Fort Repair [**2166-1-2**]
Social History:
Race: Hispanic
Last Dental Exam: Past winter
Lives with: [**Hospital1 487**], MA with wife and wife's sons
Occupation: Disabled construction worker
Tobacco: Denies
ETOH: 3-4 per week
Family History:
non-contributory
Physical Exam:
Pulse:initially SR 80's then rapid afib 120's Resp: O2 sat:
100%
on 50% FM
B/P Right: 122/88 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [decreased left [**1-24**] way up; right
decreased at the bases]
Heart: heart sounds distant RRR [] Irregular [x] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right:+2 Left:+2
DP Right:+2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Pertinent Results:
[**2168-4-10**] WBC-7.2 RBC-3.34* Hgb-10.4* Hct-30.7 Plt Ct-576*
[**2168-4-9**] WBC-8.7 RBC-3.51* Hgb-11.0* Hct-31.8 Plt Ct-597*
[**2168-4-4**] WBC-18.6* RBC-3.12* Hgb-9.8* Hct-28.4 Plt Ct-565*
[**2168-4-3**] Hct-25.3* [**2168-4-2**] Hct-21.7*
[**2168-4-2**] WBC-15.9* RBC-2.91* Hgb-9.3* Hct-27.3 Plt Ct-755*#
[**2168-4-10**] Glucose-90 UreaN-12 Creat-0.8 Na-138 K-3.7 Cl-103
HCO3-28
[**2168-4-9**] UreaN-12 Creat-0.9 Na-140 K-3.9 Cl-105
[**2168-4-2**] Glucose-121* UreaN-16 Creat-1.0 Na-128* K-5.1 Cl-96
HCO3-23
[**2168-4-10**] ALT-22 AST-27 LD(LDH)-329* AlkPhos-87 Amylase-38
TotBili-0.5
[**2168-4-10**] Albumin-3.7 Mg-2.1
[**2168-4-10**] INR(PT)-3.2*[**2168-4-9**] INR(PT)-2.9* [**2168-4-8**] INR(PT)-2.6*
[**2168-4-7**] INR(PT)-2.3* [**2168-4-6**] INR(PT)-2.1* [**2168-4-5**]
INR(PT)-1.8*
[**2168-4-4**] INR(PT)-1.8* [**2168-4-3**] INR(PT)-2.5*
[**2168-4-11**] 12:35PM BLOOD PT-23.9* INR(PT)-2.3*
[**2168-4-8**]: CT abdomen & Pelvis
1. No evidence of bowel obstruction or ileus, as clinically
queried.
2. No other acute abdominal pathology identified.
3. Status post Bentall procedure, with a small amount of
pericardial
effusion. A small loculated pericardial fluid collection
surrounding the
ascending thoracic aorta, with faint rim enhancement, without
air pockets. The superior aspect of this collection is not
imaged. This could represent a post operative seroma, but
superinfection cannot be excluded.
[**2168-4-8**]: Persistent dilation of large and small bowel
consistent with
ileus.
[**2168-4-6**]: Persistent dilation of small bowel loops consistent
with adynamic ileus
CXR
[**2168-4-6**]: The patient has been extubated in the meantime
interval
with removal of the mediastinal drains. The replaced aortic
valve appears to be in unchanged position with unchanged
angulation. The aeration of the lung bases has improved as well
as there is most likely decreased bilateral pleural effusion
although still present small. Questionable minimal apical
pneumothorax on the right is seen but also may represent
summation of shadows and should be closely followed with
subsequent chest radiographs.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Findings
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
LEFT VENTRICLE: Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Simple atheroma in descending aorta.
MITRAL VALVE: No MR.
TRICUSPID VALVE: Physiologic TR.
PERICARDIUM: RV diastolic collapse, c/w impaired
fillling/tamponade physiology.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications.
Conclusions
This is a limited, directed study to assess tamponade for
drainage in OR.
No spontaneous echo contrast is seen in the left atrial
appendage. Overall left ventricular systolic function is low
normal (LVEF 50-55%). Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the
descending thoracic aorta. No mitral regurgitation is seen.
There is right ventricular diastolic collapse, consistent with
impaired fillling/tamponade physiology.
The prosthetic aortic valve is well-seated with no AI.
Descending aorta intact.
The effusion is circumfirential and collapses the RA and RV. The
LV is functioning well but is underfilled.
After evacuation of the blood (800cc) via a subxyphoid incision,
all [**Doctor Last Name 1754**] fill and function well.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2168-4-6**] 16:08
Brief Hospital Course:
57 y.o. male who is POD # 16 following a Bentall procedure with
Dr. [**Last Name (STitle) **] . The patient was discharged to home on [**2168-3-27**]. He
represented to LGH with vague complaints of dyspnea on exertion.
On presentation to the [**Hospital1 18**], the patient became hypotensive
requiring an emergent TTE. The TTE showed a large pericardial
effusion with tamponade physiology. The patient was taken
emergently for hematoma evacuation, approximately 1000cc. He
[**Hospital1 8337**] the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. He was successfully extubated on POD1. He
developed rapid atrial fibrillation, beta-blockers were
restarted and converted to sinus rhythm within 24 hours. He was
transfused 2 units of PRBC for HCT of 21 to 25. His Coumadin
was restarted for his mechanical valve. Chest tubes
discontinued in a timely fashion. He transferred to the floor
for further monitoring. He then developed LUQ and LLQ
non-radiating pain. KUB was done and showed Diffuse small and
large bowel distension consistent with ileus. He continued to
complain of abdominal pain. Abdominal CT was performed. General
surgery was consulted and reccommendations appreciated. Ileus
resolved with decrease in narcotics, ambulation and aggressive
bowel regime. Diet was advanced and Mr.[**Known lastname **] [**Last Name (Titles) 8337**] it.
Keflex was started for a right arm phlebitis. He continued to
do well, [**Last Name (Titles) 8337**] a regular diet and was discharged to home
with VNA on POD#9 from the pericardial effusion evacuation. All
follow up appointments were advised.
Date INR Coumadin dose
3/19.. 2.9 1mg
[**4-10**].. 3.2 2.5mg
[**4-11**].. 2.3 1mg
Medications on Admission:
1. docusate sodium 100 mg [**Hospital1 **]
2. aspirin 81 mg daily
3. lisinopril 10 mg DAILY
4. sertraline 25 mg daily.
5. metoprolol tartrate 75 mg TID -on [**2168-3-30**] decreased to [**Hospital1 **] d/t
sbp 90/
6. furosemide 20 mg daily until [**2168-4-1**]
7. potassium chloride 20 mEq until [**2168-4-1**]
8. hydralazine 25 mg qid
9. atorvastatin 20 mg daily
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H prn
11. amlodipine 10 mg daily
12. ranitidine HCl 150 mg [**Hospital1 **]
13. warfarin 1mg dose based on INR
Discharge Medications:
1. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
2. sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*60 Tablet(s)* Refills:*2*
4. warfarin 1 mg Tablet Sig: [**Name8 (MD) **] MD Tablet PO Once Daily at 4
PM: INR goal mechanical AVR=[**2-25**].
[**Month/Day (3) **]:*100 Tablet(s)* Refills:*2*
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): x 7 days, then decrease to 1 tab by mouth daily.
[**Month/Day (3) **]:*60 Tablet(s)* Refills:*2*
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Month/Day (3) **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
[**Month/Day (3) **]:*90 Tablet(s)* Refills:*2*
8. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 4 days.
[**Month/Day (3) **]:*16 Capsule(s)* Refills:*0*
9. warfarin 1 mg Tablet Sig: One (1) Tablet PO one tab today,
and one tab tomorrow for 2 doses: [**4-11**] dose 1mg
[**4-12**] dose 1mg.
Discharge Disposition:
Home With Service
Facility:
Multicultural VNA
Discharge Diagnosis:
Dyspnea on exertion/pericardial effusion/tamponade.
[**2168-4-2**] Emergency evacuation of pericardial tamponade
Secondary:
Aortic insufficiency and ascending aortic aneurysm- Bentall
[**2168-3-21**]
Hypertension
Depression
Obesity
Sternal fracture [**12-29**] from fall
MVA [**2165**]
PTSD
Obstructive sleep apnea
Vitamin D defficiency
Impaired fasting glucose
Left Le Fort Repair [**2166-1-2**]
Past Surgical History
Bentall procedure with a mechanical
composite valve conduit graft, 23 mm valve on [**2168-3-21**] with Dr.
[**Last Name (STitle) **]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2168-5-5**] 3:15 in the
[**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **]
Primary Care Dr.[**First Name8 (NamePattern2) 71**] [**Last Name (NamePattern1) **] #[**Telephone/Fax (1) 85170**] [**4-22**] at 9:10 on [**Location (un) 85171**], [**Hospital1 487**]
Please call to schedule the following:
Cardiologist Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? mechanical AVR
Goal INR 2.0-3.0
First draw [**2168-4-12**]
Results to phone ([**Telephone/Fax (1) 85169**] to [**Hospital **] Clinic at Greater
[**Hospital1 487**] Family Health Center, care of [**First Name4 (NamePattern1) 16212**] [**Last Name (NamePattern1) 13275**], plan
confirmed with [**Doctor First Name **]
Completed by:[**2168-4-11**]
|
[
"9971",
"2761",
"4019",
"2859",
"42731",
"311",
"32723",
"V5861"
] |
Admission Date: [**2175-12-2**] Discharge Date: [**2175-12-3**]
Date of Birth: [**2143-4-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
assault
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 30876**] is a 32 y.o. F s/p assault by male friend. She was hit
in the face with fists without any loss of consciousness. She
remembers the events of the assault. She denies loss of
consciousness although she reports he also tried to choke her.
He also pushed her against several walls. She complains of chest
pain secondary to assault and feeling sore all over. She says
that the swelling in her left eye does not permit her to open it
much. Occassionally she can open it a little and her vision is
clear she reports.
.
In the ED, vital signs were stable. She was given percocet for
pain and had a head CT and CT sinus to look for trauma
fractures, and CXR.
UA was negative. SW was contact[**Name (NI) **] in the [**Name (NI) **]. The patient is
being admitted for a safe bed.
.
Currently, she is sore all over but no one area of pain.
Past Medical History:
glaucoma in right eye from trauma as a child
frequent UTIs
Social History:
She is a teacher at [**Location (un) 86**] Montessori School. She smokes three
cigarettes per month and drinks alcohol on weekends, no drug
use.
Family History:
Unknown. She is adopted.
Physical Exam:
GENERAL: lying in bed.
HEENT: Swollen shut left eye with surrounding ecchymoses. No
drainage. Can not open lids to see pupil. Right eye is anicteric
and non-injected, pupil is reactive. She has no pain with eye
movements. MMM, no JVP
CARDIAC: RRR no m/r/g. Tender to palpation along chest sternum
and ribs.
LUNG: CTAB no w/r/r
ABDOMEN: +BS, soft, NTND
EXT: no e/c/c
NEURO: alert and oriented x3. Strength is full throughout.
Sensation in tact.
.
Pertinent Results:
UA negative
CT HEAD: Soft tissue swelling over the left face and preseptal
area,
without evidence of acute intracranial hemorrhage or skull
fracture.
Incompletely imaged left nasal bone fracture as better seen on
concurrent CT of the facial bones.
CT SINUS: 1. Minimally depressed left nasal bone fracture. 2.
Extensive soft tissue swelling over the left face and preseptal
area,
without evidence of globe rupture. 3. Moderate sinus disease
within the ethmoidal air cells and sphenoid sinuses.
Brief Hospital Course:
32 y.o. F s/p assault, admitted for safe bed.
SAFETY: Her boyfriend threatened to kill her with a gun.
Security guards were in place until she was discharged to a safe
location that is unknown to her primary medical team. This was
arranged by social work.
FRACTURE: Final reads on imaging show no other fractures besides
minimally depressed left nasal bone fracture. This fracture did
not appear to need intervention. Her pain was controled with
ibuprofin and percocet as needed.
CONTACT: mother [**Telephone/Fax (1) 30877**]
Medications on Admission:
Timolol eye drops and Trivora.
Discharge Medications:
Unchanged
Discharge Disposition:
Home
Discharge Diagnosis:
minimally displaced left nasal bone fracture.
Discharge Condition:
stable
Discharge Instructions:
You were admitted after an assault. You had a minimally
displaced fracture of a bone in your nose. The swelling around
your eye should get better with time.
For pain you can take tylenol 1000 mg three times a day and/or
ibuprofen 800 mg three times a day.
Please follo-up with your PCP in the next week or two.
Please return to the hospital if you have acute change in vision
or bleeding or any other symptoms which are concerning to you.
Followup Instructions:
Please see your PCP in the next week or two for follow up. It is
the weekend and we could not make the follow up appointment for
you.
After an assault, it is common to need to speak to counselors,
social workers or psychiatrists/psychologists.
Completed by:[**2175-12-3**]
|
[
"3051"
] |
Admission Date: [**2101-10-21**] Discharge Date: [**2101-10-28**]
Date of Birth: [**2039-11-26**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Septra
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Acute lower extremity weakness
Major Surgical or Invasive Procedure:
Decompression of T9-T12 for mass lesion with T12 Vertbroplasty
History of Present Illness:
Mr. [**Known lastname 26153**] is a 61 yo male with a hx of melanoma diagnosed in
[**5-7**]. We do not have access to his records (his treatment has
been in [**State 2690**] and [**State 108**]). Per his report, he had a lesion on
his L flank which was excised. He subsequently had a imaging,
including a PET CT which demonstrated an FDG avid lymph node in
his L axilla. He then had L axillary lymph node dissection. He
discussed additional treatment with his local oncologist but
decided not to pursue it. He reports that he is overdue for his
follow up scans.
He had been having back pain for about two months that was not
improving. While here in [**Location (un) 86**] on business he started to
develop
lower extremity weakness. This was bilateral and developed over
several days. He was worried that this might be due to the
melanoma. He fell in his hotel room and sought medical attention
at [**Hospital3 **]. He was transferred here for emergent
evaluation and MRI demonstrated a mass lesion at T12 with
"moderately severe compression deformity with retropulsion into
the spinal canal and compression along the ventral and left
aspect of spinal cord."
Past Medical History:
- hx of MI, CABG x 4
- melanoma as above
- HTN
- hyperlipidemia
Social History:
Patient is married and has three children. He was in the
military
for 30 yrs, served in [**Country 3992**] and Desert Storm. He works
in bomb disposal in the civilian division and was here on
business. No tobacco or illicits.
Family History:
father - MI in 50s
no FH of cancer
Physical Exam:
PE: bp 145/83, hr 105, rr 12, sat 96% on 2l nc
Gen: nad, lying in bed
HEENT: perrla, eomi, op - clear, mmm
Neck: no lad
Resp: clear anteriorly
CV: tachy, regular, no murmur appreciated
Abd: + bs, soft, non-tender
Ext: no edema, venodynes in place
Neuro: able to move both left and right foot but unable to left
legs off bed, sensation grossly intact
Pertinent Results:
[**2101-10-24**] 06:45AM BLOOD WBC-15.1*# RBC-4.38* Hgb-12.5* Hct-36.7*
MCV-84 MCH-28.6 MCHC-34.1 RDW-14.9 Plt Ct-248
[**2101-10-22**] 02:32AM BLOOD WBC-7.8 RBC-3.93* Hgb-11.5* Hct-32.1*
MCV-82 MCH-29.3 MCHC-35.8* RDW-14.3 Plt Ct-216
[**2101-10-21**] 01:38PM BLOOD WBC-7.7 RBC-4.07* Hgb-11.9* Hct-34.4*
MCV-85 MCH-29.2 MCHC-34.5 RDW-14.4 Plt Ct-239
[**2101-10-21**] 12:35AM BLOOD WBC-12.6* RBC-3.95* Hgb-11.4* Hct-34.0*
MCV-86 MCH-28.8 MCHC-33.5 RDW-14.6 Plt Ct-362
[**2101-10-24**] 06:45AM BLOOD Glucose-130* UreaN-9 Creat-0.7 Na-136
K-4.5 Cl-99 HCO3-29 AnGap-13
[**2101-10-23**] 01:57AM BLOOD Glucose-113* UreaN-11 Creat-0.7 Na-140
K-3.6 Cl-105 HCO3-26 AnGap-13
[**2101-10-22**] 02:32AM BLOOD Glucose-152* UreaN-12 Creat-0.8 Na-142
K-3.6 Cl-110* HCO3-26 AnGap-10
[**2101-10-24**] 06:45AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.0
[**2101-10-23**] 01:57AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname 26153**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2101-10-21**] after experiencing acute onset lower extremity
weakness. He was found to have a mass lesion in the thoracic
spine for which he underwent a posterior decompression and
fusion. Please refer to the dictated operative note for further
details. The surgery was without complication and the patient
was transferred to the PACU in a stable condition.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were given per standard protocol.
Initial postop pain was controlled with a PCA. His hematocrit
was low and he was transfused multiple blood products.
The oncology service was consulted and recommendations followed.
He will follow up with their clinic in two weeks for further
treatment.
He was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley remained in place and
will be discontinued at rehab. He was thought to have bowel and
bladder disfunction upone presentation and this will need to be
evaluated after his foloey is discontinued.
He was fitted with a TLSO brace for comfort whcih is to be worn
while out of bed. Physical therapy was consulted for
mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
Insulin
tizanidine
Metoprolol
simvastatin
famotidine
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
syringe Injection ASDIR (AS DIRECTED).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection TID (3 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Metastatic disease
Acute post-op blood loss anemia
Resolving paraplegia
Discharge Condition:
Stable
Discharge Instructions:
You have undergone the following operation: Decompression of
T9-T12 for mass lesion with T12 Vertbroplasty
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
Thoracic lumbar spine: when OOB
should wear brace when OOB to chair .
Treatment Frequency:
Please continue to change the dressings daily and look for signs
of infection.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 363**] in his clinic in two weeks.
Call [**Telephone/Fax (1) **] for an appointment.
Please follow up with your PCP [**Name Initial (PRE) 176**] 2-3 weeks.
Please follow up in the [**Hospital 11884**] Clinic on [**11-8**] at
4:00pm in the [**Hospital Ward Name 23**] Building [**Location (un) **] area A.
Completed by:[**2101-10-26**]
|
[
"2851",
"4019",
"412",
"2724",
"V4581"
] |
Admission Date: [**2138-12-16**] Discharge Date: [**2139-1-6**]
Date of Birth: [**2138-12-16**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname **] is an ex 36-1/7 week
infant born to a 36-year-old, G4P4 mother via repeat
cesarean section secondary to IUGR less than 5th percentile.
Maternal history is significant for advanced maternal age and
gestational diabetes. The pregnancy was complicated by twin
gestation that spontaneously reduced to 1 at 12-14 weeks
gestation. Amniotic fluid testing showed elevated AFP and
acetylcholinesterase but no fetal anomalies were noted on
ultrasound.
Prenatal labs were significant for blood type A positive,
antibody negative hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, GBS unknown. There were
no maternal risk factors for sepsis.
At delivery the infant emerged with spontaneous cry. Routine
resuscitation with drying, stimulation and suctioning was
administered. Blow-by oxygen was also given. Apgars 9 and 9.
The infant was noted to have skin defects along both flanks
and thus was brought to the NICU for monitoring and
specialist evaluation by plastic surgery and general surgery.
PHYSICAL EXAMINATION ON ADMISSION: Weight is 2475 g (25%-
50%), length 47.3 cm (50%), head circumference 33 cm
(50-75%).
VITALS: HR 159, RR 49, BP 83/40 (56), O2 SAT 94% in RA T 98.3.
General: Active and vigorous.
HEENT:Anterior fontanel open and flat. Opens eyes bilaterally.
Palate intact.
Chest: Clear to auscultation bilaterally.
Cardiovascular: S1 and S2 normal. Regular rate and rhythm.
Abdomen: Soft and nondistended.
Extremities: Pink and well perfused.
Skin: Skin defects consistent with cutis aplasia
along bilateral flanks encompassing parts of the abdomen and
back. No areas of complete defects where internal structures
are exposed.
GU: Normal female. Preterm genitalia. Anus patent
Neurologic: Positive suck, positive moro.
PHYSICAL MEASUREMENTS AT DISCHARGE: Weight 3020g (25-50%),
length 49cm (50%), head circumference 34cm (50-75%)
HOSPITAL COURSE:
1. Respiratory: Baby has had no respiratory issues. Has
remained on room air and never had any spells.
2. Cardiovascular: Upon admission baby's vital signs were
normal. She was noted to have a high-pitched, soft,
intermittent murmur around day of life 13 which
continues to today but otherwise she has no concerns.
3. Fluids, electrolytes, nutrition: The baby was started
NPO on IV fluids. She was started on feeds on day of
life 2 which were advanced as tolerated. She is
currently on ad lib feeds of breast milk 24 made with
Enfamil powder which she tolerates well.
4. GI: Baby was noted to have hyperbilirubinemia with a
peak bilirubin of 10.9 on day of life 5. She never
received phototherapy and has no current issues.
5. Hematology: Upon birth a CBC revealed a hematocrit of
38.4 and platelets of 400. She was started on iron on
day of life 10 which she continues currently.
6. Infectious disease: Upon birth, the baby had a rule out
sepsis work-up showing a white blood cell count of 8
with 40 neutrophils and 0 bands. She was treated with
ampicillin and gentamicin for 48 hours which was stopped
when the blood culture was negative.
7. Neurology: The baby had a normal neurologic exam upon
admission and has had no issues and has needed no
imaging.
8. Dermatology: The baby was diagnosed with bilateral
truncal cutis aplasia which is being followed by plastic
surgery. She is receiving twice a day dressing changes
with bacitracin and xeroform covered by a dry, clean
gauze dressing which should be continued at home. She
will be followed up by plastic surgery, Dr. [**First Name4 (NamePattern1) 3788**] [**Last Name (NamePattern1) 7474**],
1 week after discharge.
9. Sensory:
A: Audiology hearing screen was performed with
automated auditory brain stem responses which was passed
on [**2139-1-5**]
B: Ophthalmology: Secondary to a gestational age greater
than 32 weeks the patient did not need an ophthalmology exam.
CONDITION ON DISCHARGE: Excellent.
DISCHARGE DISPOSITION: Home.
PRIMARY CARE PEDIATRICIAN: [**First Name8 (NamePattern2) 57342**] [**Last Name (NamePattern1) **] at South Care
Pediatrics in [**Hospital1 392**].([**Telephone/Fax (1) 57344**]
CARE RECOMMENDATIONS:
1. Feeds at discharge: Please continue breast milk 24 made
with Enfamil powder.
2. Medications: Iron sulfate 2 mg/kg/day which is 0.2 ml
p.o. daily (25 mg/ml).
3. Iron and vitamin D supplementation:
A: Iron supplementation is recommended for preterm and low
birth weight infants until 12 months corrected age.
B. All infants that predominantly breast milk should receive
vitamin D supplementation at 200 international units
(may be provided as a multivitamin preparation) daily
until 12 months corrected age.
4. Car seat position screening: Was done and passed on
[**2139-1-6**].
5. State newborn screening: Was sent at birth and on
[**12-31**] which were normal.
6. Immunizations received: Baby received hepatitis B
immunization on [**2139-1-5**]. 7. Immunizations
recommended:
A: Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following 4 criteria: 1)
born at less than 32 weeks, 2) born between 32 and 35
weeks with 2 of the following: Day care during RSV
season, a smoker in the household, neuromuscular
disease, airway abnormalities, or school-age siblings,
3) chronic lung disease, or 4) hemodynamically
significant congenital heart disease.
B: Influenza immunization is recommended annually in the
Fall for all infants once they reach 6 months of age. Before
this age(and for the first 24 months of the child's life),
immunization against influenza is recommended for
household contacts and out-of-home caregivers.
C: 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 but fewer than 12 weeks of age.
8. Follow-up appointments scheduled/recommended:
A. Pediatrician appointment is scheduled for tomorrow.
B. Follow-up appointment with plastic
surgery needs to be made for next week.
DISCHARGE DIAGNOSIS:
1. Truncal cutis aplasia.
2. Rule out sepsis.
[**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **], MD
Dictated By:[**Last Name (NamePattern1) 69933**]
MEDQUIST36
D: [**2139-1-5**] 14:46:06
T: [**2139-1-5**] 15:58:55
Job#: [**Job Number 75616**]
|
[
"V053",
"V290"
] |
Admission Date: [**2123-3-1**] Discharge Date: [**2123-3-18**]
Date of Birth: [**2061-4-6**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
progressively worsening abdominal distention
Major Surgical or Invasive Procedure:
exam under anesthesia, exploratory laparotomy, tumor debulking,
BSO, omentectomy, sigmoid resection w/ sigmoid-rectal end to end
reanastomosis
History of Present Illness:
61 yo W w/ho GERD/hiatal hernia, hemorrhoids, IBS admitted for
increased abdominal distention and CT showing peritoneal
carcinomatosis and sigmoid compression, likely due to ovarian
primary. Pt reports she was in her USOH until [**12-31**] wks ago when
she noted progressively increasing abdonminal girth. She denies
any associated abdominal pain, nausea, vomiting, fever, chills,
but does note pencil stools and increased frequency of loose
stools, BRB on her TP (which she attributed to hemorrhoidal
bleeding) as well as increased satiety and anorexia. She has not
had any weight loss or urinary symptoms. Pt spoke with Dr.
[**Last Name (STitle) 1940**] who suggested she increase her zelnorm dose and
follow-up with him this week for these symptoms, but the
symptoms persisted, so she came to the ED. In the ED, she was HD
stable, and CT showed large amount of asites with omental,
peritoneal, and mesenteric implants, concerning for
carcinomatosis.
Past Medical History:
PMH: GERD/hiatal hernia,IBS,htn, hypercholesterolemia,
^triglycerides, migraines, hemorrhoids, depression
PSH: TAH, hemorrhoid rubber banding ([**2-12**]), B breast reduction,
wrist ganglion cyst
OB: P2
Gyn: nl [**Last Name (un) 3907**], no abnl pap
Social History:
no tobacco/EtOH/ilicits
Was a clothes saleswoman in [**Country 18084**].
Family History:
No ovarian, colon, endometrial, breast ca
Physical Exam:
99.5 128-140/70 82-85 18 96%RA
GEN: Lying in bed, NAD
HEENT: PERRL, OP clear
Neck: No JVD, no LAD
CVS: RRR, no M/R/G
Chest: CTA bilat
Abd: NT, moderately distended, no rebound/guardind, no HSM, NABS
Ext: on c/c/e
Skin: No [**Last Name (un) **]
Neuro: Non-focal
Pertinent Results:
[**2123-3-2**] 05:20AM BLOOD WBC-7.1 RBC-4.08* Hgb-12.7 Hct-37.4
MCV-92 MCH-31.1 MCHC-33.9 RDW-12.6 Plt Ct-424
[**2123-3-2**] 05:20AM BLOOD Plt Ct-424
[**2123-3-2**] 05:20AM BLOOD PT-12.8 PTT-27.4 INR(PT)-1.0
[**2123-3-1**] 03:04PM BLOOD Glucose-101 UreaN-13 Creat-0.7 Na-137
K-4.5 Cl-100 HCO3-31* AnGap-11
[**2123-3-1**] 03:04PM BLOOD ALT-33 AST-37 AlkPhos-78 Amylase-37
TotBili-0.2
[**2123-3-1**] 03:04PM BLOOD Lipase-25
[**2123-3-1**] 03:04PM BLOOD Albumin-4.1
[**2123-3-1**] 03:04PM BLOOD CEA-1.7 CA125-922*
CT pelvis: 1) Large amount of ascites with omental, peritoneal,
and mesenteric soft tissue implants suggestive of
carcinomatosis.
2) Soft tissue structures in the expected location of the
ovaries. If indicated, further evaluation may be performed by
ultrasound.
3) 10-cm segment of narrowing in the sigmoid colon, without
evidence of mechanical obstruction. While no infiltrating mass
is detected, it cannot be excluded.
Brief Hospital Course:
The patient was initially admitted to the general medicine
service. She was transferred to gyn oncology on [**3-2**] for further
management of bowel obstruction and likely metastatic ovarian
cancer. She was started on IV fluid and given nothing by mouth.
She also had initial consultation with medical oncology service.
She was taken to the OR on [**3-5**] for staging, cytoreduction, and
relief of obstruction. Her surgery was notable for extensive
tumor debulking and 6L of ascites requiring prolonged surgery.
She was admitted to the SICU post operatively for post op volume
management.
Her ICU course was notable for a blood transfusion of 1 unit to
increase oncotic pressure. Otherwise she had no acute events and
was transferred to the floor on post op day 1.
The remainder of her post operative course is as follows:
1) GI: The pt's postop course was complicated by post-op ileus.
She was kept NPO with IVF. Her IV access was lost on [**2123-3-9**]
(POD 4) and a PICC was placed. Her bowel function resumed and
she was advanced to a full diet on [**2123-3-11**] (POD 6).
2) Pulmonary: The pt was noted to have decreased oxygen
saturations on [**2123-3-9**] (POD
4). A CTA could not be obtained as contrast could not be
administered through the pt's PICC. A V/Q scan revealed high
probability of pulmonary embolism. She was started on a heparin
gtt per weight-based protocol. She was weaned off oxygen by POD
6. She received 10 mg [**Date Range 197**] on [**3-11**] and [**2123-3-12**]. Her INR was
then noted to be increased to 3.4 on [**2123-3-13**]. Her heparin gtt
was d/c'd and she was started on Lovenox 80 mg SQ [**Hospital1 **]. Her
[**Hospital1 197**] was held on [**3-13**]. Her INR was then 2.3 on [**3-14**] and she
was given 2.5 mg [**Month/Year (2) 197**] that night. The [**Month/Year (2) 197**] was
discontinued on [**3-15**] in preparation for port-a-cath placement.
3) Renal: The pt's urine output was adequate. Her foley catheter
was maintained in place until POD 3.
4) CV: The pt's blood pressure was stable on her home regimen of
Norvasc 5 mg qd.
5) FEN: The pt's electrolytes were checked and repleted daily as
needed.
6) Access: The pt received a port-a-cath on [**2123-3-17**] without
complications. Her PICC line was d/c'd on the day of discharge.
7) Psychiatry: The pt requested to be seen by psychiatry on the
day of discharge. She was evaluated and no medication was
recommended. She has outpatient psychiatric followup.
On day of discharge she was ambulating, voiding and tolerating
regular diet. Her pain was well controlled with oral
medication.
Medications on Admission:
amlodipine, lipitor, effexor
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 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) as needed.
Disp:*60 Capsule(s)* Refills:*0*
3. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours).
Disp:*20 syringes* Refills:*2*
4. [**Date Range 197**] 2.5 mg Tablet Sig: Four (4) Tablet PO at bedtime:
Start Friday [**2123-3-19**].
Disp:*50 Tablet(s)* Refills:*2*
5) Amlodipine 5 mg po QD
Discharge Disposition:
Home
Discharge Diagnosis:
Ovarian cancer
Postoperative ileus
Pulmonary embolism
Discharge Condition:
good
Discharge Instructions:
no heavy lifting, nothing in vagina, no exercise 6 weeks
no driving 2 weeks
Followup Instructions:
*** Call ([**Telephone/Fax (1) 1921**] and say that you MUST be seen on Monday
[**2123-3-22**] with Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) **] followup
*** [**Hospital 197**] clinic will call you on [**2123-4-8**]
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], M.D. Where: LM [**Hospital Unit Name 22399**] Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2123-4-22**] 8:30
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. [**Telephone/Fax (1) 5777**] Call to schedule
appointment
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-3-25**] 4:00
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 273**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2123-3-25**]
4:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7167**], RD Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 3681**] Date/Time:[**2123-5-10**] 4:00
|
[
"53081",
"4019"
] |
Admission Date: [**2174-10-19**] Discharge Date: [**2174-10-28**]
Date of Birth: [**2095-6-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Weakness, s/p fall, "I was about to die."
Major [**First Name3 (LF) 2947**] or Invasive Procedure:
CVVHD.
History of Present Illness:
79 yo Italian speaking male with h/o cirrhosis [**12-20**] Hep C, who
presented with chief complaint of weakness to [**Location (un) 745**] [**Hospital 3678**]
Hospital ([**Telephone/Fax (1) 65997**]) after falling in bathtub in the water.
Per OSH recs, he said he "didn't feel right" and his "legs were
weak" and he lowered himself into the tub. He hit his left
shoulder (unclear how if he lowered himself down). Did not hit
his head, no LOC. He was unable to pull the cord for help and
yelled until a neighbor came to his assistance. Paramedics took
him to [**Location (un) 745**] [**Hospital 3678**] hospital ED for evaluation.
.
At OSH, he underwent a head CT which was normal, and CXR that
was concerning for PNA. He was thought to be in heart failure
and was given lasix 40mg IV. He received azithromycin 500mg IV
x1 and ceftriaxone 1g IV x1. He was also given 1.5L NS. Labs
were noteworthy for Na 129, Cr of 1.6, and a troponin of 0.12
(last measured here at 0.01). His SBP ~90, which is his
baseline. EKG there demonstrated RBBB.
.
In the ED at [**Hospital1 18**], initial vs were: T97.9 P96 BP 101/68 R30
O2 sat 97% 2L NC. Labs were notable for troponin of 0.05 and pt
received ASA 325mg PO x1, no heparin per discussion with
cardiology in ED. RBBB seen on OSH EKG, but was not noted on EKG
at [**Hospital1 18**]. His T. bili was noted to be elevated 3.8 (previously
2.2). Pt underwent RUQ US, L shoulder plain film, and diagnostic
paracentesis. He was admitted to medicine/liver service for
evaluation fo [**Last Name (un) **] and pneumonia. VS on transfer were T 97.9 P95
BP99/57 R32 O2sat 97% RA.
.
On the floor, pt states he feels "normal." When prompted, he
complains of L shoulder pain. No chest pain or abdominal pain.
He says his abdominal distention has gone down. When asked about
fevers or SOB, he states it depends on "the winds and drafts"
coming in and out of the room. Denies DOE. He endorses chronic
cough, non-productive, and is unable to describe it more.
Sometimes it is so severe he feels like vomiting. No nausea. His
last bowel movement looked "normal"- unable to detail further.
.
His friend who [**Name2 (NI) **] for him ([**Name (NI) **]) is present and states the pt
eats little, only fruit and water. [**Doctor Last Name **] is concerned that the
patient can no longer live alone and properly take care of
himself and he needs more help at home. He states the patient is
more confused than his baseline.
.
Of note, pt was recently admitted [**Date range (1) 65998**] for acute
kidney injury for which he was given albumin with an appropriate
response. He was also treated for pneumonia/UTI completing 7 day
course of levofloxacin [**2174-10-7**]. He was started on diuretics at
that time for increased weight gain due to his cirrhosis.
.
Review of sytems:
(+) LLE is chronically "sick because of diabetes" -he has
decreased sensation and is unable to walk on it without a walker
(-) Denies fever, chills, recent weight loss or gain. Denies
headache. Denied chest pain or tightness, palpitations. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
-PERCUTANEOUS CORONARY INTERVENTIONS: [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**] in mid-RCA
on [**2172-6-5**]. Mid LAD shows 50% long lesion with a 90% discrete
1st diagonal lesion. OM1: 70% long lesion, OM2: 80% ostial
lesion, and OM3: 70% ostial lesion
--Diabetes mellitus Type II with peripheral neuropathy
--peripheral vascular disease
--Chronic hepatitis C genotype 2a/2c (untreated) with cirrhosis
portal hypertension and splenomegaly. EGD [**12/2172**] revealing
esophageal and gastric varices.
--Chronic mild anemia and thrombocytopenia (thought secondary to
splenic sequestration)
--left portal vein thrombosis (seen U/S on [**2174-6-10**])
--left testicular mass versus recurrent hernia ([**3-/2174**]), was
supposed to be evaluated by ultrasound
--osteoarthritis
--varicose veins
Social History:
Smoke: never
EtOH: never
Drugs: never
Italian-speaking
Lives/works: The patient lives alone. He walks with a walker. He
is divorced and estranged from his children. His friend [**Name (NI) **]
stops by frequently and [**Name (NI) **] for him but is unable to
completely care for him.
Family History:
non-contributory
Physical Exam:
Physical Exam on admission [**2174-10-19**]:
VITALS: T: 96.6 BP: R 91/60 L 98/60 P:86 R:30 O2: 100% RA
GENERAL: Alert, oriented, no acute distress, occassionally
perseverates on story of how he fell
SKIN: nbruise on L shoulder, no jaundice, chronic skin changes
in LE b/l, no open lesions,
HEENT: Sclera mildly icteric, dry MM, no jaundice under tongue,
oropharynx clear
Neck: supple, no LAD
Lungs: Good inspiratory effort. Faint diffuse crackles
bilaterally except at left base. No wheezes or ronchi.
CV: Soft heart sounds, regular rate and rhythm, normal S1 + S2,
no murmurs, rubs, gallops
Abdomen: soft, non-tense, distended with ascitic fluid,
non-tender, small reducible umbilical hernia, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
hepatomegaly, no caput.
Ext: warm, well perfused, 1+ DP pulses, 2+ pitting edema in LE
to knees bilaterally, L shoulder with full ROM, no effusion at
joint
Neuro: no asterixis, CN II-XII intact, 5/5 strength in UE b/l,
5/5 strength in RLE, 4/5 strength in LLE, sensation decreased in
LLE compared to RLE.
Pertinent Results:
OSH labs [**2174-10-19**]:
6.9 >------< 84
31.9
129 94 57
-------------<161
5.5 21 1.6
Cholesterol 90
Lipase 29
Amylase 41
LFTs:
AST 110, ALT 32, Alk Phos 220, T bili 4.6, D bili 2.9, Alb 2.6
.
CK 105, CKMB 1.0 (nl), Trop 0.12 (0.04-0.78 indeterminant per
OSH ranges)
.
Utox negative
[**Hospital1 18**] LABS:
Labs on admission [**2174-10-19**]:
WBC-7.3 RBC-3.19* Hgb-9.4* Hct-28.6* MCV-90 MCH-29.3 MCHC-32.7
RDW-21.7* Plt Ct-89*
Neuts-73* Bands-1 Lymphs-12* Monos-9 Eos-0 Baso-0 Atyps-5*
Metas-0 Myelos-0
PT-15.9* PTT-33.1 INR(PT)-1.4*
Glucose-156* UreaN-53* Creat-1.5* Na-130* K-5.1 Cl-97 HCO3-25
AnGap-13
ALT-30 AST-90* CK(CPK)-92 AlkPhos-167* TotBili-3.8*
Albumin-2.3* Calcium-7.9* Phos-3.5 Mg-2.1
Cardiac enzymes:
[**2174-10-19**] 06:45AM BLOOD cTropnT-0.05*
[**2174-10-19**] 03:40PM BLOOD cTropnT-0.02*
[**2174-10-20**] 06:50AM BLOOD cTropnT-0.02*
MICRO:
[**2174-10-19**] UCx: no growth
[**2174-10-19**] Peritoneal fluid: NGTD
[**2174-10-20**] BCx: NGTD
IMAGING:
[**2174-10-19**] L shoulder xray (AP, neutral, axillary): 1. No acute
fractures or dislocation of the left shoulder joint. 2. Moderate
degenerative change at acromioclavicular joint and mild
glenohumeral degenerative change.
[**2174-10-19**] CXR: Low lung volumes persist. Hilar prominence and
cephalization of flow suggest pulmonary edema, which may be
accentuated due to low lung volumes. The heart remains enlarged
and likely somewhat accentuated by the low lung volumes.
Previously seen right lung peripheral reticular interstitial
opacity is less prominent on the current study. While reticular
interstitial opacity in the peripheral right lung is less
prominent as compared to the prior exam, subtle peripheral
reticular opacities persist bilaterally, which may be secondary
to component of chronic interstitial lung disease.
_____________
ICU course labs/reports are present in [**Hospital1 1388**] [**Hospital 58922**] Medical
Record.
Brief Hospital Course:
FLOOR COURSE [**Date range (1) 65999**]:
79 yo italian speaking male with h/o cirrhosis [**12-20**] Hep C, CAD
s/p fall and with acute renal failure and elevated T bili.
.
# Fall - appears to be mechanical rather than syncopal as pt
denies dizziness or LOC prior to episode. He felt weak, possibly
due to poor nutrition or leg weakness from his diabetes. There
may have been a component of orthostatis due to aggressive
diuresis after last admission. Only injury was to shoulder
without fracture or dislocation. CT head at OSH negative.
Physical therapy evaluated patient and recommended rehab.
.
# NSTEMI/Troponin leak/RBBB - RBBB noted on OSH EKG, likely due
to rate 118bpm. RBBB not noted on EKG at [**Hospital1 18**]. Pt denies chest
pain but has h/o CAD with stenting of RCA in [**2171**]. Troponin
mildly elevated, possibly due to renal failure. Received ASA
325mg but no heparin needed per cardiology (discussed in ED).
Started aspirin 325mg until troponin trended down, then returned
to home dose 81mg. Continued statin, niacin SR.
.
# Acute kidney injury - Pt with elevated creatinine 1.5 on
admission. Cr 0.9-1.1 during last admission but 0.6-0.8 prior.
FeUrea suggests pre-renal etiology and per friend, pt has poor
intake. [**Month (only) 116**] also be due to hepatorenal syndrome or ATN although
no known new insults/meds. ([**2174-9-27**] ECHO with EF >55%). Pt was
challenged with albumin 50g x2 and 25gm x1 with improvement in
Cr to 1.0. He was given lasix 20mg PO x1 on [**10-22**] with good urine
output. Spironolactone was held through hospitalization.
.
# Hyponatremia - Na improved with albumin + NS suggesting
hypervolemic hyponatreima, esp given pt's total body fluid
overload. Unlikely due to primary polydipsia as pt has low PO
fluid intake per friend. [**Name (NI) **] clear reason for pt to have SIADH.
.
# Ascites - pt had diagnostic paracentesis in ED, labs suggest
transudate c/w known cirrhosis and portal hypertension. No
evidence of SBP. Pt is not uncomfortable and abdomen is not
tense. No therapeutic tap done on floor prior to [**2174-10-24**].
.
# Cirrhosis - pt with known cirrhosis due to Hep C. AST elevated
without ALT increase. T bili increased but RUQ US does not show
obstruction. RUQ US PRELIM demonstrates persistent thromboses.
Per friend, pt is confused but he does not appear
encephalopathic. T bili began to trend downwards. INR remained
stable 1.3-1.6. He was given lactulose and remained oriented.
Nadolol, which he takes for his gastric varices, was stopped
[**2174-10-23**] due to frequent episodes of hypotension with SBP 70s.
.
# Anemia - pt with falling Hct (baseline 26-29). Pt had Hct
decrease from 35 to 27 sometime between [**Month (only) 216**] and [**Month (only) **]
[**2173**]. He had no evidence of active bleeding on morning of
[**2174-10-23**] and was transfused 1 unit blood for Hct ~23 without
reaction.
.
# Infiltrate on admission CXR - Pt completed 7 day levo course
for PNA last admission. CXR with improving R opacity (likley
prior PNA) and persistent peripheral reticular opacities. He was
saturating well. He remained afebrile without leukocytosis.
Tachypnea is most likely due to lying flat with ascites. No
antibiotics were given during his floor course.
.
# Living situation - friend concerned about patient's ability to
care for himself at home. Pt concerned about cost of Nursing
home
-SW evaluation for available home services/home health aide
.
# DM - c/b with peripheral neuropathy. His avandaryl was held
and he started on humalog ISS.
.
# Hypothyroidism - continued levothyroxine
# Communication: Patient, friend [**Name (NI) **]
.
.
On [**2174-10-24**], the pt had 2 episodes of BRBPR, complained of
epigastric pain. He was hyperkalemic, tachypneic with RR 40s,
and the pt was noted to be in respiratory distress. Lactate 10.4
on ABG. He was transferred to MICU [**Location (un) 2452**] for further evaluation
and management.
**************
In the ICU:
HD line placed by renal (Right IJ). Received CVVHD with
aggressive regimen to decrease K+. On broad-spectrum
antibiotics. Lactate elevated, then improving. Transfused blood
nad platelets and FFP as needed. Transplant surgery consulted -
signed off, no [**Location (un) **] issues. Hepatology's consultation noted:
continue octreotide drip, protonix drip, and transition to CMO.
Multiple family updates occurred, with patient's son and
daughter and his friend [**Name (NI) **].
A family meeting was held on [**10-28**] with the patient's son and
daughter and his friend [**Name (NI) **] and an Italian interpreter and a
social worker. Family understood the patient's critical illness
and acuity. Goals of care were discussed; patient was determined
to be CMO. All at the meeting were in agreement.
Social work and ethics consultation service involved in
end-of-life care.
Comfort measures only:
Pressors discontinued on [**10-28**]. Family at bedside. Patient had
morphine available for comfort. Patient expired on [**2174-10-28**] in
the MICU.
Medications on Admission:
(per d/c summary [**2174-10-4**], pt unable to recall meds, no changes
since discharge per friend):
1. Atorvastatin 10 mg DAILY
2. Niacin SR 500 mg Capsule [**Hospital1 **]
3. Nadolol 40 mg daily
4. Levothyroxine 50 mcg daily
5. Aspirin 81 mg daily
6. Furosemide 20 mg daily - held on admission
7. Spironolactone 50 mg daily - held on admission
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID:
titrate to 3 loose bms daily
9. Avandaryl 4-2 mg daily - change to insulin
10. Levofloxacin - ended [**2174-10-7**]
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
s/p fall
ARF
Hepatitis C cirrhosis, ascites
GI bleed
Hypotension
Elevated lactate
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
Completed by:[**2174-11-3**]
|
[
"5849",
"41071",
"51881",
"0389",
"99592",
"2762",
"2761",
"2851",
"2767",
"4019",
"4280",
"2875",
"41401",
"V4582",
"2449"
] |
Admission Date: [**2182-10-27**] Discharge Date: [**2182-10-30**]
Date of Birth: [**2125-9-30**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Gentamicin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Right lower quadran pain
Major Surgical or Invasive Procedure:
Pacemaker placement
History of Present Illness:
Mr. [**Known lastname **] is a 57 year old man with a history of type I
diabetes mellitus, status post pancreas-[**Known lastname **] transplant
(failed), coronary artery disease, s/p multiple stents,
congestive heart failure with EF: 50-55%, hepatitis B and C who
p/w RLQ pain.
The patient states that he had onset of severe (can't rate),
sharp, RLQ pain 1d prior to admission that woke him from sleep.
The pain was non-radiating worse w/ any movement and
non-positional. He reports that the pain is essentially
constant. He had 2 bowel movements that were normal and large
yesterday. He did not strain, and they were formed and of
normal consistency.
The pain was unchanged after the bowel movement. He has had no
bowel movement today. The stool is non-bloody, and normal in
color (not tarry or [**Male First Name (un) 1658**] colored). He has had minimal PO intake
[**1-2**] anorexia. No change in pain w/ p.o. intake. Denies
n/v/diarrhea. Denies fever/chlls/rash. +chills, no rigors.
In the emergency department transplant surgery evaluated him and
felt he had no surgical issues. He received synthroid,
amiodarone, toprol xl, prednisone, prontonix, lipitor, phoslo,
renagel, regular insulin (doses as listed in med list), dilaudid
2mg iv x4, vanc/levo/flagyl, and decadron 8mg iv (given as
stress dose because ED thought pt would need surgery). Noted to
be hypoglycemic to 20s in ED, and he was given 1amp D50.
Past Medical History:
1. ESRD: status pancreas-kidney transplant [**2164**], status post
cadaveric [**Year (4 digits) **] transplantation in [**2172**], now requiring dialysis
3x/wk
2. CAD: s/p myocardial infarction in [**2164**], s/p LCX stenting in
[**2174**], s/p LCX and OM3 stenting in [**2175**], s/p mid-LCX stenting on
'[**78**], s/p OM3 restenting in '[**78**]
3. DM
4. Hypothyroidism
5. Hypercholesterolemia
6. Hep C (dx in '[**75**]), viral load and Hep B
7. CVA in [**2174**] with residual left-sided weakness
8. PVD
9. Diverticulitis, status post colostomy and Hartmann's pouch in
[**2175**],
status post reversal in [**6-3**], last Colonscopy ([**12-4**]): Erythema,
friability and granularity in the very distal portion of the
colon, just inside the afferent limb of the stoma, with
overlying clot. Brown stool with no bleeding proximal to this.
10. PVD s/p multiple digit amputations
11. GERD
12. Wheelchair bound after gentamicin related vertigo
13. PAF: diagnosed in [**2175**], continued on CCB and started on Amio
at that time
14. Benign prostatic hypertrophy, status post transurethral
resection of the prostate.
15. SBP [**1-31**]
16. CHF with an EF:50-55%
Social History:
Patient lives with his wife. They have two children who live
nearby. He previously worked as a plummer but is now retired. He
has a 30pk year smoking hx but quit 10 years ago. He denies IVDU
and alcohol use.
Family History:
[**Name (NI) 1094**] father died at age 56 of MI, with DM and a "big heart".
Mother died age 84 of "old age" s/p CVA, with DM and HTN. Sister
has Grave's dz and brother died of 56 with DM.
Physical Exam:
t97.3, bp 142/37, p 60, r 14, 97% ra
Well appearing male in NAD
Pupils: L 1mm- surgical, R 3mm reactive.
OP clr, dry MM
Neck supple, 7cm JVP
Regular s1,s2. no m/r/g. L chest HD catheter w/o
erythema/swelling.
b/l basilar rales R>L
R 5 cm subchondral scar, 7cm midline laparotomy scar. +bs. soft.
+exquisite RLQ tenderness, moderate RUQ tenderness. +guarding.
no rebound.
guiac neg by ED note.
no le edema/cyanosis/clubbing
+mult digital amputations.
alert and oriented x3
Pertinent Results:
EKG: sinus brady, LAD/ LAFB, QTC prolonged at 516
.
cxr: No radiographic evidence of acute cardiopulmonary process.
No free air under the diaphragm
.
ct: No evidence of appendicitis or other focal fluid
collections.
ADMISSION LABS:
[**2182-10-27**] 02:32PM GLUCOSE-100 UREA N-40* CREAT-7.8*# SODIUM-135
POTASSIUM-5.1 CHLORIDE-95* TOTAL CO2-24 ANION GAP-21*
[**2182-10-27**] 02:32PM ALT(SGPT)-14 AST(SGOT)-24 ALK PHOS-433*
AMYLASE-21 TOT BILI-0.3
[**2182-10-27**] 02:32PM WBC-5.1# RBC-4.37*# HGB-14.2# HCT-42.6#
MCV-98# MCH-32.5* MCHC-33.4 RDW-14.6
[**2182-10-27**] 02:32PM PLT COUNT-134*
[**2182-10-27**] 02:32PM PT-12.9 PTT-33.1 INR(PT)-1.1
[**2182-10-27**] 02:37PM LACTATE-1.9
Brief Hospital Course:
Patient is a 55 year-old gentleman with history of DMI,
pancreas/[**Month/Day/Year **] transplant (failed), ESRD, CAD s/p multiple
stents, CHF (EF 50-55%), Hep B/C who was initially admitted on
[**10-27**] for RLQ pain. Pt reported RLQ pain to be sharp ([**9-9**])and
consistent exacerbated by movement. Pt reports similar pain in
[**2179**] that resulted in colostomy for perforated colon. Pt reports
intermittent episodes of chills since [**10-26**] but denies
F/N/V/BRBPR/diarrhea/constipation. CT negative for obstruction
or appendicitis. Evaluated by transplant team but determine not
to have any surgical issues. While on floor, patient became
bradycardic to 30s, hypotensive to systolic 90s, and developed
chest pain on [**10-28**]. EKG revealed ventricular escape rhythm. EP
was consulted and patient received pacer, placed in right
cephalic vein.
.
# Cardiac
= Rhythm: Patient received pacer [**2182-10-28**]. Unknown etiology of
arrhythmia, most likely secondary to extensive CAD. Pt back on
beta-blocker and amiodorone
= PUMP: EF >60% per ECHO [**7-5**]. Fluid overloaded per CXR and labs
but dry on exam - dealt with via dialysis.
= ISCHEMIA: Patient with chest pain in setting of bradycardia.
Pt found to have elevated 0.20 trop, likely due to [**Month/Year (2) **] failure
.
# RLQ pain - unclear etiology. ruled out for appendicitis,
perforation. pyelonephritis a possibility but no stranding
related to either native or transplant kidneys. in d/w
radiology, not clearly related to constipation as not impressive
amts of stool. symptoms not c/w mesenteric/colonic ischemia and
pt is guiac neg. possible infectious etiology, ? c.diff, but nl
wbc so not high suspicion. Patient with history of abdominal
pain in past- could be hepatic or splenic infarct vs. atypical
chest pain. At this point pt describes that pain has decreased
signficantly and now has a good appetite.
- PRN Dilaudid for pain control
- Check [**Last Name (un) 104**] stim, could be related to adrenal insufficiency
# ESRD s/p [**Last Name (un) **] transplant
- continued on HD, monitor electrolytes
- HD M/W/F , this wk, pt received HD on Tuesday as well
continue renagel/phoslo
- increase phoslo to 3 pills TID, send PTH
- check ionized calcium
- pt found to be hyperkalemic with a potassium of 6 given 15 of
kayexalate and 1 amp of bicarb.
# ? ANEMIA - at goal
- continue epo 10,000
- iron studies TIBC decreased at 216 ,Ferritin levels wnl at
315, TRF decreased at 166.
# s/p transplant
- can stop t-plant meds per transplant team (bactrim,
prednisone)
# DM
- cont lantus and humalog SS
Medications on Admission:
Renagel
Phoslo
synthroid 200mcg qday
prednisone 5mg qday
toprol xl 12.5 mg qday
amiodarone 400 mg qday
asa 325mg qday
protonix 40mg qday
lipitor 10mg qday
lantus 15 hs, humalog ss
bactrim TIW
Discharge Medications:
1. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
3. Levothyroxine Sodium 100 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous once a day.
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
0.5 Tablet Sustained Release 24HR PO DAILY (Daily).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed: no substituion.
Disp:*20 Tablet(s)* Refills:*0*
13. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
Disp:*1 tube* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (un) 2646**]
Discharge Diagnosis:
Bradycardia
Type I diabetes mellitus complicated by [**Last Name (un) **] failure
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Please take your medications as directed.
Followup Instructions:
1) Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2182-11-5**] 10:30
2) Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 14200**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2182-11-14**] 8:35
|
[
"4280",
"42731",
"2767",
"4019",
"41401",
"V4582"
] |
Admission Date: [**2161-12-24**] Discharge Date: [**2161-12-25**]
Date of Birth: [**2101-9-10**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Elective admission for R carotid stent/angioplasty
Major Surgical or Invasive Procedure:
R carotid angioplasty/stent
History of Present Illness:
60 yo male with hx of CAD s/p CABG in [**2159**], and hx of bilateral
carotid disease initially found during the pre-op workup for
CABG. Pt had [**Doctor First Name 3098**] stent in [**2159**] prior to CABG. He hever had a
TIA or any neurological symptoms. No weakness, numbness,
transient blindness, word finding difficulty, or gait
instability. Pt has not had any anginal like sx since CABG. Pt
had follow up carotid U/S in [**2161-5-16**] which showed right sided
stenosis of 80-99%, and left sided stenosis of 70-79% distal to
the stent. Pt has been followed by his neurologist and was
decided to pursue conservative measure at that time. He had
another carotid u/s on [**2161-12-1**] which showed again 80-89% [**Country **]
stenosis and 70-79% [**Doctor First Name 3098**] stenosis. CTA of the head and neck was
done which showed high grade stenosis at the [**Country **], and high
grade stenosis of the [**Doctor First Name 3098**] with concordant narrowing of the
stent. He denies ever having any neurological symtoms. Pt was
electively admitted for [**Country **] stent/angioplasty.
[**Last Name (NamePattern4) **]dical History:
HTN
Hyperlipidemia
CAD s/p CABG [**6-17**] (LIMA to LAD, SVG to OM1, SVG to ramus, SVG to
PDA) by Dr. [**Last Name (Prefixes) **]
Hernia repair
L thumb repair after laceration
Carotid dz s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] stent in [**6-17**]
Anxiety disorder
Social History:
Pt lives with hs wife and their dog. Has one adult daughter.
[**Name (NI) **] works as an insurance broker. He smokes socially (4
packs/month x 35 yrs), and drinks 1-2 drinks daily. Denies
illicit drug use.
Family History:
Father with stroke in 60's
Physical Exam:
VS: T 97.0 BP 139/79 HR 67 RR 16 O2sat 96% RA
GEN: Pleasant, well nourished, male lying in bed in NAD
HEENT: NC/AT, PERRL (3->2mm bilaterally), nl OP, neck supple, no
carotid bruits bilaterally, no JVD.
COR: RRR S1, S2, no murmurs/rubs/gallops
LUNGS: CTA anteriorly
ABD: +BS, soft, NTND, no guarding
EXT: no edema, R groin with no hematoma, no bruit. 2+ DP
bilaterally
NEURO: A+Ox3, CN III-XII intact, [**5-20**] strengths inall major
muscle groups. Quad not tested since pt post-cath. No obvious
higher cognitive fxn deficits.
Pertinent Results:
Cath:
Angiography demonstrated normal RCCA, the [**Country **] had a tubular 90%
lesion. The [**Country **] filled the ipsilateral ACA and MCA. The LCCA
was normal. The [**Doctor First Name 3098**] stent is patent with 50% stenosis. The [**Doctor First Name 3098**]
filled the ipsilateral ACA and MCA without evidence of cross
filling. Successful stenting of the [**Country **] with a [**6-23**] x 30 mm
tapered Acculink stent post dilated with a 4.5 x 20 mm highsail
balloon at 10 atms with no residual stenosis, no dissection and
normal flow.
Brief Hospital Course:
1)Carotid dz: Pt underwent successful [**Country **] stent with 6-8 taper
Acculink stent. [**Country **] [**Male First Name (un) **] a 90% tubular lesion. ICA filled the
ipsilateral ACA and MCA. LCCA was normal. The [**Doctor First Name 3098**] stent was
patent with 50% restenosis. Pt was continued on Plavix 75 mg po
qd. His BP was controlled with nitro gtt overnight. He resumed
his home meds of atenolol 100 mg po qd and Lisinopril 2.5 mg po
qd with adequate BP control post-stent.
2)CAD: Pt was continued on Atenolol 100 mg po qd, lisinopril 2.5
mg po qd, Lipitor 40 mg po [**Last Name (LF) **], [**First Name3 (LF) **] 325 mg po qd.
3)HTN: Pt was temporarily BP controlled with nitro gtt. He was
continued on atenolol 100 mg po qd and lisinopril 2.5 mg po qd
with good BP control.
4)Hyperlipidemia: He was continued on Lipitor 40 mg po qd.
Medications on Admission:
[**First Name3 (LF) **] 325 mg po qd
Lisinopril 2.5 mg po qd
Plavix 75 mg po qd
Lipitor 40 mg po qd
Atenolol 100 mg po qd
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Atenolol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral carotid disease s/p [**Country **] stent
Discharge Condition:
Stable.
Discharge Instructions:
Patient was instructed to take all of the medications as
directed. Pt was instructed to seek medical attention if he
were to develop dizziness, headache, visual changes, weakness,
numbness, and any other concerning neurological symptoms. Pt
needs to follow up with Dr. [**First Name (STitle) **] with follow-up Doppler
Ultrasound. Pt should resume all of the home meds he did
before.
Followup Instructions:
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-2-23**] 10:30
Provider: [**Name10 (NameIs) **] STUDY Where: CC CLINICAL CENTER RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-2-23**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 920**] Date/Time:[**2162-2-23**] 1:00
Completed by:[**2161-12-25**]
|
[
"4019",
"V4581"
] |
Admission Date: [**2164-3-7**] Discharge Date: [**2164-3-15**]
Date of Birth: [**2096-5-2**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
esophageal cancer
Major Surgical or Invasive Procedure:
[**2164-3-7**]: Minimally-invasive esophagectomy.
History of Present Illness:
The patient is a 67-year-old gentleman with a T2 esophageal
cancer who underwent
neoadjuvant chemotherapy and radiation and presents for
resection. He underwent a lap jejunostomy and port placement on
[**2163-11-15**] that went well without complication. Since that time
patient was on tube feeds to help maintain his nutrition and
increase his weight. He was seen in clinic by Dr. [**Last Name (STitle) **] on
[**2164-3-1**]. At that time patietn had already completed his
neoadjuvant therapy. His weight was stable, and his mood had
improved. PET scan was negative for metastatic disease. It was
determined that patient was no suitable for resection of his
cancer.
Past Medical History:
PMH: hypertension, prostate cancer, depression, and anxiety.
PSH: prostatectomy [**2158**] ([**Location (un) 770**]), lap jejunostomy and port
placement [**2163-11-15**] by Dr. [**Last Name (STitle) **]
Social History:
The patient drinks occasionally. He has never smoked. He is
retired.
Family History:
Family history is notable for a father with renal insufficiency
and a mother who died of a myocardial infarction at the age of
88.
Physical Exam:
On Discharge:
AVSS
GEN: NAD, resting comfortably
NECK: Incision CDI, dry guaze over JP site
CV: RRR
Lungs: No respiratory distress
ABD: Soft, appropriately tender around incisions. Wound sites
are clean, dry, intact.
EXT: warm, well perfused
Pertinent Results:
[**2164-3-7**] 04:12PM BLOOD WBC-14.3*# RBC-3.33* Hgb-11.1* Hct-31.4*
MCV-94 MCH-33.2* MCHC-35.3* RDW-13.4 Plt Ct-203
[**2164-3-12**] 05:15AM BLOOD WBC-5.5 RBC-2.97* Hgb-9.8* Hct-27.8*
MCV-93 MCH-33.0* MCHC-35.3* RDW-13.2 Plt Ct-213
[**2164-3-7**] 04:12PM BLOOD Glucose-172* UreaN-18 Creat-1.0 Na-141
K-4.0 Cl-106 HCO3-25 AnGap-14
[**2164-3-12**] 05:15AM BLOOD Glucose-102* UreaN-13 Creat-0.9 Na-139
K-3.2* Cl-106 HCO3-27 AnGap-9
[**2164-3-12**] UGI: IMPRESSION: No evidence of leak or obstruction.
[**2164-3-12**] CXR: On today's image, no right apical pneumothorax is
seen. The
previously existing small pneumothorax appears to have
completely resolved. Unchanged left basal areas of atelectasis.
No evidence of pneumonia.
Brief Hospital Course:
Mr [**Known lastname 13669**] was admitted to the General Surgical Service
following his surgery on [**2164-3-7**] which went well without
complication. Please see the operative report from the same day
for further details. After a brief, uneventful stay in the PACU,
he was transferred to the ICU with an NGT, 1 chest tube, JP in
neck, J-tube and Foley catheter. He was hemodynamically stable
in the PACU and in the ICU. He was transferred to the floor on
POD2.
Neuro: He initially recieved dilaudid PCA with good effect and
adequate pain control. When transferred to the floor on POD2,
his PCA was stopped and he was transitioned to Roxicet through
the J-tube and IV dilaudid for breakthrough. When tolerating
soft solid diet, patient was switched to oral pain medication.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization. Chest tube was pulled on
[**2164-3-10**]. Post pull film showed a small R sided apical PTX. This
was followed with serial CXRs, and resolved by [**2164-3-12**].
GI/GU/FEN: Post-operatively, he was NPO with IV fluids. On
[**2164-3-12**], BAS was performed that showed no leak or obstruction.
NGT was then pulled, and patient was started on sips. This was
advanced to soft solids, which the patient tolerated well. JP
drain was pulled on [**2164-3-14**]. Tube feeds were continued
throughout [**Hospital 228**] hospital course, and patient will go home
on tube feeds until taking adequate nutrion on his own.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary. Electrolytes were routinely
followed, and repleted when necessary.
ID: His white blood count and fever curves were closely watched
for signs of infection. On [**2164-3-13**], patient began to have
dysuria and UA was consistent with urinary tract infection. He
was started on a 5 day course of ciprofloxacin, which he will
complete at as an outpatient.
Endocrine: His blood sugar was monitored throughout his stay;
insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to
ambulate as early as possible.
Patient received discharge teaching and instructions. He agreed
with the plan.
Medications on Admission:
ATENOLOL 25', COLCHICINE 0.6', LORAZEPAM 1mg Q6PRN, MOEXIPRIL
15', COLACE 100 UD, SENNA 2 UD
Discharge Medications:
1. Tube Feeds
Tubefeeding: Fibersource HN Full strength
Goal rate: 80 ml/hr
Cycle start: 1600 Cycle end: 0800
Refills: 11
2. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*200 ML(s)* Refills:*0*
3. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
6. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO BID (2
times a day).
7. lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for anxiety.
8. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
esophageal cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-8**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
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 steri-strips will fall off on their own. Please remove
any remaining strips 7-10 days after surgery.
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2164-3-29**]
11:15
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-4-10**] 9:30
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD Phone:[**0-0-**] Date/Time:[**2164-4-10**] 10:00
|
[
"5990",
"4019"
] |
Admission Date: [**2118-9-20**] Discharge Date: [**2118-10-10**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2118-9-20**] Aortic Valve Replacement(21mm St. [**Male First Name (un) 923**] Porcine Valve)
and Three vessel coronary artery bypass grafting(LIMA to LAD,
svg to obtuse marginal, svg to posterior descending artery)
History of Present Illness:
Mr. [**Known lastname **] is an 85 year old male with known aortic stenosis
and long standing dyspnea on exertion. Recent cardiac
catheterization showed severe three vessel coronary artery
disease including a left main disease. Given his severe aortic
stenosis and multivessel coronary artery disease, he was
referred for cardiac surgical intervention.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
Non-Insulin Dependent Diabetes Mellitus
Dyslipidemia
Obesity
Benign Prostatic Hypertrophy
Spinal Stenosis
History of Herpes Zoster
Appendectomy
Lumbar Laminectomy
Umbilical Hernia Repair
Carpal Tunnel Repair
Hemorrhoid Surgery
Social History:
20 pack year history of tobacco, quit 40 years ago. No prior
ETOH abuse, drinks wine with dinner. Married, lives with wife.
Family History:
Denies premature coronary artery disease
Physical Exam:
discharge exam:
VS T 97.8 HR 92 SR BP 128/54 RR 24 99%RA
Awake and alert.MAE.Some dysphagia to thin liquids, receiving
tube feedings.
Lungs- slightly dece=reased BS at bases. No rales/ rhonchii.
Cor- RRR, no murmur. Crisp heart sounds.
Exts- warm, palpable pulses. Trace edema.
Wounds- clean and dry with stable sternum.
Pertinent Results:
[**2118-9-20**] 06:07PM WBC-15.4* RBC-3.02* HGB-9.6* HCT-26.5* MCV-88
MCH-32.0 MCHC-36.3* RDW-14.8
[**2118-9-20**] 06:07PM PLT COUNT-179
[**2118-9-20**] 04:16PM GLUCOSE-117* NA+-139 K+-3.8
[**2118-9-20**] 03:53PM UREA N-13 CREAT-0.7 CHLORIDE-115* TOTAL
CO2-20*
[**2118-10-9**] 05:00AM BLOOD WBC-10.0 RBC-3.75* Hgb-11.3* Hct-33.3*
MCV-89 MCH-30.1 MCHC-33.9 RDW-15.0 Plt Ct-556*
[**2118-10-9**] 05:00AM BLOOD Glucose-130* UreaN-27* Creat-0.8 Na-135
K-4.2 Cl-99 HCO3-28 AnGap-12
[**2118-10-9**] 05:00AM BLOOD Glucose-130* UreaN-27* Creat-0.8 Na-135
K-4.2 Cl-99 HCO3-28 AnGap-12
[**2118-10-8**] 03:22AM BLOOD Glucose-105 UreaN-27* Creat-0.7 Na-136
K-4.2 Cl-100 HCO3-29 AnGap-11
PRE-BYPASS:
The left atrium is moderately dilated. 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 and free wall motion
are normal. There are simple atheroma in the descending thoracic
aorta. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is moderate to
severe aortic valve stenosis (area 0.8-1.0cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is mild valvular mitral stenosis (area
1.5-2.0cm2). Mild to moderate ([**11-24**]+) mitral regurgitation is
seen. There is no pericardial effusion.
POST- BYPASS:
The patient is in sinus rhythm. Left and right ventricular
function is preserved. An aortic valve replacement (tissue) is
in good position. There is no AI. The AV peak and mean gradients
are 20 and 8 mmHg. Mitral regurgitation is now mild. The aorta
is intact. Otherwise, the examination is unchanged.
Dr. [**Last Name (STitle) **] was notified in person of the results at the time of
study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2118-9-23**] 10:52
[**Known lastname **],[**Known firstname **] [**Medical Record Number 80049**] M 86 [**2032-9-30**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2118-10-9**] 7:24
AM
[**Hospital 93**] MEDICAL CONDITION:
86 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
evaluate for infiltrates and effusion
Final Report
HISTORY: CABG.
FINDINGS: In comparison with the study of [**10-8**], there is little
change. The aberrant Dobbhoff tube is again seen and there is
consistent increased
opacification at the left base.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: SUN [**2118-10-9**] 9:08 AM
Brief Hospital Course:
The patient was admitted and underwent AVR/CABG x3 with Dr.
[**Last Name (STitle) **] as noted. He was transferred to the CVICU in stable
condition on titrated phenylephrine and propofol The evening of
surgery he developed facial twitching and benzodiazepines were
started. Head CTs were done twice in the postop period with no
evidence of CVA. A neurology consultation was obtained and this
was felt to not clearly represent seizure activity, as confirmed
by continuous EEG monitoring. Keppra was started, however,
seizures did not resolve. Dilantin was added to his treatment
and a MRI of head done on POD #5 showed multiple areas of
infarction. Repeat EEGs were done, again inconsistent with
seizures The facial twitching slowly resolved. The Keppra was
discontinued and the patient had slow neurologic advancement
over the next few days.
Hemodynamically he remained stable and pressors were weaned and
discontinued over several days. He continued to improve
neurologically and was extubated. There is some dysphagia and
because of this a Dobhoff tube was placed and tube feeds begun.
Speech and swallowing will need to be reassessed as he continues
to rehabilitate.
He remained stable and his respiratory status stabilized with
some need for suctioning. He was kept in the ICU setting prior
to transfer to rehab to optimize his care. He is ready for
transfer at this time. Discharge medications and follow up
appointment requirements are as noted in the discharge
paperwork.
Medications on Admission:
Coreg 3.125 [**Hospital1 **], Detrol 4 qd, Flomax 0.4 qd, Simvastatin 80 qd,
Aspirin 81 qd, Calcium
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
4. Simvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO HS (at
bedtime).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**11-24**]
Drops Ophthalmic PRN (as needed).
7. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
8. Bisacodyl 10 mg Suppository [**Month/Day (2) **]: One (1) Suppository Rectal
DAILY (Daily).
9. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO once a day.
10. Amiodarone 200 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
13. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: Three (3) ml Inhalation Q2H (every 2 hours) as
needed.
14. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
15. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Thirty Five (35)
units Subcutaneous once a day: Give at 2200 hours.
16. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: see
sliding scale Subcutaneous AC & HS: 120-160:2 units SQ
161-200:4 units SQ
201-240:6 units SQ
241-280:8 units SQ
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Aortic Stenosis
Coronary Artery Disease
s/p Aortic Valve replacement & coronary artery grafting
Non-Insulin Dependent Diabetes Mellitus
Dyslipidemia
Obesity
Benign Prostatic Hypertrophy
Spinal Stenosis
postop CVA
Discharge Condition:
Good
Discharge Instructions:
no lifting more than 10 pounds for 10 weeks
no driving for 4 weeks and off all narcotics
report any drainage from, or redness of incisions
report any temperature greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
shower daily, no simming or baths
no lotions, creams or powders to incisions
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] in [**12-26**] weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-26**] weeks
Please call for appointments
Completed by:[**2118-10-10**]
|
[
"41401",
"4241",
"42731",
"2724",
"25000",
"V5867"
] |
Admission Date: [**2180-6-13**] Discharge Date: [**2180-6-19**]
Date of Birth: [**2117-1-6**] Sex: M
Service: OMED BMT SERVICE.
AGE: 63.
HISTORY OF THE PRESENT ILLNESS: The patient was admitted
with the chief complaint of belly pain and rising white
count. The patient was recently discharged from [**Hospital1 346**] on [**6-8**]. Please see discharge
summary in the computer for details.
This is a 63-year-old man with a history of AML diagnosed on
[**1-/2180**] status post two cycles of idarubicin and ARA-c on
[**2-22**] and [**3-21**]. He was discharged to
rehabilitation on [**6-8**]. He had had a hospital course that
was complicated by Staph abscesses requiring drainage and
MRSA, positive blood culture, as well as small bilateral
pleural effusion felt to represent foci infected with MRSA.
On [**6-8**], it was noted that he line tip grew out coagulase
negative Staphylococcus, MRSA, which was sensitive to
Vancomycin. Starting at 5 AM on the [**6-12**], the patient
noted abdominal pain described as a moderate negligible to
mild right upper quadrant and right lower quadrant discomfort
on rest, which became tender when palpated. At baseline he
had frequent nausea and vomiting for the past few months, but
he feels that he may have had more in the past few days. He
also noticed new leg swelling that began three days ago,
bilaterally. He also has ankle swelling. There was no
diarrhea. Position does not change the pain. However, he
also complained of mid sternal chest pain times two to three
weeks and he complaints of shortness of breath and worsening
pain while lying down that improved when he sits up and leans
forward. There was no cough, no fever, no chills associated
with this. The patient also complains of significantly
decreased urine output over the past few days. He feels that
has been taking a normal amount of PO intake.
PAST MEDICAL HISTORY:
1. History was significant for acute myelogenous leukemia
diagnosed in [**2180-1-8**], status post idarubicin and ARA-c
treatment times two with consolidation chemotherapy on [**2180-5-1**].
2. Hypertension.
3. Carotid stenosis.
4. History of alcohol abuse.
5. Acoustic neuroma.
6. Benign prostatic hypertrophy.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg p.o.q.d.
2. Zoloft 125 mg p.o.q.d.
3. Vancomycin 1 gram IV q.d., dose only for a trough level
less than 20. The patient was to receive this dose through
[**2180-8-14**].
4. Flomax 0.4 mg p.o. q.d.
5. Multivitamin one p.o.q.d.
6. Reglan 10 mg p.o.q.i.d.
7. Oxycodone 5 mg to 10 mg p.o.q.4h to 6h p.r.n. for pain in
the deltoid of his left calf.
8. Protonix 40 mg p.o.q.d.
ALLERGIES: The patient is allergic to CEFTAZIDIME, which
causes anaphylaxis.
PHYSICAL EXAMINATION: Examination revealed the following:
Temperature on admission was 98.7, pulse 72, blood pressure
110/70, pulsus paradoxus 16. GENERAL: The patient is
elderly-appearing, mildly uncomfortable, no apparent
distress. Pupils equally reactive to light. Extraocular
muscles are intact. Oropharynx moist. There was no
adenopathy. JVD was to the ankles. LUNGS: Clear to
auscultation bilaterally. HEART: Heart revealed regular
rate and rhythm, normal S1 and S2. Heart sounds were
distant. There was a 2/6 systolic ejection murmur at the
left lower sternal border. Abdomen was mildly distended,
moderate tender in the right upper quadrant and the right
lower quadrant. Bowel sounds were positive. There were no
masses felt at the time. There was 2+ edema to the knees
bilaterally. The patient had a left leg abscess and a right
upper arm abscess, both packed. There was no erythema or
exudate.
LABORATORY DATA: Laboratory values on admission revealed the
following: White count of 36.6, hematocrit 29.0, MCV 92.
Differential on the white count was 67 neutrophils, 14 bands,
2 lymphs, 8 monos, 3 atypical cells, 4 metamyelocytes, and
myelocytes. Coagulations studies revealed the following:
13.9, 25.5, and 1.3 with a platelet count of 63. SMA 7:
132, 3.8, 121, 17, 1.8, glucose of 121, albumin 2.6, globulin
8.9, calcium 8.9, phosphatase 3.3, magnesium 1.4, troponin
less than .3, CK 29, ALT 167, AST 89, LDH 251, alkaline
phosphatase 649, total bilirubin 0.4 and 0.2 direct, GTT 614.
Urinalysis showed a large amount of blood, pH 6, leukocyte
Estrace positive, no nitrites, 49 reds, 3 whites, no
bacteria, less than 1 squamous epithelial cell. Urine sodium
was 43, urine creatinine 95. Blood culture pending.
Catheter tip was coagulase negative staphylococcus, sensitive
to Vancomycin; multiple laboratory studies with MRSA.
EKG: Sinus rhythm at 80 beats per minute, normal axis,
diffuse flattening of the T waves especially in the lateral
leads, Q wave in lead three and lateral ST flattening, now
new compared to old EKG of [**2180-6-5**]. Chest CT, without
contrast, showed a new large pericardial effusion. There was
small bilateral pleural effusions, no the right being greater
than the left. There was associated bibasilar compressive
atelectasis. Mediastinal lymph nodes were again noted with a
slight increase in size of the lymph nodes and in the
paratracheal space, previous noted 6-mm and curly measuring
8 -mm and a short axis considered to be likely reactional
given increase in size during the short interval. There was
no significant axillary or hilar lymphadenopathy. Lung
demonstrated bilateral parenchymal marginal opacities without
cavitation, no changed compared with the prior examination
and concerning foci for infection.
CT of the abdomen showed no focal masses within the liver and
no intrahepatic biliary ductal dictation. Gallbladder was
not distended. Spleen, pancreas, jejunum, and kidneys were
unchanged and unremarkable. There was a pigtail catheter,
which was previously seen within the right psoas muscle, had
been removed. There was a partial re-accumulation of the
collection from the right psoas. This current measured
3.7 cm x 2.1 cm and could represent recurrence of the
abscess. CT of the pelvis was unremarkable.
Bone window show degenerative changes, but no suspicious
lyticoblastic lesions seen.
There was a focal area of fat straining within the left lower
quadrant of uncertain source or significance.
The patient, Mr. [**Known lastname **], upon admission, was then referred
to the Cardiology Department because the large pericardial
effusion, drained by pericardial centesis on [**6-14**] and 700
cc of hemorrhagic fluid was removed. Hematocrit was 6%, LDH
400, albumin 2.4, with improvement in the patient's blood
pressure and symptoms in terms of pain and the blood pressure
which had gone down to about systolic of 100 to 110.
Pericardial fluid cytology was negative and cultures showed
no growth.
The patient was transferred to the Medical Intensive Care
Unit following the pericardial centesis to permit additional
drainage from the pericardium with additional 450 cc. The
drain was discontinued on [**6-16**] after the drainage rate
was down to 3 cc per hour. The patient had experienced
transient atrial fibrillation on [**6-15**], but that
spontaneously corrected. The patient remained in normal
sinus rhythm. In addition, the patient was found as
mentioned on CT to have an increased fluid collection in the
right psoas muscle with accompanying leukemoid reaction with
increased white cells. As the patient remained in the
hospital, the white cell count increased from that noted on
admission to, what would be found by the day of discharge, at
120 white cells; 50 cc of fluid was removed by interventional
radiology. It was found that the psoas mass had
gram-positive cocci in pairs and clusters. The patient's
coverage for that was broadened to Levofloxacin and Flagyl.
Pigtail catheterization was left in place protruding from the
right posterior thorax. A pericardial window was not
determined to be necessary at the time. The patient had
transient hypotension with a systolic blood pressure in the
70s overnight, remaining symptomatic, responding to a 500 cc
fluid bolus times one. The Atenolol was held. Because of
the pericardial centesis and fluid drainage, it was expected
that his white count would go down, however, it continued to
rise and reached 109 white cells with many immature cells and
blasts, seen on peripheral smear. Aspirate was attempted,
however, no cells could be removed so that an iliac bone
marrow biopsy and aspirate was done and evaluated under the
microscope by Drs. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. It was
determined that the bone marrow was full of immature cells
and blasts indicating that the patient had a relapsed AML.
Given that the patient had relapsed AML and had been unable
to clear his disseminated Methicillin-resistant
Staphylococcus aureus infections in different parts of his
body, it was determined that the patient, in discussion with
him and the rest of his family, he would go home from the
hospital with hospital care. So, the patient was discharged
on [**2180-6-19**] to home-hospice care in stable condition.
He was discharged on the following medications:
DISCHARGE MEDICATIONS:
1. Fentanyl 25 mcg patch transdermally q 72 hours.
2. Linezolid 600 mg p.o.b.i.d.
3. Flomax 0.4 mg p.o.q.d.
4. Tylenol 650 mg p.o.q.4h. to 6h.p.r.n.
5. Zoloft 125 mg p.o.q.d.
6. Xanax 1 mg to 2 mg q.h.s.p.r.n.
7. Morphine sulfate elixir 10 mg to 20 mg p.o.q.4h.p.r.n.
8. Home hospice also included Lorazepam 0.5 to 2 mg
q.4h.p.r.n. sublingual; Levsin 0.125 mg to 0.25 mg q.4h. to 6
h.P.r.n. sublingual and Morphine concentrate 5 mg to 20 mg
q.1h. to 2h.p.r.n. sublingual.
The patient was aware of his diagnosis and in favor of this
treatment plan. The patient went home as a comfort measure
only.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], M.D. [**MD Number(1) 10999**]
Dictated By:[**Last Name (NamePattern1) 3033**]
MEDQUIST36
D: [**2180-6-19**] 15:26
T: [**2180-6-19**] 15:29
JOB#: [**Job Number 101389**]
|
[
"42731",
"4280",
"25000",
"4019"
] |
Admission Date: [**2111-4-8**] Discharge Date: [**2111-4-21**]
Service: NEUROLOGY
Allergies:
Tetanus Toxoid / Azithromycin
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
flank and back pain
Major Surgical or Invasive Procedure:
CT HEAD W/O CONTRAST
MR HEAD W/O CONTRAST
MRA BRAIN & NECK W/O CONTRAST
Cardiology ECHO
RENAL U.S.
CT CHEST W/O CONTRAST
CT ABDOMEN W/O CONTRAST
CT CHEST W/O CONTRAST
CTA ABD W&W/O C & RECONS
CTA PELVIS W&W/O C & RECONS
History of Present Illness:
The patient is an 89 year old woman with CAD s/p IMI in [**2103**],
PVD, HTN who initially presented to [**Hospital **] hospital with left
sided chest/flank pain. A CT scan without contrast was performed
which showed a possible intramural thrombus with a 5 cm aneurism
extending to the left renal vein, with 2 areas of ulceration.
She continued to have back pain so she was transferred to the
vascular surgery service at [**Hospital1 18**]. CTA of the abdomen/pelvis
here with contrast confirmed the findings. CT scan of the chest
without contrast showed possible extension to the thoracic
aorta.
.
During this admission she developed a different pain in the
chest, which lasted minutes. Her cardiac enzymes were checked
which showed CK peak of 468 on [**4-15**] with MB of 41, index 8.8,
and troponin climbing to 5.15. Her renal function also
deteriorated during this time, with creatinine from 1.3 to 3.4
today. She was transferred to cardiology for possible cardiac
catheterization.
.
ROS: Currently, she feels frustrated that she's in the hospital.
Denies chest pain, flank pain, urinary symptoms. At home she is
able to perform activities of daily life without difficulty. She
did have previous chest pain, DOE, occasional SOB, and LE edema.
All other ROS are negative.
Past Medical History:
PVD, gout, [**Last Name (un) **] esophagus, GERD, atrial fibrillation,
vetigo, skin squamous cell CA s/p excision, Dyslipidemia,
Hypertension
Social History:
Social history is significant for previous tobacco use (25 pack
years). There is no history of alcohol abuse. .
Family History:
Her son had CABG age 50
Physical Exam:
O: T: 97.5 BP: 1160/80 HR:89 R 14 O2Sats 100% RA
Gen: opens eyes to voice. Moans, agitated and
attempting to climb
out of bed.
HEENT: Has left gaze preference and eyes cross
just past midline
on right with Doll's. Right lower facial droop.
Mouth dry.
Neck: Supple. No bruits appreciated
Lungs: CTA bilaterally.
Cardiac: Irreg irreg. +M S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Moans to voice. Agitated, moaning.
Does not regard
examiner in the right hemispace. Not following
midline or
appendicular commands.
Cranial Nerves:
I: Not tested
II: 4mm on left and 4.5 mm on right, reactive.
Does not blink to
threat in right visual fields.
III, IV, VI: Moves eyes just past midline when
called from right.
V, VII: right facial palsy. VIII: Hearing intact
to voice.
IX, X: severe dyasrthia
[**Doctor First Name 81**]: def
XII: Tongue midline without fasciculations.
Pertinent Results:
[**2111-4-8**] 02:30AM BLOOD WBC-9.7 RBC-3.94* Hgb-12.4 Hct-36.7
MCV-93 MCH-31.4# MCHC-33.7 RDW-14.8 Plt Ct-164
[**2111-4-8**] 02:30AM BLOOD Neuts-84.1* Lymphs-12.3* Monos-2.6
Eos-0.8 Baso-0.3
[**2111-4-8**] 02:30AM BLOOD PT-11.7 PTT-23.5 INR(PT)-1.0
[**2111-4-8**] 02:30AM BLOOD Glucose-167* UreaN-29* Creat-1.4* Na-140
K-4.4 Cl-100 HCO3-28 AnGap-16
[**2111-4-8**] 02:30AM BLOOD CK(CPK)-67
[**2111-4-14**] 05:05PM BLOOD ALT-29 AST-65* AlkPhos-99 Amylase-79
TotBili-0.3
[**2111-4-14**] 05:05PM BLOOD Lipase-44
[**2111-4-8**] 08:11AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.4*
[**2111-4-14**] 05:05PM BLOOD Albumin-3.7
[**2111-4-15**] 04:30AM BLOOD Cholest-121
[**2111-4-15**] 04:30AM BLOOD Triglyc-80 HDL-56 CHOL/HD-2.2 LDLcalc-49
[**2111-4-10**] 08:57PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.018
[**2111-4-10**] 08:57PM URINE Blood-LG Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-8.0 Leuks-MOD
[**2111-4-10**] 08:57PM URINE RBC-0-2 WBC-[**1-19**] Bacteri-MANY Yeast-NONE
Epi-0-2
Brief Hospital Course:
Patient is a 89 yo RHF with ho PVD, HTN, hyperlipidemia, afib,
DMII who was admitted aneurysmal dilatation with intramural
thrombus formation complicated by NSTEMI and now clinical left
MCA syndrome s/p IV TPA. Patient's event recorded at 11:11 AM
[**2111-4-19**]. Patient exam prior TPA is significant for left eye gaze
deviation, right hemianopsia, severe dysarthia, not following
commands and left arm/face > leg motor weakness. Patient
received IV TPA at 1:58 pm. Likely etiology of stroke is
cardioembolic with known Afib and recent MI with known
hypokinesis/akiniesis in the inferior lateral ventricle (no
thrombus visualized on TTE) or thrombus visualized in
intraabdominal aortic aneurysm.
.
#. Neuro: There was minimal improvement in exam the morning
following TPA administration (L gaze deviation, weak withdrawal
R arm, no speech, does not follow any commands), repeat Head CT
at 24 hours showed some R cerebellar hemorrhage and hemorrhage
into infarct. Results were discussed with family and she was
subsequently made her CMO. She was given Ativan PRN anxiety,
Morphine PRN pain and Scopolamine and Levsin for secretions.
Palliative care was following. Patient passed away from
cardiorespiratory failure on [**2111-4-21**].
.
#. NSTEMI with elevated troponin to >5, CK peak at 468
continuing to trend down. likely unstable plaque. Continue to
hold on cath until renal failure resolves. currently chest pain
free. Continued telemetry. Continued ASA, plavix, BB (target
HR 60-70, sbp <130) heparin gtt. Held ACE given renal failure.
.
#. Pump EF 40% - Received hydration to improve creatinine.
Increased BB, held ACEi.
.
#. Rhythm - NSR, no arrhythmias. monitor by tele
.
# Acute renal failure - likely secondary to contrast or prerenal
etiology. Renal ultrasound showed patent right artery; left
kidney old and small in size. Cr starting to trend down
following hydration supporting initial CIN likely exacerbated by
pre-renal azotemia. Continued to dose adjust meds. Needed to
place foley catheter with regard to urinary retention and renal
failure.
.
#. AAA with intramural thrombus - stable per vascular surgery.
No plans for OR at this time. Heparin OK. Appreciated vascular
recs.
.
# Bladder spasm - likely related to UTI given spasm, dysuria,
and +UA. had 3 days of cipro with no significant improvement in
symptoms. Given baseline urinary dysmotility and retention,
would prefer to treat as "complicated" UTI and use 7 days of
therapy. the current symptoms appear acute worsening of her
chronic urinary problems. [**Name (NI) **] growth on multiple UCxs. Treated
with empiric cipro x 7 days. Needed foley as above.
.
#. FEN - PO, low salt diet
.
#. Access: PIV
.
#. PPx: heparin GTT, PPI, bowel regimen
Medications on Admission:
1. Allopurinol 300 mg daily
2. Aspirin 325 mg daily
3. Centrum 1 tab daily
4. Crestor 10 mg daily
5. Hydrochlorothiazide 25 mg daily
6. Lisinopril 20 mg daily
7. Metoprolol 12.5 mg [**Hospital1 **]
8. Prilosec 20 mg daily
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Left middle cerebral artery infarct
Thoracoabdominal aortic aneurysm
NSTEMI
Acute renal failure
Peripheral vascular disease
Secondary:
GERD
gout
Discharge Condition:
Deceased
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2111-4-27**]
|
[
"41071",
"5849",
"42731",
"5990",
"412",
"4019",
"53081"
] |
Admission Date: [**2125-1-2**] Discharge Date: [**2125-1-8**]
Date of Birth: [**2069-5-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 14879**] is a 55 year old gentleman who was found sleeping
outside by the police and brought into the ED. His initial
complaints were back pain and progressive dyspnea. He reports
last drink was approximately 1-2 days prior from admission. He
denies any falls or other recent trauma.
.
In the ED, initial VS: 120 164/99 20 85% RA. He was cold to the
touch and shivering with wet clothing and also tremulous. He
complained of nausea and vomited once approximately 200mL of red
bloody vomitus. NG lavage returned another 100mL of bloody fluid
that cleared with an additional 200mL. Guaiac Negative.
Hepatology was initially consulted as he is followed there. The
patient was given Zofran, Ativan 6mg IV total(for nausea and
withdrawal) and protonix, 3L IV fluid including 1 banana bag. K
2.9, started on 40 PO Potassium, 40mEq IV. Transfer VS: 99.8 132
116/73 25 94% RA, never hypotensive, persistently tachycardic.
.
Currently, the patient is comfortable on arrival to the ICU. He
reports that his back pain is chronic lower back pain, and
continues to deny any falls or trauma. He denies chest pain, but
reports baseline worsening progressive dyspnea. He denies
abdominal pain or nausea at this time. He reports that his
bloody emesis was his only recent episode of vomiting. He denies
black or bloody stools, lightheadedness or dizziness.
.
ROS: Denies night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Atrial fibrillation
Tachycardia induce cardiomyopathy; resolved
Alcohol abuse
Hypertension
2.5-cm cystic lesion in pancreatic tail ([**2121**])
Colonic polyposis
Status post knee replacement
Hepatitis B & C/ETOH grade 3 fibrosis.
Back arthritis
C.diff colitis
Social History:
Currently homeless, sleeps "where you return your bottles and
boxes for recycling." He drinks ~ 1 quart of alcohol including
listerine daily. Smokes 2 packs daily.
Family History:
Positive for coronary artery disease (details unknown) and
hypertension. His father had an aortic aneurysm. There is a
history of cancer of the brain and the breast.
Physical Exam:
Admission Exam:
Vitals - T: 100.1 BP: 154/85 HR: 127 RR: 17 02 sat: 98% RA
GENERAL: Non-toxic appearance, breathing comfortably
HEENT: No LAD, Dry mucous membranes
CARDIAC: S1 & S2 fast without murmur
LUNG: B CTA, cough on deep inspriation x1
ABDOMEN: nontender, nondistended. BS present
BACK: Tender to palpation in lumbar spine, no ulcers
EXT: 2+ DP, contracted/stiff limbs, no edema
NEURO:
MS: AAOx3, answers most questions appropriately but some
inappropriately responses
CN: II-XII grossly intact
Strength: [**3-21**] all extremities, equal
+ Bilateral lower extremity clonus
DERM: weathered skin, no obvious lesions
Pertinent Results:
Admission Labs:
[**2125-1-2**] 01:00PM WBC-9.0# RBC-3.88*# HGB-12.8*# HCT-36.4*
MCV-94# MCH-33.1* MCHC-35.2*# RDW-15.0
[**2125-1-2**] 01:00PM CALCIUM-8.2* PHOSPHATE-4.0 MAGNESIUM-1.9
[**2125-1-2**] 01:00PM LIPASE-30
[**2125-1-2**] 01:00PM ALT(SGPT)-95* AST(SGOT)-281* ALK PHOS-105 TOT
BILI-0.8
[**2125-1-2**] 01:00PM GLUCOSE-65* UREA N-28* CREAT-0.9 SODIUM-139
POTASSIUM-2.7* CHLORIDE-86* TOTAL CO2-19* ANION GAP-37*
[**2125-1-2**] 01:14PM LACTATE-4.2*
[**2125-1-2**] 01:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2125-1-2**] 01:00PM URINE HOURS-RANDOM
[**2125-1-2**] 01:00PM ASA-5 ETHANOL-155* ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-N
[**2125-1-8**] 06:15PM BLOOD WBC-5.2 RBC-3.26* Hgb-10.5* Hct-31.8*
MCV-97 MCH-32.2* MCHC-33.1 RDW-14.9 Plt Ct-237
[**2125-1-8**] 07:15AM BLOOD PT-12.6 PTT-26.8 INR(PT)-1.1
[**2125-1-8**] 07:15AM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-135
K-3.8 Cl-106 HCO3-22 AnGap-11
[**2125-1-5**] 07:10AM BLOOD ALT-96* AST-295* AlkPhos-90 TotBili-0.8
[**2125-1-8**] 07:15AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.6
[**2125-1-4**] 07:55PM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
[**2125-1-2**] 09:41PM BLOOD TSH-1.1
[**2125-1-2**] 09:41PM BLOOD Osmolal-305
[**2125-1-3**] 11:08AM BLOOD calTIBC-152* Ferritn-779* TRF-117*
[**2125-1-4**] 07:55PM BLOOD IgG-1352 IgM-398*
[**2125-1-2**] 01:00PM BLOOD ASA-5 Ethanol-155* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2125-1-6**] Cardiology ECG: Sinus tachycardia. Occasional
premature atrial contractions. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2125-1-2**] no change.
[**2125-1-4**] Radiology ABDOMEN U.S. (COMPLETE): IMPRESSION:
Echogenic liver consistent with fatty infiltration. However,
other forms of liver disease and more advanced liver disease
(i.e., significant hepatic fibrosis/cirrhosis) cannot be
excluded. No concerning focal hepatic lesions.
[**2125-1-3**] Radiology CHEST (PORTABLE AP): There is again a left
lower lobe consolidation demonstrated, that appears to be
slightly progressed since the prior study and might be
consistent with worsening infectious process. Cardiomediastinal
silhouette is stable.
[**2125-1-2**] Radiology CHEST (PORTABLE AP): IMPRESSION: Limited
study as the entire left chest is not seen on this film. Left
lower lobe opacity, non-specific, possibly representing
atelectasis or pneumonia.
[**2125-1-2**] Cardiology ECG: Sinus tachycardia. Indeterminate
axis. Low limb lead QRS voltage. Findings are non-specific.
Otherwise, baseline artifact makes assessment difficult. Since
the previous tracing of [**2124-6-1**] sinus tachycardia is now present
but, otherwise, baseline artifact makes assessment difficult.
[**2125-1-6**] URINE CULTURE - NEG
[**2125-1-5**] BLOOD CULTURE - PENDING
[**2125-1-5**] BLOOD CULTURE - PENDING
[**2125-1-5**] C. Diff - NEG
[**2125-1-4**] C. Diff - NEG
[**2125-1-4**] URINE URINE -PENDING
[**2125-1-3**] BLOOD CULTURE -PENDING
[**2125-1-3**] BLOOD CULTURE -PENDING
[**2125-1-2**] URINE URINE - NEG
[**2125-1-2**] MRSA SCREEN - NEG
[**2125-1-2**] BLOOD CULTURE - NEG
[**2125-1-2**] BLOOD CULTURE - NEG
Brief Hospital Course:
ASSESSMENT & PLAN:
A 55-year-old homeless gentleman admitted to the MICU for upper
GI bleed and alcohol withdrawal. He is not acting as though he
is having a major GI bleed as the cause of his symptoms, nor is
there any clear source of infection or underlying pathology to
explain why he would withdraw at this time. He is comfortable at
the time of admission.
.
#. Hematemesis: The patient had one episode of
nausea/hematemesis after receiving PO Potasssium. He denied any
nausea or vomiting and was guaiac negative. Last EGD [**2119**] with
no varices but does have known liver disease. No evidence of
ongoing bleeding, abdominal pain, etc. Possible etiologies
include variceal bleed, ulcer disease or [**Doctor First Name **]-[**Doctor Last Name **] tear (if
he has vomited in the past few days). He was given Protonix IV
BID. Serial Hct were stable. Liver was consulted and agreed to
do endoscopy non-urgently; however, given patient was
hemodynamically unstable due to withdraw (tachycardia, agitated,
tachypnic)- this was deferred to an outpatient process. Patient
was discharged with these appointments and instructions.
.
#. Tachycardia: Initially sinus tachy to the 110s-130s, likely
secondary to fever, EtOH withdrawal, and fluid depletion. His
BP was consistently normal to high. Home anti-hypertensive
(atenolol) was changed to half the equivalent dose of
metoprolol. This was additionally titrated up prior to
discharge. His heart rate came down appropriately.
.
# Fever and infiltrate: CXR and CT indicated LLL pneumonia,
likely secondary to aspiration. Ceftriaxone and azithromycin
were started for CAP, he continued to spike. Antibiotics were
swtiched to levofloxacin and flagyl. Fever resolved and he
improved clinically at time of discharge.
.
#. Elevated transaminases: History of Hep B/C. LFTs elevated
somewhat above previous values on admission. Liver followed and
will continue to as outpatient.
#. Alcohol withdrawal: Patient, tachycardic, tremulous,
anxious. No history of withdrawal seizures per patient. He was
initially given diazepam IV per CIWA, then converted to PO.
Thiamine, folate, MVI were started.
#. Elevated Anion Gap: Patient's anion Gap 34. Given a lactate
of 4 reducing with fluids, this likely represented alcoholic and
starvation ketoacidosis. Gap closed after hydration.
#. Abnormal U/A: + Hematuria possibly myoglobin from muscle
damage as 0 RBCs on sediment. Urine culture was negative.
#. Paroxysmal Atrial fibrillation: Currently in sinus, will hold
anticoagulation given bleed. He was placed on his home
medications at the time of discharge.
#. H/o hypertension: Will permit him to be mildly hypertensive
as he is now, will control hypertension via withdrawal as above
and address any urgency without beta blockade given GI bleed.
# CODE: Full
# Discharge: Patient demanded to leave multiple times during his
stay. He initially refused EGD and all testing. Psychiatry was
called to evaluate patients ability to make decisions. He
voiced appropriate understanding of the pros and cons of having
the procedure and that he understood the reasons of why we want
he to get the test (please refer to omr for full note). He
contiued to be belligerant and threatening to his medical team.
On the day of discharge, he demanded to be leave the hospital
with or without the approval of his medical team. Since he does
appear to have full appreciation of his medical issues and
understand the importance to follow up with outpatient doctors.
He was seen by social work and physical therapy, who cleared him
to go. He was discharged in stable condition with new
prescriptions to all his medications.
Medications on Admission:
Aspirin 81mg POdaily
Atenolol 100mg PO Daily
Cyanocobalamin 50mcg PO daily
Diltiazem HCl 300mg PO Daily
Hydrochlorothiazide 12.5mg PO daily
Pantoprazole 40mg PO Q24
Thiamine HCl 100mg PO daily
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
12. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
hypothermia
alcohol withdraw
hematemesis
aspiration pneumonia
Discharge Condition:
Mental Status:Confused - sometimes
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
It was a pleasure taking care of you here at [**Hospital1 771**].
You came to the hospital with hypothermia, alcohol withdraw, and
vomited blood. We were not able to perform the endoscopy due to
your vital signs being unstable secondary to your alcohol
withdraw. You also had a pneumonia that was treated. We
provided you with medications that treated the withdraw and
treated you for GI bleed. You were discharged in stable
condition. You need to follow up with your doctors listed
below.
You need to complete you antibiotics (metronidazole and
levofloxacin) because you are being treated for pneumonia.
Please note we made the following changes to your medications.
STOPPED:
1. Atenolol 100 mg Tablet Sig: 1.5 Tablets PO once a day.
2. Diltzac ER 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
STARTED:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO twice a day.
5. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Mag-Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
once a day.
9. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 10 days.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 10 days.
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
12. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One
(1) Capsule, Sustained Release PO DAILY (Daily).
13. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You need to follow up with GI doctors to get [**Name5 (PTitle) **] EGD to evaluate
for the source of you bleed in your gut. You have an appointment
on Monday, [**1-15**] at 3:00 with Dr. [**First Name (STitle) 908**] [**Hospital Ward Name 516**], [**Hospital1 18**]
[**Hospital Unit Name 1825**] please book for EGD procedure by calling ([**Telephone/Fax (1) 667**].
Please call your PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2205**] to have a
follow up evaluation within the week.
|
[
"5070",
"2762",
"42789",
"4019"
] |
Admission Date: [**2107-5-25**] Discharge Date: [**2107-6-7**]
Date of Birth: [**2069-10-8**] Sex: M
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: The patient is a otherwise
healthy 37 year-old male who had his wisdom teeth extracted
on [**2107-5-24**]. Postoperatively, the patient was
prescribed Amoxicillin and Percocet, which he first took at
13:00 on [**5-24**]. By 14:45 he felt nauseous and vomiting.
Around 18:00 took next dose of medications and again vomited
around 20:30 so violently that he "threw out his back." He
came to the Emergency Department at 21:30 where he received
morphine, Toradol and Compazine and was discharged with
Cyclobenzaprine and Compazine. He took Compazine at 6:45 and
Flexeril at 7:38. Shortly thereafter he felt antsy and "all
hopped up." Could not sit still and was sweating so he went
to his primary care physician's office at 13:00 and was sent
to the Emergency Department from there for evaluation. In
the Emergency Department the initially vital signs were heart
rate 170s, blood pressure 170/120 and temperature 97.8. He
received 12 mg of Adenosine to unmask his rhythm. Symptoms
though were consistent with a drug reaction, questionable
dystonic reaction and treated with Benadryl 50 intravenously,
Ativan and repeated doses of Lopressor totally 15 mg
intravenously and 50 mg po. Benadryl 25 intravenously given
again as there was no change in symptoms. Ceftriaxone and
Clindamycin were given empirically for systemic infection of
possible oral source after his temperature spiked to 102.4.
Toxicology was consulted and felt dystonic reaction not
neuroleptic malignant syndrome. He was treated with repeated
doses of intravenous Valium followed by Propanolol in case
thyroid storm was the cause with no effect after 25 mg.
Attempted Esmolol drip with good heart rate and blood
pressure control with a bolus. The patient subsequently
seized and was intubated and transferred to the MICU.
PAST MEDICAL HISTORY:
1. Obstructive sleep apnea.
2. Nephrolithiasis.
ALLERGIES: No known drug allergies.
MEDICATIONS:
1. Amoxicillin.
2. Percocet.
3. Flexeril.
4. Compazine.
SOCIAL HISTORY: Married, smokes one pack per week. Works as
an accountant.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature 104.0. Blood pressure
205/150, heart rate in the 130s. The patient was diffusely
sweating, shaking, unable to sit still, very uncomfortable.
HEENT pupils are equal, round and reactive to light. No
nystagmus. No wound infection in the oropharynx noted.
Cardiovascular tachy without murmurs. Lungs were clear.
abdomen was soft. Extremities no edema.
LABORATORY: Serum and urine tox screen was negative. White
blood cell count was 22.9 with 90% neutrophils, hematocrit
45, platelets 262. CT of the head revealed a subtle
hyperdensity and a few sulci, which could indicate blood or
exudate, but otherwise was unremarkable.
HOSPITAL COURSE:
1. Possible drug reaction: It was felt that the patient's
presentation was most likely consistent with a severe
dystonic type drug reaction to a combination of Compazine and
Flexeril. Toxicology was on board from the start and
assisted in the care, which was largely supportive. In the
MICU the patient was rapidly weaned off the ventilator as
well as weaned off the Esmolol drip. An LP was attempted to
obtain cerebral spinal fluid to rule out a subarachnoid
hemorrhage as well as meningitis. Unfortunately the LP was
unsuccessful after numerous attempts including one IR guided
attempt, one attempt by neurology. It was therefore decided
to treat the patient with empiric antibiotics. He was
treated with 10 days of Ceftriaxone and Acyclovir. Since no
cerebral spinal fluid could be obtained an MRI with
gadolinium was performed to assess for possible meningeal
enhancement and thus the suggestion of meningitis. There was
an abnormal signal extending along the sulci of the occipital
parietal lobes that was nonenhancing, which was a nonspecific
finding and was read as possibly reflecting a subarachnoid
hemorrhage, pus or other pernicious material. The patient
continued to spike low grade fevers while on antibiotics and
also following the completed course of his antibiotics.
There was never another source or infection found. All
cultures were negative and a chest x-ray was negative as
well. Infectious disease was consulted. They recommended a
CT scan of the neck to rule out a retropharyngeal abscess
given the patient's recent dental work and this was negative.
It was eventually believed that the patient's mildly
elevated white blood cell count and persistent low grade
fevers were likely due to blood in the subarachnoid space as
will be discussed below.
2. Subarachnoid, subdural/epidural hematoma: The patient
had severe back pain following multiple LP attempts. He was
imaged with an MRI of the L spine, which revealed evidence of
an epidural and subdural hematoma. It was felt that his
blood was most likely due to the traumatic lumbar puncture
attempts. Neurosurgery was consulted to review the films and
this was the conclusion that they came to and they
recommended a repeat film in a few days to see if there was
resolution. A review of the MRI findings discussed in
problem number one was felt to be blood as well and most
likely tracking up from the lumbar spine blood. A repeat MR
of the L spine revealed basically no change. Neurosurgery
continued to emphasize that there was nothing to do except
follow with serial MRIs. An MRA of the brain was performed
to rule out an aneursym as the possible cause for the
subarachnoid blood. The MRI revealed spasm of the basal
artery, which was felt to be secondary to the subarachnoid
hemorrhage, but no aneurysm. Neurology who was following as
well felt there was once again nothing interventional to do
and that the patient should be followed clinically. At the
time of discharge the patient still had considerable low back
pain that was treated with pain medications and Valium and
was instructed to have a follow up MR of the head and MR of
the L spine in approximately one week.
3. Hyponatremia: The patient developed hyponatremia ranging
between 127 and 130. This was felt due to syndrome of
inappropriate antidiuretic hormone secondary to blood in the
brain and possibly secondary to pain. A fluid restriction
was put in place and the patient's sodium responded and was
132 at the time of discharge. The patient will have a follow
up sodium check by visiting nurse two days after discharge.
4. Hypertension: The patient was noted to be hypertensive
throughout his course. He was started on Amlodipine 10 mg a
day as this will also help treated the basal artery spasm
noted on MRA. He will have a blood pressure check by VNA and
will follow up with his outpatient doctor.
5. Hyperglycemia: The patient was noted to have occasional
random glucoses of greater then 200 and some glucosuria. It
was felt that this might represent type 2 diabetes as he has
a family history of that. He was recommended to follow up
with his primary care physician for workup of this. He did
have a hemoglobin A1C, which was within normal limits.
DISCHARGE CONDITION: The patient was discharged to home in
stable condition.
FINAL DIAGNOSIS:
1. Severe adverse drug reaction to Compazine and/or
Flexeril.
2. Subarachnoid hemorrhage and subdural epidural hematomas
in the L spine secondary to lumbar puncture.
3. Syndrome of inappropriate antidiuretic hormone.
4. Type 2 diabetes.
5. Hypertension.
FOLLOW UP: The patient is recommended to follow up with his
primary care physician within one week as well as to have a
repeat MRI of the head and L spine within seven to ten days.
DISCHARGE MEDICATIONS:
1. Ibuprofen 800 mg po q 8 hours prn pain.
2. Valium 5 mg po q 8 hours prn pain.
3. Morphine instant release 15 mg q 4 to 6 hours prn pain.
4. Norvasc 10 mg one po q day.
5. Tylenol 1 gram q 6 hours prn pain.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 13747**]
MEDQUIST36
D: [**2107-6-7**] 05:17
T: [**2107-6-8**] 07:08
JOB#: [**Job Number 93257**]
|
[
"4019"
] |
Admission Date: [**2128-11-29**] Discharge Date: [**2128-12-1**]
Date of Birth: [**2054-10-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 74 year old male with a history of pulmonary
fibrosis with home O2 requirement of 2-3L, former smoker with
COPD, who presented on [**2128-11-28**] to [**Hospital6 33**] with
complaints of dyspnea.
The patinet has been followed for the last three years by Dr.
[**Last Name (NamePattern1) 84016**]at [**Hospital1 3278**], carying a diagnosis of IPF. He reports
to have been treated for many years for COPD, but describes a
change in his dyspnea in [**2125**]. Of note, in [**2124**] patient had an
oil spill in his basement with significant concrete dust in the
construction requiring hospitalization due to pulmonary
symptoms. He also describes a remote asbesstos exposure when in
the arm. He has been managed by Dr. [**First Name (STitle) **], but has never been on
any immunologic therapy. We have no recent CT scan or PFTs
available to us at this time. Over the last year, he has also
been on home O2, and has noted a progessive worsening of
symptoms over the last 6 months. He has noted increasing dyspnea
and a slow escalation of O2 requirment. He was started on a
prednisone taper in [**4-3**], but has not been able to taper off
10mg daily. He is on a series of inhaler regimens given below,
but not currently anticoagulated. It does not seem the patient
has had a lung biopsy.
The patient had an admission to [**Hospital1 34**] in [**10-4**], for which he was
treated with a steroid burst and antibiotics for brochroncitis,
which improved but again gradualy worsended. It appears he was
on an extended course of azythromycin.
The patient noted that his respiratory symptoms worsened since
around the [**Holiday 944**] holiday, with incrasing dyspnea on
excersion, a productive cough with mildly blood tinged sputum.
His symptoms continued to worsen, and he began to notice audible
wheese and a marked decline in his dyspnea. On [**2128-11-28**] the
patients son found him to be hypoxic to the 70s on RA and
activated EMS. The patinet was treated intermittent BIPAP 10/5,
but was never able to maintain adequate oxygen saturations on
less than 50% venti-mask oxygen supplementation. CXR showed now
right middle and lower chest opacities which were felt to most
likely be consisent with airspace disease with possible
superimposed pneumonia. BNP was 517, urine leginlla was
negative, strep pneumoniae antigen were both negative. BCx were
no growth to date. He was treated with solumedrol and
levofloxacin with a pulmonology consultation. The patient was
transfered to [**Hospital1 18**] for further manegment.
Past Medical History:
Pulmonary Fibrosis with 2L Home O2
CAD, w/ stent in [**2125**] at [**Hospital1 336**] for UA
HTN
HLD
AAA s/p endograft repair in [**2124**]
Vasovagal syncope
COPD
Social History:
The patient is a widower. History of smoking, but quit in [**2108**]
after a bad pneumonia. He worked as both a professor as was
active in the US army Medicore. No history of significant
alcohol use. Live alone, but has invovled supportive family. He
had multiple dogs, but never had pet birds or other animals.
Family History:
No family history of malignancy, autoimmune idease, or lung
disease save for emphysema in his father.
Physical Exam:
General Appearance: Well nourished, No acute distress, On NRB
Lymphatic: No(t) Cervical WNL, No(t) Supraclavicular WNL, No(t)
Cervical adenopathy
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal),
(Murmur: No(t) Systolic, No(t) Diastolic)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Not assessed), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Rhonchorous: diffuse dry rales
worse )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent
Skin: Not assessed
Neurologic: Attentive, Follows simple commands, Responds to: Not
assessed, Movement: Not assessed, Tone: Not assessed
Pertinent Results:
[**2128-12-1**] 03:06AM BLOOD WBC-25.0* RBC-3.55* Hgb-10.2* Hct-30.5*
MCV-86 MCH-28.9 MCHC-33.6 RDW-14.5 Plt Ct-408
[**2128-11-29**] 08:29PM BLOOD Neuts-95.7* Lymphs-2.3* Monos-1.9* Eos-0
Baso-0.1
[**2128-12-1**] 03:06AM BLOOD Plt Ct-408
[**2128-12-1**] 03:06AM BLOOD Glucose-115* UreaN-22* Creat-1.1 Na-135
K-3.9 Cl-99 HCO3-25 AnGap-15
[**2128-11-29**] 08:29PM BLOOD Glucose-130* UreaN-25* Creat-1.1 Na-139
K-4.2 Cl-104 HCO3-23 AnGap-16
[**2128-11-29**] 08:29PM BLOOD LD(LDH)-552*
[**2128-12-1**] 03:06AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2
[**2128-11-30**] 04:54AM BLOOD Iron-22*
[**2128-11-30**] 04:54AM BLOOD calTIBC-255* Ferritn-821* TRF-196*
[**2128-11-30**] 11:40AM BLOOD Type-[**Last Name (un) **] pO2-62* pCO2-45 pH-7.35
calTCO2-26 Base XS-0
[**2128-11-30**] 11:40AM BLOOD Lactate-1.4
[**2128-11-30**] 11:40AM BLOOD freeCa-1.08*
[**2128-11-30**] 1:00 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final [**2128-11-30**]):
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
IMPRESSION:
1. No pulmonary embolism.
2. Moderate progression of diffuse interstitial abnormality,
predominantly
subpleural reticulation and fibrosis. Honeycombing is new from
previous exam.
3. Diffuse ground-glass opacity superimposed on background
interstitial
changes. Findings are concerning for acute pulmonary edema, and
could be due to cardiogenic, or non-cardiogenic causes.
Differential includes acute drug reaction, and ARDS. Pneumonitis
secondary to infectious causes, such as PCP, [**Name10 (NameIs) **] also possible.
4. Mediastinal lymphadenopathy is consistent with reported
history of IPF.
Brief Hospital Course:
The patient is a 74 year old male with a history of IPF, COPD,
tobacco use who presents with hypoxia, tranfered for further.
mangement.
# Hypoxia: Most likely etiology of patient's hypoxia and dyspnea
is worsening of his underlying pulmonary fibrosis. He was
initially treated with antibiotics and steroids without any
improvement. He had a CT chest which showed worsening of his
underlying disease. His micro data did not show any new
microorganism. His viral respiratory panel was also negative.
He was maintained on a non-rebreather mask at 15L/min and nasal
cannula at 10L/min. He was evaluated by palliative care, and
after much discussion with the patient and family, he was made
DNR/DNI and CMO with palliative care/hospice set up at home. He
will be discharged with morphine solution and oxygen for home
therapy. His other medications will be discontinued.
# CODE: DNR/DNI confirmed with patient- comfort measures only
# CONTACT: [**Known firstname **] [**Name (NI) 84017**] [**Name (NI) **] (Son and HCP)
Medications on Admission:
Advair 500/50 1 puff [**Hospital1 **]
Asprin 81mg daily
Atenolol 50mg daily
Boniva 150mg qmonth
Plavix 75mg daily
Spiriva 18mcg daily
Prednisone 5mg daily (has not been able to taper off steroids;
on for last 6 months)
Albuterol neb PRN
VB12
Fish Oil 300
Folic Acid
Glucosamine
MVI
Lovastatin 80mg qHS
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 5-20 mg PO Q1H as
needed for shortness of breath or wheezing.
Disp:*60 mL* Refills:*0*
2. Scopolamine Base 1.5 mg Patch 72 hr Sig: [**11-27**] patches
Transdermal every seventy-two (72) hours.
Disp:*20 patch* Refills:*2*
3. Ativan 1 mg Tablet Sig: 0.5-2 Tablets PO every four (4) hours
as needed: sublingual.
Disp:*40 Tablet(s)* Refills:*0*
4. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*60 Tablet(s)* Refills:*2*
5. oxygen
high flow oxygen, 10-20L/min with non-rebreather mask
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] VNA services
Discharge Diagnosis:
Primary Diagnosis: Idiopathic Pulmonary Fibrosis
Hypoxia
Discharge Condition:
hypoxia to 78-85% on high flow oxygen. unable to ambulate
without further hypoxia. Mental status normal and at baseline
Discharge Instructions:
You were admitted to [**Hospital1 18**] for worsening of your breathing and
low oxygen saturations. This is likely worsening of your
underlying pulmonary fibrosis. You were initially treated with
steroids and antibiotics, but there was no significant
improvement. A repeat CT scan showed evidence of worsening of
your disease. This is an end stage process. You were seen by
the palliative care team, and after further discussions with you
and your family, you decided to go home with hospice services.
You will be sent home with medications for your comfort.
Followup Instructions:
none
|
[
"41401",
"V4582",
"4019",
"2724"
] |
Admission Date: [**2147-11-23**] Discharge Date: [**2147-11-26**]
Date of Birth: [**2114-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 7591**]
Chief Complaint:
Atrial fibrillation and rapid ventricular response
Major Surgical or Invasive Procedure:
Transesophageal echocardiogram
DCCV Cardioversion
History of Present Illness:
33 yo male with AML now day 42 s/p matched unrelated donor
allogeneic stem cell transplant. Transplannt complicated by
graft vs host dz (GI involvement on steroids),
fever/neutropenia, and pneumonia who presents with A fib with
RVR and hypotension.
Further oncological hx includes that he had a persistant
abnormal lung wheeze and was treated for infectios bronchiolitis
with ceftazidine and azithromycin which was completed last
friday. His GI flare of his graft vs host disease is being tx
with steroids which are being slowly tappered.
He presented to oncology clinic today for a routing visit. He
looked unwell on arrival. He reports that for 24-36 hrs prior to
arrival he was feeling fatigued and occasionally lightheaded
when he stood up. HR was noted to be 120 with BP 93/60 ( his nl
110-120 SBP). He was irregular on cardiac exam. EKG showed HR
180-220s and a fib. He was given 500cc IVF in clinic and sent to
the emergency department. En route to the ED he got adenosine
6mg with no response.
On arrival to the ED BP was 74/58. He was started on neo. He
received cefepime 2g IV x1, vancomycin 1 gram x1, 3L of IVF
(with good UOP), and blood cx x2. Cards was consulted. Plan was
for admission for TEE and cardioversion. CXR noted port to be
terminating in the mid SVC. Vitals prior to transfer to the
floor were 117/80 (neo at 3) HR 170s 16 99%.
On arrival to the floor VS were 99.2 150/100 HR 170 RR15 99% RA.
He reports he is feeling fine.
Past Medical History:
Presented [**2147-7-27**] with tonsillar swelling and cervical
lymphadenopathy. He had a WBC count of 94.8K (N0 L13, Blasts
87%). Bone marrow aspirate/biopsy demonstrated AML with
monocytic differentiation. He began remission induction therapy
with Idarubicin/Cytarabine (7+3) on [**2147-7-28**]. His early course
was
complicated by DIC, requiring product support, and a
peritonsillar phlegmon with significant airway compromise. He
required ICU admission for the first several days of his
hospitalization, but ultimately improved. Bone marrow
examination following treatment demonstrated a hypercellular
marrow (80-90%) with megakaryocytic hyperplasia and clustering,
and diagnostic morphologic features of involvement by acute
leukemia were not seen. He received cycle 1 of post remission
therapy with high dose cytarabine from [**Date range (3) 85117**], which
was
uncomplicated.
He underwent matched unrelated donor ([**10-29**] match) allogeneic
stem cell transplantation, day 0 was [**2147-10-12**]. Course was
complicated by febrile neutropenia, and left lower lobe
pneumonia
was discovered on imaging. He developed skin and GI GVH after
engraftment, but improved with steroids. He was discharged to
the
apartments on day +26. Following discharge, he was treated for
bronchiolitis with a course of ceftriaxone/azithromycin. He
continues ongoing management of GI GVH.
Social History:
Pt works as a business [**Company 85116**] from home. He lives with
several roommates. He denies exposure to chemicals or toxins.
Smoking: None
Alcohol: He has alcohol socially on weekends, with up to 10
drinks at a time.
Drugs: Denies illicit drug use.
Family History:
Father -- deceased from motorcycle accident
Mother -- alive and healthy
[**Name (NI) 85115**] (2) -- alive and healthy
Grandparents -- deceased, no known cancer history
No known bleeding disorder, leukemia, lymphoma, or other cancer
in the family.
Physical Exam:
Gen: unwell, fatigued, pale compared with prior examinations
HEENT: PERRL, EOMI, OP clear, MM dry with thick coating
Skin: mild rash on the back of his neck, but otherwise, no
evidence of GVH
Chest: line c/d/i, right chest--not erythematous or tender
Car: Irregular, tachycardic
Resp: clear to auscultation bilaterally
Abd: soft, not tender, not distended, no HSM
Ext: no LE edema
Back: no midline tenderness
Pertinent Results:
[**2147-11-23**] 09:35AM GRAN CT-[**Numeric Identifier 70565**]*
[**2147-11-23**] 09:35AM PLT COUNT-115*
[**2147-11-23**] 09:35AM NEUTS-89.8* LYMPHS-4.1* MONOS-5.7 EOS-0.2
BASOS-0.1
[**2147-11-23**] 09:35AM WBC-13.1* RBC-3.85* HGB-13.4* HCT-38.0*
MCV-99* MCH-34.8* MCHC-35.3* RDW-19.9*
[**2147-11-23**] 09:35AM CYCLSPRN-277
[**2147-11-23**] 09:35AM TSH-0.29
[**2147-11-23**] 09:35AM CALCIUM-8.5 PHOSPHATE-4.2 MAGNESIUM-1.7
[**2147-11-23**] 09:35AM ALT(SGPT)-85* AST(SGOT)-34 ALK PHOS-63 TOT
BILI-1.2
[**2147-11-23**] 09:35AM UREA N-29* CREAT-1.2 SODIUM-134 POTASSIUM-4.3
CHLORIDE-101 TOTAL CO2-21* ANION GAP-16
[**2147-11-23**] 11:17AM HGB-13.4* calcHCT-40
[**2147-11-23**] 11:17AM GLUCOSE-123* LACTATE-1.5 NA+-137 K+-4.4
CL--104 TCO2-24
CXR: IMPRESSION: No acute intrathoracic process.
TRANSESOPHAGEAL ECHOCARDIOGRAM: IMPRESSION: No left or right
atrial appendage clot. Normal LV function. Normal valvular
function.
Brief Hospital Course:
Patient was admitted to the ICU with hypotension in the setting
of atrial fibrillation with a rapid ventricular response which
required pressors. Rate control was attempted with Diltiazem
bolus and drip, without success. He underwent TEE which was
negative for clot and then had DCCV Cardioversion wtih 200 J X 1
with conversion to normal sinus rhythm. Following cardioversion,
his blood pressure returned to [**Location 213**] and pressors/diltiazem
were stopped.
.
The etiology of atrial fibrillation was unclear. Echocardiogram
did not demonstrate structural abnormalities to his heart, TSH
was normal, electrolytes were normal. He sustained NSR after
cardioversion. He was treated empirically with antibiotics
(Cefepime/Vancomycin) and cultures were taken.
.
He was then transfered to [**Location 3242**] for further evaluation. He was
placed on tele, and it was noted that his resting HR was in
sinus in the high 90's to 100's. When he would walk to the
bathroom his heart rate would increase in sinus to the 140's.
After discussing his sinus tachycardia with the cardiology
fellow, he was sent for a CTA which did not demonstrate any
pulmonary embolism. To date, no clear etiology for his AFIB
with RVR has been established.
.
One day prior to discharge, his antibiotics were discontinued.
Blood cultures and a urine culture from the time of his
admission to discharge were negative for any growth. He was
discharged to the apartments with follow up appointment the next
day.
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a
day
BUDESONIDE [ENTOCORT EC] - 3 mg Capsule, Sust. Release 24 hr - 1
Capsule(s) by mouth three times per day
CYCLOSPORINE MODIFIED - (Dose adjustment - no new Rx) - 25 mg
Capsule - 2 Capsule(s) by mouth twice daily Total dose is 150 mg
[**Hospital1 **] - No Substitution
CYCLOSPORINE MODIFIED [NEORAL] - 100 mg Capsule - 1 Capsule(s)
by
mouth twice dailyFOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth
daily
LORAZEPAM [ATIVAN] - 0.5 mg Tablet - [**1-21**] Tablet(s) by mouth
every
6 hours as needed as needed for nausea, insomnia
PREDNISONE 15mg qam and 20mg qpm
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1
Tablet(s)
by mouth daily
URSODIOL - 300 mg Capsule - [**1-21**] Capsule(s) by mouth twice daily
as directed take 300 mg (1 tab) every morning, take 600 mg (2
tab) every evening
VORICONAZOLE [VFEND] - 200 mg Tablet - 1 Tablet(s) by mouth
twice
a day
MAGNESIUM OXIDE-MG AA CHELATE [MG-PLUS-PROTEIN] - 133 mg Tablet
-
[**1-21**] Tablet(s) by mouth three times a day to be adjusted by
physician
[**Name Initial (PRE) 26391**] - (OTC) - Capsule - 1 Capsule(s) by mouth once a
day
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO TID (3 times a day).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
5. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. ursodiol 300 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
7. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO QPM (once a
day (in the evening)).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. cyclosporine modified 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours): total dose 150 mg [**Hospital1 **].
10. voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
11. prednisone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day): total dose 15 mg twice daily.
12. enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours).
13. cyclosporine modified 25 mg Capsule Sig: Two (2) Capsule PO
twice a day: total dose 150 mg twice daily.
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Atrial Fibrillation with Rapid Ventricular Response
Hypotension
Graft versus Host disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with atrial fibrillation with rapid
ventricular response. You underwent cardioversion and had
normalization of your heart rhythm. You were treated with
antibiotics in case there was an infectious cause, but your
cultures were negative.
Please continue your home medications as you were prior to this
hospitalization. In addition:
1. Start enoxaparin 80 mg subcutaneous twice daily (this will be
a 30 day course)
Please call your providers if you develop any new or concerning
symptom.
Followup Instructions:
Provider: [**Name10 (NameIs) 3242**] [**Apartment Address(1) 1246**] [**Apartment Address(1) 3242**] CHAIRS & ROOMS Date/Time:[**2147-11-27**] 8:30
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 13863**], RN Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2147-11-27**] 8:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2147-11-27**] 9:30
Completed by:[**2147-11-27**]
|
[
"42731",
"2875",
"42789"
] |
Admission Date: [**2124-4-28**] Discharge Date: [**2124-5-3**]
Date of Birth: [**2075-3-20**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Enlarging brain mass
Major Surgical or Invasive Procedure:
Left Craniotomy for Mass resection
History of Present Illness:
49 F with a left insular mass that had enlarged on serial
imagings. She presents for consideration of surgical resection.
The lesion was initially found in [**2120**] as part of a work up for
headache. The patient was subsequently diagnosed with migrainous
headache, and her headache was subsequently controlled with
Verapmil and Midrin. Of note, in recent weeks, the patient
complains that her headache is less well controlled with the
medical reigmen.
The patient denied episodes of nausea, vomiting, visual changes,
seizure like activities, difficulty with speech, weakness of
arm/legs. The review of system is otherwise unremarkable.
Past Medical History:
1. h/o atypical chest pain - [**5-24**] P-MIBI without myocardial
perfusion defects
2. last echo [**8-25**]: EF 40-50%, moderate symmetric LVH, mild
global LV hypokinesis
3. hypertension
4. cocaine use
5. h/o palpitations
6. Arthritis
Social History:
No tobacco (past or present); occasional EtOH "several
times"/month drinks 2 40-oz containers of beer (denies ever
having tremors or seizures with alcohol); smokes cocaine, last
use 2 days prior to admission (Friday afternoon). She lives with
4 kids, ages 24, 19, 16, 12, all in good healht.
Family History:
MGM - died of CHF 78y/o; HTN in mother, siblings, MGM
Physical Exam:
On discharge:
A&0 x 3. Expressive aphasia, improving. Otherwise non focal.
Motor and sensory gorssly intact
Pertinent Results:
MRI brain [**2124-4-28**]:Left temporal meningioma is identified,
unchanged in size
compared to the prior study.
CT head [**2124-4-28**]: S/p left extra-axial mass resection, with
expected postsurgical changes, frontal pneumocephalus. There is
mild effacement of the
sulci and midline shifting towards the right, approximately 4
mm.
MRI brain [**4-29**]: Expected post-surgical changes are seen. No
acute infarcts, mass effect, or hydrocephalus. No residual
nodular enhancement.
CT head [**5-1**]:
IMPRESSION:
1. Decrease of pneumocephalus and decreased density of blood
products
posterior to the surgical cavity.
2. Unchanged surgical cavity size, and unchanged 3-4 mm midline
shift to the right.
3. No new hemorrhage or infarction.
Brief Hospital Course:
Ms. [**Known lastname 101385**] was admitted to [**Hospital1 18**] under the care of Dr. [**First Name (STitle) **].
She had MRI imaging and then was taken to the OR. She underwent
a craniotomy for mass resection. The procedure went well without
complications. She went to the ICU for Q1 hour neuro checks. Her
post-op head CT showed some pneumocephalus but no hemorrhage.
She was transferred to the neurosurgical floor on [**4-30**]. The
patient was stable and a steroid taper was begun.
Post-operatively the patient developed expressive aphasia that
improved on subsqeuent days. As work up, the patient underwent a
head CT in the morning of [**5-1**] The scan showed no hemorrhage or
CVA. Post-operative MRI was equally reassuring.
Physical therapy evaluated the patient, and they determined that
she could go home with PT services. The patient was dicharged
home thereafter.
Medications on Admission:
Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
Discharge Medications:
1. Outpatient Speech/Swallowing Therapy
Please allow this patient to have outpatient speech therapy for
her expressive aphasia.
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
5. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
8. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*84 Tablet(s)* Refills:*0*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-22**]
Tablets PO Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Left temporal meningeoma
Expressive Aphasia
Discharge Condition:
Neurologically Stable
Mental status:oriented x 3 but has expressive aphasia
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
GENERAL 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 have dissolvable sutures. They do not need to be 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. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
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 discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? 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.
?????? You are being sent home on steroid medication. Make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
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:
FOLLOW UP APPOINTMENT INSTRUCTIONS
-Please call Dr.[**Name (NI) 9399**] office to schedule an appointment in 2
weeks with a non-contrast head CT [**Telephone/Fax (1) 1669**].
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2124-5-29**] at
3:30pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2124-5-3**]
|
[
"4019"
] |
Admission Date: [**2164-5-15**] Discharge Date: [**2164-5-18**]
Date of Birth: [**2092-8-19**] Sex: M
Service: C-MEDICINE
CHIEF COMPLAINT: Syncope.
HISTORY OF PRESENT ILLNESS: This is an 71 year old Caucasian
male with a history of myocardial infarction in [**2152**], status
post catheterization times three, most recent in [**2163-1-31**], showing three vessel disease. He was admitted at this
time after syncope in his primary care physician's office the
morning of admission. He had noted weakness and chills for
approximately two days with heart rate up to 110 one day
prior to admission.
He presented to his primary care physician this morning and
was sitting in his office. His heart rate was noted to be
high though was unrecorded. The patient began to feel his
vision darken, had witnessed syncope. He denies
light-headedness, shortness of breath, chest pain, nausea,
vomiting or diaphoresis.
In the Emergency Department, first CK was negative. It
should be noted that the patient had mild nausea with stable
vital signs. He was given Aspirin 325 mg p.o. times one in
the Emergency Department.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post anterolateral
myocardial infarction with known three vessel disease in
[**2152**], ejection fraction of 20%, apical hypokinesis and ?
known left ventricular clot per Dr. [**Last Name (STitle) 3357**]. Most recent
catheterization in [**2163-1-31**], showed 60% left anterior
descending lesion, midsegment, 30 to 40% left circumflex
lesion, OM1 which was totally occluded, right coronary artery
which showed 70% diffuse disease and ejection fraction of
27%.
2. Benign positional vertigo.
3. Hypertension.
MEDICATIONS ON ADMISSION:
1. Isordil 20 mg p.o. t.i.d.
2. Atenolol 25 mg p.o. q.d.
3. Procardia XL 30 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Vasotec 5 mg p.o. q.d.
6. Coumadin 5 mg p.o. q.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Mother died of coronary artery disease, and
father died when he was young of unknown disorder.
SOCIAL HISTORY: The patient denies tobacco or alcohol use.
He is retired and lives in a [**Hospital1 **] community. He lives with
his wife and has two sons who are in good health.
PHYSICAL EXAMINATION: On physical examination, temperature
is 98.8, blood pressure 102/64, respiratory rate 20, heart
rate 72, weight 164.2 pounds. In general, this is a
moderately obese Caucasian male lying in bed in no acute
distress. Head, eyes, ears, nose and throat examination -
The pupils are equal, round, and reactive to light and
accommodation, arcus senilis bilaterally, anicteric sclera,
extraocular movements are intact. Mucous membranes are
slightly dry, no jugular venous distention. Cardiovascular -
regular rate and rhythm, no murmurs, rubs or gallops. Lungs
are clear to auscultation bilaterally. The abdomen reveals
normoactive bowel sounds, nontender, nondistended. No
hepatosplenomegaly. Extremities - no swelling. The patient
is diaphoretic and clammy, 2+ dorsalis pedis, posterior
tibial femoral pulses, no bruits.
LABORATORY DATA: On admission, complete blood count showed a
white count 6.1, hematocrit 40.7, platelets 180,000. Chem7
showed sodium 137, potassium 4.9, chloride 101, bicarbonate
25, blood urea nitrogen 14, creatinine 1.2, blood sugar 128.
CK 166 with CK MB 2.0, troponin less than 0.3.
Echocardiogram from [**10-30**], showed left atrial enlargement,
dyskinetic apex, positive clot, inferolateral and anterior
hypokinesis. There was a mildly sclerotic aortic valve with
trace aortic regurgitation. There was mild to trace tricuspid
regurgitation. There was 2 to 3+ mitral regurgitation.
Electrocardiogram showed pseudonormalization of T wave
inversions in V5 and V6. There are Q waves apparent in leads
III, aVF, V1 and V3, and V4 to V6. There is mild J point
elevation in leads V1 to V6 which are the same as previous.
HOSPITAL COURSE:
1. Syncope - The patient was ruled out for myocardial
infarction with three consecutive negative CKs. His
presentation was very unlikely to be secondary to arrhythmia
and more likely to be secondary to vasovagal etiologies. The
patient was diaphoretic with slightly decreased blood
pressure with nausea and feeling of fatigue and fever. He
likely had viral illness. Infection was ruled out with two
negative blood cultures, one negative urine culture and
negative urinalysis. The patient was at risk for ventricular
tachycardia secondary to history of three vessel disease and
ejection fraction less than 30%. He was evaluated by the
arrhythmia service and thought to be suitable for
electrophysiology study.
2. Coronary artery disease - The patient was continued on
Aspirin, Lipitor, Atenolol, Vasotec and Procardia. Norvasc
was considered but the patient has known allergic reaction.
3. Hematology - The patient had history of left ventricular
thrombus on Coumadin. INR at admission was 1.7. He was
placed on Heparin for anticoagulation. Echocardiogram was
repeated on [**2164-5-17**], showing the following: mildly dilated
left atrium. There is mild symmetric left ventricular
hypertrophy. There is moderate regional left ventricular
systolic function. Overall, there is left ventricular
systolic function depression. Resting wall motion
abnormalities including akinesis of the distal half of the
left ventricle and dyskinesis of the true apex. There is 2+
mitral regurgitation. The ventricular inflow pattern
suggested mild impaired relaxation. There is no pericardial
effusion or left ventricular thrombus noted. Heparin was
thus held.
DISPOSITION: At this time, the patient was evaluated for CT
Surgery and is being transferred to the CT Surgery service
for coronary artery bypass and removal of aneurysm.
Discharge addendum to follow.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1211**], M.D. [**MD Number(1) 1212**]
Dictated By:[**Name8 (MD) 8073**]
MEDQUIST36
D: [**2164-5-18**] 15:03
T: [**2164-5-20**] 12:46
JOB#: [**Job Number 15992**]
|
[
"41401",
"4240",
"5990",
"4280",
"412",
"4019",
"2720"
] |
Admission Date: [**2112-5-16**] Discharge Date: [**2112-6-14**]
Date of Birth: [**2048-1-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
5/8/115/8/11 Exploratory laparotomy, antrectomy, Roux-en-Y
gastrojejunostomy
[**2112-5-25**] Exploratory laparotomy, evacuation hematoma, suture
ligation bleeding varix behind the head of the pancreas, and
then suture ligation of bleeding varix in the anterior abdominal
wall
History of Present Illness:
Mr. [**Known lastname **] is a 64yo M w/hx of EtOH Cirrhosis (Child's Class B,
MELD 17) and hx of grade I varices with prior GI bleeds who
presents to [**Hospital1 18**] [**Hospital Unit Name 153**] as an OSH transfer for hematemesis.
.
The patient originally admitted to [**Hospital 8**] Hospital on [**2112-5-10**]
with hematemesis, melena and altered mental status. The patient
reports going out for dinner on [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1017**] ([**5-8**]) and felt
well after this. He had 2 beers on [**Month/Year (2) 1017**]. On [**5-10**] he developed
hematemesis and abdominal pain and came to [**Hospital 8**] Hospital
where he was found to have an upper GI bleed. HCT dropped to
from 30s to 21 at its lowest. He required 6 units PRBCs. EGD
showed a duodenal ulcer with visible non-bleeding vessel which
was injected with epi and clipped with 9 clips. Hemostasis was
obtained. He was transferred to the medicine floor and started
on clears on [**2112-5-12**]. H. Pylori antigen was negative. On [**2112-5-14**]
he developed coffee-ground emesis and was transferred back to
the ICU. He was started on IV Protonix gtt. Repeat EGD showed
large clot and active oozing at the site of the prior duodenal
ulcer. This was injected with epi but unable to be clipped
again. GI stated there was no further endoscopic intervention
that could be done. Surgery was consulted and felt that he was
not a surgical candidate and recommended that if he rebleeds he
should have IR intervention.
.
The afternoon of transfer he developed recurrent hematemesis
with ?50-100ccs of bloody emesis. His repeat HCT was 31 at 2pm
(from 30 at 4am that day). He was hemodynamically stable with BP
of 132/67, HR 78. He continued to be nauseous at the time of
transfer. He was on a pantoprazole gtt. Of note he received 2
bags of platelets on [**2112-5-15**] for platelet count of 42. .
On the floor, he complains of persistent nausea. He vomited
~20ccs of brown liquid on arrival. He continues to have
epigastric abdominal pain. He denies constipation but states he
has been having loose stools without melena or hematochezia.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. No dysuria. Denied arthralgias or
myalgias.
.
After arrival, to the ICU, he had intermittent hematemesis and
coffee ground emesis, but with stable Hct. He required no
further transfusions. He developed abdominal pain and
distension, and underwent a CT scan that showed gastric outlet
obstruction. An NGT was placed with drainage of almost 3L of
bilious material. After placement, he felt improved. Today
prior to being transferred, he had a fever to 101.2.
Past Medical History:
EtOH abuse
EtOH Cirrhosis, Child's class B, MELD 17, c/b Grade 1 varices
seen [**2111-11-19**] on EGD, portal HTN
Barrett's esophagus
Multiple UGI Bleeds since [**2109**]
heterozygote for hemachromatosis
Cholecystectomy performed [**2109**]
Diverticulitis
Hemicolectomy 15 years ago
Tubular adenoma on colonoscopy [**2109-3-26**], [**3-19**] year f/u recommended
Macrocytic Anemia
Social History:
Retired treasurer from [**University/College 5130**] [**Location (un) **] in [**2105**]. Lives
alone, has 4 daughters in the area. Prior smoker; smoked 1 ppd x
10 years, quit 35 years ago. Previously drank heavily hard
alcohol + wine for most of his life, [**7-24**] quit drinking wine.
Had quit drinking hard liquor previously. Currently drinks ~ 2
beers per day. Denies illicit or IV drug use.
Family History:
No hx of liver disease in the family. Father with high
cholesterol. Mother with HTN.
Physical Exam:
Physical Exam:
Vitals: T: 99.8 BP: 134/64 P: 70 R: 18 O2: 94% RA
General: Alert, oriented, no acute distress, speaks slowly
HEENT: Sclera icteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, hyperdynamic S1, normal S2, no
murmurs, rubs, gallops
Abdomen: soft, tender to palpation in epigastric area,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs: [**2112-5-16**]
WBC-8.0 RBC-3.10* Hgb-10.7* Hct-30.1* MCV-97 MCH-34.6*
MCHC-35.7* RDW-18.2* Plt Ct-131*
Neuts-76.1* Lymphs-12.0* Monos-9.2 Eos-2.3 Baso-0.4
PT-17.4* PTT-32.4 INR(PT)-1.6*
Glucose-117* UreaN-12 Creat-0.7 Na-136 K-3.8 Cl-101 HCO3-27
AnGap-12
ALT-29 AST-42* LD(LDH)-228 AlkPhos-79 TotBili-3.9*
Lipase-66* Albumin-3.1* Calcium-8.4 Phos-3.1 Mg-2.3
.
On Discharge [**2112-6-14**]:
WBC-8.2 RBC-2.91* Hgb-9.4* Hct-27.8* MCV-96 MCH-32.3* MCHC-33.9
RDW-18.9* Plt Ct-102*
PT-21.2* INR(PT)-2.0*
Glucose-101* UreaN-22* Creat-0.9 Na-135 K-4.1 Cl-100 HCO3-29
AnGap-10
ALT-17 AST-43* AlkPhos-103 TotBili-2.5*
Calcium-7.8* Phos-3.6 Mg-1.9
Brief Hospital Course:
Mr. [**Known lastname **] is a 64 yo M w/hx of EtOH Cirrhosis who presented to
an OSH with an upper GI bleed, found to be due to a duodenal
ulcer, transferred to [**Hospital1 18**] for possible IR intervention. Hct
was initially stable. Pantoprazole drip was administered. CT of
abd/pelvis on [**5-17**] revealed a large clot at the junction of D1
and D2 with resultant proximal gastric distension. On [**5-20**], an
EGD was performed with the following findings: varices at the
middle third of the esophagus and lower third of the esophagus.
Blood was in the stomach. The area from the pyloric channel
extending into and past the duodenal bulb was edematous,
deformed, and ulcerated, to the point that it obstructed the
view completely. The scope was able to pass but with difficulty.
There was significant friability and oozing. The ulcer could not
be evaluated. No intervention could be carried out. Otherwise
normal EGD to just past duodenal bulb. Surgery was consulted.
On [**5-21**] CTA showed increasing size of the duodenal hematoma and
an area concerning for active extravasation at D1. Surgery
service was consulted and on [**5-22**], he was taken to the OR for
antrectomy and roux en y gastrojejunostomy. Postoperatively, the
hct continued to decrease. Abd/Pelvic CT demonstrated a small
anterior abdominal hematoma and a R paracolic gutter hematoma.
Active bleeding could not be assessed given that this was not a
CTA. The patient appeared stable and was transferred to the
floor in the afternoon; however, by the evening his hct had
fallen from 31 to 24, and the patient was transferred back to
the SICU of CT of abdomen/pelvis showed partially loculated
hematomas in ant omentum and R paracolic gutter with no evidence
of bowel leak. Hct did not increase despite multiple
transfusions (hct down to 23 from 31)
On [**5-25**], he was taken back to the OR by surgeons, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and [**First Name4 (NamePattern1) 3742**] [**Last Name (NamePattern1) **] for an exlap evacuation hematoma, suture
ligation bleeding varix behind the head of the pancreas, and
then suture ligation of bleeding varix in the anterior abdominal
wall. Multiple transfusions were given. He was then transferred
back to the SICU. He remained intubated. A RUQ U/S was done on
[**5-26**] to evaluate for portal vein thrombus. No thrombus was seen.
There was reversal of flow (hepatofugal) in the portal veins.
Biopsy during surgery revealed Duodenal ulcer with mural
necrosis, and acute and chronic inflammation, consistent with
perforation.
On [**5-27**] an abdominal CT was done for bilious drain output and
tense abdomen. Increased complex ascites was noted. Given lack
of enteric contrast extravasation
and bilious catheter drainage, this is concerning for bile leak
from the
duodenal stump. Volume overload was also noted with small
bilateral pleural effusions and body wall edema.
On [**5-26**] he was extubated in AM, however, he became more
tachycardic and tachypneic requiring reintubation. On [**5-27**] he
was hypothermic with glucoses in 400s on insulin drip. Given
concern for fungemia, TPN was stopped and he was switched to
micafungin. He was pan-cultured including the PICC tip.
Hypotensive, required NS and albumin with neo on and off over
the night. Hct 29/3 -> 26.1. Gave 2uPRBC.
TPN was restarted. On [**5-30**] he was extubated. NG Tube was removed
and he started sips to clears. JP outputs appeared more bilious.
The patient had fevers to 101.7 on POD 1 and 101.3 on POD 3.
Fluconazole, Vanco and Zosyn were started. Blood Cultures have
been sent on multiple occasions and all have returned with no
growth. Fluid sent from the JP drains grew enterococcus and
staph coag negative. Antibiotics were switched to Vanco and [**Last Name (un) **]
and micafungin was continued for broadened coverage due to bile
leak from the duodenal stump. nystatin oral solution started for
thrush on [**5-29**].
The patient was transferred out of the ICU on POD 6. Mental
status waxed and waned during the initial surgical course. He
was kept NPO secondary to the antrectomy, and was continued on
TPN via PICC line. The patient was slowly started on sips to
clears and then to regular diet, however PO intake has been very
poor and calorie counts reflect less than half of caloric need
being met. Attempt was made to place feeding tube, however due
to the antrectomy, placement was difficult and passage to the
gastrojejunostomy was unable to be achieved. Feeding tube
attempt was d/c'd, the TPN was continued and the patient was
allowed to eat. The TPN will be continued for now and on
discharge to rehab.
JP drains have remained in place and continue to have bilious
appearing drainage, output typically up to 100 cc daily in
recent days.
CT of abdomen on [**6-2**] showed continued hematoma and new concern
for colonic wall thickening. The patient was started on flagyl
for a 2 week course, c diff samples x 3 were sent and are all
negative. The patient is not having diarrhea, WBC stable and
WNL.
His mental status has improved over the course of the
hospitalization, however evaluation by physical therapy
determined need for rehab placement, as well as need for
continuing TPN and increased monitoring needs. Incision has been
C/D/I. He ambulates with assistive device and has had return of
bowel function.
Medications on Admission:
Folic Acid 1mg PO daily
Nadolol 40mg PO daily
Prilosec 40mg PO daily
.
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
2. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for SBP < 100 or HR < 60 .
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for perineal rash: perineal rash .
7. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-17**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
8. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
9. metronidazole in NaCl (iso-os) 500 mg/100 mL Piggyback Sig:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 6
days: until [**6-15**].
10. 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.
11. insulin regular human 100 unit/mL Solution Sig: follow
sliding scale Injection ASDIR (AS DIRECTED).
12. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day:
Weight daily. If d/c TPN then 40 PO BID.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] northeast hosp [**Location (un) **]
Discharge Diagnosis:
UGI bleed/varicele bleed
duodenal ulcer
delerium
Malnutrition and s/p antrectomy on TPN
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You will be transferring to [**Hospital **] [**Hospital 89294**] rehab
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office [**Telephone/Fax (1) 673**] if you have
nausea, vomiting (vomiting blood), inability to eat/drink,
increased abdominal pain, incision redness/bleeding/drainage, JP
drain outputs stop or volume increases significantly,bloody or
black stools.
No heavy lifting
You should continue sponge baths for now and avoid showering or
tub baths
Please weigh the patient daily and call the office for weight
gain or loss of > 3 pounds in a day or 5 pounds in a week as
lasix may need adjustment. If TPN is d/c'd please drop Lasix
dose to 40 PO BID
Please keep Ace wraps or [**Male First Name (un) **] hose on patient during the day and
encourage feet up when sitting to avoid dependent edema
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-6-23**] 3:00
Completed by:[**2112-6-14**]
|
[
"51881",
"2851",
"2875"
] |
Admission Date: [**2177-7-17**] Discharge Date: [**2177-8-12**]
Service:
HISTORY OF PRESENT ILLNESS: This 85-year-old white male has
a history of hypertension, hypercholesterolemia, and had a
positive stress test. He has had six months of increased
dyspnea on exertion, shortness of breath, and nausea. His
exercise tolerance test on [**7-4**] revealed moderate-severe
inferior apical ischemia and inferior apical hypokinesis. He
underwent cardiac catheterization on [**2177-7-17**] at [**Hospital1 346**] which revealed the left main
coronary artery had 80% distal concentric stenosis, LAD had
70 and 80% tandem mid vessel lesions and diffuse disease with
left to right collaterals. Diagonal 1 had a 60% lesion.
Left circumflex had a 70% OM-1 lesion, and the RCA had a 50%
mid lesion. The left ventricle had an apical aneurysm with
an ejection fraction of 55%, apical dyskinesis. Dr.
[**Last Name (STitle) 70**] was consulted for CABG.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Status post gastrointestinal bleed secondary to
nonsteroidal use.
4. History of prostate cancer status post radiation therapy.
5. Status post orchiectomy.
6. Status post inguinal hernia repair.
7. History of gout.
MEDICATIONS ON ADMISSION:
1. Lopressor 50 mg po q am, 25 mg po q pm.
2. Imdur 60 mg po q am, 30 mg po q pm.
3. Lipitor 10 mg po q day.
4. Allopurinol 100 mg po q day.
5. Aspirin 81 mg po q day.
6. Iron 325 mg po q day.
ALLERGIES: Ether.
FAMILY HISTORY: Positive for coronary artery disease.
SOCIAL HISTORY: He lives alone. He has a 120 pack year
smoking history, quit 25 years prior to admission. Does not
drink alcohol.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: On physical exam, he is a
well-developed elderly white male in no apparent distress.
Vital signs stable, afebrile. HEENT exam: Normocephalic,
atraumatic. Extraocular movements are intact. Oropharynx is
benign. He had upper and lower dentures. Neck was supple,
full range of motion, no lymphadenopathy or thyromegaly.
Carotids are 2+ and equal bilaterally with a positive
radiating murmur. Lungs were clear to auscultation and
percussion. Cardiovascular examination regular, rate, and
rhythm, normal S1, S2, with no murmurs, rubs, or gallops.
Abdomen was soft and nontender with positive bowel sounds.
No masses or hepatosplenomegaly. Extremities are without
clubbing, cyanosis, or edema. Pulses were 2+ and equal
bilaterally throughout. He had an intra-aortic balloon in
place in the right groin. Neurologic examination was
nonfocal.
The patient was admitted to the CCU following cardiac
catheterization, and Dr. [**Last Name (STitle) 70**] was consulted, and on
[**7-18**], the patient underwent a CABG x3 with LIMA to the LAD,
reverse saphenous Y graft to the diagonal and OM.
Cross-clamp time was 87 minutes, total bypass time 112
minutes. He was transferred to the CSRU on nitroglycerin and
propofol in stable condition. He did have increased chest
tube output immediately postoperatively, and was re-explored
for bleeding. There was no specific source found. Hematoma
was evacuated, and the patient was transferred back to the
CSRU in stable condition.
He remained intubated overnight. He did have his
intra-aortic balloon pump removed on postoperative day #1.
He did remain intubated as he was quite fluid overloaded. He
continued to be diuresed, was off all drips. He did complain
of right lower quadrant abdominal tenderness and General
Surgery was consulted, that was on postoperative day #3.
He got an abdominal CT scan which revealed question of
thickened cecum with stranding, but was negative for free
air. He was followed and continued to have abdominal
distention and pain which waxed and waned.
He was extubated on postoperative day #5. His chest tubes
were also discontinued. He was then started on a regular
diet. He did then continue to complain of right lower
quadrant abdominal pain, so he had an abdominal CT scan on
[**7-24**] and was taken to the operating room for small bowel
resection, and a necrotic ileal segment was found. The
patient was transferred back to the CSRU and was stable. He
was intubated and on TPN.
He slowly improved. He is on Flagyl and Zosyn, and he was
followed by ID. He was extubated on postoperative day of
abdominal surgery. Continued to require pulmonary therapy
and diuresis. He remained on TPN. He had some temperature
spikes. All the cultures were negative, and he was continued
empirically on Zosyn.
Patient remained NPO and on postoperative day #7 he had his
nasogastric tube inserted and started on clear liquids. He
continued to advance his diet. Continued to progress and on
postoperative day 17 and 10, he started to have melena. He
was seen by GI. He had a negative upper scope, EGD, and then
he continued to bleed required 10 units of packed cells. He
also had a colonoscopy on [**8-6**] in which the anastomotic
site of the ileum was not shown, but there was no evidence of
active bleeding throughout the entire colon and distal
terminal ileum. So he was treated conservatively and
continued to eat, and eventually this bleeding resolved.
The patient was transferred to the floor postoperative day
#22. He continued to progress, and was discharged to
rehabilitation on postoperative day 25.
LABORATORIES ON DISCHARGE: Hematocrit is 33.3, white count
9,700, platelets 420. Sodium 133, potassium 4.1, chloride
102, CO2 22, BUN 26, creatinine 1.1, blood sugar 89.
DISCHARGE MEDICATIONS:
1. Ecotrin 325 mg po q day.
2. Percocet 1-2 tablets po q4-6h prn pain.
3. Amiodarone 200 mg po q day x6 weeks.
4. Combivent 1-2 puffs q6h.
5. Miconazole powder tid.
6. Protonix 40 mg po q day.
7. Lipitor 10 mg po q day.
8. Allopurinol 100 mg po q day.
FOLLOW-UP INSTRUCTIONS: He will be followed by Dr. [**Last Name (STitle) **]
in two weeks, by Dr. [**Last Name (STitle) **] in [**1-23**] weeks, by Dr. [**Last Name (STitle) **] in [**2-24**]
weeks, and Dr. [**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 32413**]
MEDQUIST36
D: [**2177-8-11**] 16:43
T: [**2177-8-11**] 16:50
JOB#: [**Job Number 52254**]
|
[
"41401",
"2720",
"4019",
"42731"
] |
Admission Date: [**2119-10-11**] Discharge Date: [**2119-10-31**]
Date of Birth: [**2070-10-2**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 1865**]
Chief Complaint:
Respiratory failure
Major Surgical or Invasive Procedure:
Right subclavian central line placement
Intubation
PICC placement
History of Present Illness:
The patient presented to OSH ED yesterday w/neck pain since the
17th. Per the OSH, she was somnolent and found to be acidotic on
ABG; she was then intubated and R triple lumen femoral placed.
Discussion with family per OSH records indicates that she was
found down for an undetermined amount of time. CXR initially
showed extensive right-sided PNA and the next day (day of
transfer) was notable for left upper lobe infiltrate. Exam was
notable for fresh track marks. Pt was treated with vancomycin,
gatifloxicin and Unasyn per OSH ID consult. Utox + for cocaine
and opiates, BZ. By report, responded to Narcan (awoke). Head
CT was negative for acute intracranial abnormality. 2 sets of
blood cultures were + for gram + cocci; echo (TTE) negative for
vegetations and EF was 70%.
*
The patient was transferred to [**Hospital1 18**] per her son's request. She
was on Levophed and dopamine prior to transfer, and transferred
on dopamine and bicarb gtts. She received 6 liters of IVFs by
report to resident over the phone. She has been ordered 1 U
PRBC, but needs to come from Red Cross, so they're trying to get
the blood sent directly here. Her last abg was 7.37/40/287 on AC
500, Peep 8, rr 22, FiO2 100%. She had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim test but no
results are available yet.
Past Medical History:
Hepatitis C (liver biopsy in [**2116**] as showing stage III fibrosis)
Waldenstrom's macroglobulinemia/lymphoma
history of IVDU
depression
sialolithiasis
fine tremor
peripheral neuropathy
s/p prolonged ICU stay for heroin and benzodiazepine overdose
multi-lobar pneumonia (M. cattharalis)
Social History:
hx for polysubstance abuse, lives with her son
Family History:
Noncontributory
Physical Exam:
PE: AF 37.2C/ 105/65// 88// 100% Vented and on dopamine
Acutely-ill female, looks younger than stated age. Flushed,
awake, uncomfortable in appearance.
HEENT: EOMI, perrl, conjunctiva injected, tan exudate right eye,
MM dry.
Neck: supple, no LAD
Heart: rr, no m/g/r nl s1s2
Lungs: Diffusely rhonchorous, r>l, reduced BS at left base, no
rales
Abd: Distended, diffusely tender, no BS audible, no organomegaly
Ext: Warm, well-perfused, no lower extremity edema, track marks
in left antecub, no splinter hemorrhages. 2+ DPs b/l
Pertinent Results:
OSH Labs: Select labs below
[**10-11**]: wbc 0.9, 39%pmns, 31%Bands, 16L, 12M, 1 atyp, 1 meta
[**10-10**]: wbc 2.2, 11%pmns, 62%band, 9L, 4 atyps, 2 M, 1 B, 9 metas
INR 1.5
CK 2628, BUN 40, Creat 1.7, Ti .02
[**2119-10-23**] - Echo - The left atrium is normal in size. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and systolic function (LVEF>55%). Regional left ventricular
wall motion is normal. Right ventricular chamber size and free
wall motion are normal. The 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.
The pulmonary artery systolic pressure could not be determined.
There is a small (~1cm) anterior pericardial effusion but
without evidence of hemodynamic compromise.
[**2119-10-27**] CXR - 1. Peripheral and basilar predominant interstitial
pattern affecting the right lung to a much greater degree than
the left, in corresponding to more extensive areas of
consolidation on earlier radiograph of [**2119-9-23**]. These
findings may be due to slowly resolving pneumonia, but areas of
interstitial disease from drug toxicity, previously masked by an
overlying pneumonia, is within the differential diagnosis,
particularly if the patient has received bleomycin therapy.
Continued radiographic followup is recommended to assess for
resolution. If persistent, a high-resolution CT may be
considered. 2. Splenomegaly.
.
CXR PA/LAT [**2119-10-29**]:
IMPRESSION:
1. No radiographic evidence of acute, displaced rib fracture. If
symptoms are localized to a specific area, coned-down rib films
with metallic marker may be helpful.
2. Interstitial lung opacities as described above. Please see
recent report [**2119-10-27**] regarding differential diagnosis
and recommendations.
[**2119-10-11**] 11:54PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2119-10-11**] 11:54PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0
LEUK-TR
[**2119-10-11**] 09:05PM TYPE-[**Last Name (un) **] PH-7.30*
[**2119-10-11**] 09:05PM LACTATE-5.1*
[**2119-10-11**] 09:05PM freeCa-0.96*
[**2119-10-11**] 08:38PM GLUCOSE-220* UREA N-30* CREAT-1.1 SODIUM-137
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-21* ANION GAP-17
[**2119-10-11**] 08:38PM ALT(SGPT)-81* AST(SGOT)-196* LD(LDH)-528*
CK(CPK)-[**2096**]* ALK PHOS-62 AMYLASE-22 TOT BILI-1.1
[**2119-10-11**] 08:38PM ALT(SGPT)-81* AST(SGOT)-196* LD(LDH)-528*
CK(CPK)-[**2096**]* ALK PHOS-62 AMYLASE-22 TOT BILI-1.1
[**2119-10-11**] 08:38PM ALBUMIN-2.6* CALCIUM-6.6* PHOSPHATE-2.2*
[**2119-10-11**] 08:38PM ALBUMIN-2.6* CALCIUM-6.6* PHOSPHATE-2.2*
[**2119-10-11**] 08:38PM VANCO-13.8*
[**2119-10-11**] 08:38PM WBC-5.5# RBC-4.09* HGB-11.5* HCT-34.2* MCV-84
MCH-28.2 MCHC-33.7 RDW-16.0*
[**2119-10-11**] 08:38PM NEUTS-82* BANDS-14* LYMPHS-1* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2119-10-11**] 08:38PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
Brief Hospital Course:
49 year-old female with history significant for Hepatitis C, IV
drug use, and Waldenstrom's macroglobulinemia now transferred
from outside hospital with high grade bacteremia, septic shock,
and respiratory failure.
*
1) Respiratory failure:
Her respiratory secondary to a right upper lobe pneumonia. On
transfer, her PaO2 to FiO2 ratio was less than 200, which is
consistent with ARDS. Therefore, she was switched to pressure
control ventillation to keep her peak pressures less than 30.
At those pressures, she was pulling tidal volumes of about 400
cc. She was intially covered with broad spectrum antibiotics
vancomycin, levofloxacin, and cefepime. When her blood cultures
grew out strep. pneumonia, noted from the OSH, she was switched
to penicillin. She became febrile on [**10-19**] and [**10-20**]
self-extubated on [**10-20**], and later had to be reintubated on
[**10-21**] due to tachypnea and alkalemia. She was extubated
successfully on [**10-25**] and weaned without difficulty to nasal
cannula.
switched to vanco on [**10-21**] for positive blood culture (GPC) on
[**10-19**]. The plan is 14 days should finish on [**11-3**]. The pt
remained satting well on room air until discharge.
.
2) Strep Pneumo sepsis:
Initially, the etiology of her gram positive cocci bacteremia
was unclear. [**Name2 (NI) 227**] her history of IV drug use and her fresh
track marks on exam, there was initial supicion for
Endocarditis. However, at the outside hospital, she had a
negative transthoracic echocardiogram for endocarditis. She had
an abdominal ultrasound that was negative for ascites,
therefore, SBP was unlikely the source. Once her blood cultures
grew out strep. pneumonia, it seemed most likely that her
pneumonia was the source of her bacteremia. On transfer, she was
on dopamine through a femoral line to maintain her blood
pressure. On arrival, she had a subclavian line placed.
Initially, she required 3L of IV boluses to maintain her CVP
above 15 (accounting for PEEP). She was continued on the
dopamine and vasopressin was added. On hospital day 2, she was
weaned off of the dopamine and maintained on the vasopressin;
however, due to low urine output, she was switched back to the
dopamine and off of the vasopressin. Her cortisol stimulation
test at the outside hospital showed an appropriate response.
however, when she was taken off of the stress dose steroids, she
desaturated. Therefore, she was continued on the steroids. 7
days of high-dose steroids, then transitioned to prednisone. LP
on [**10-19**]. The sepsis was likely from pnumococcal pneumonia.
See Respitroy failure section for discussion of pneumonia
treatment.
The plan was to continue vanc at discharge for a 14 day course
to be be completed [**2119-11-3**].
.
3) Rhabdomyolysis:
She was found down by report. He CKs were elevated on initial
presentation to the outside hospital, which is consistent with
rhabdomyolysis. Her CK trended down with IV hydration within
her first few days here.
.
4) Acute renal failure:
Her elevated creatinine was likely secondary to hypoperfusion in
the setting of hypotension. Her creatinine improved with IV
fluids. On discharge the patient's Cr was 0.5.
.
5) Hepatitis C:
Her interferon was held during this admission. Her liver
enzymes were elevated. She had a negative abdominal ultrasound
for ascites. Dr. [**Last Name (STitle) **] aware pt was admitted. Cryocrit was
negative.
.
6) Pancytopenia:
The etiology is not clear and may be related to HCV and
interferon treatment, possibly to Waldenstrom's
macroglobulinemia. She was transfused when hct dropped less than
than 22.
.
7) Rash: groin rash c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. treated with miconazole
topical
.
8) s/p fall on [**10-25**] overnight. d/ced her own A-line during the
fall. no head trauma. patient c/o lumbar back pain, mild
headache.
- oxycodone prn
- fall precautions, one to one sitter
.
9) EKG changes: noted [**10-23**]. cards consulted for flipped T
waves in precordial leads. TTE with nothing remarkable. EKG
changes reversed once extubated.
.
8) FEN: She was started on tube feeds. Her electrolytes were
repleted. She was given IV fluid boluses as above.
transitioned to PO diet once extubated.
.
9) UTI - found to have positive urinalysis on [**10-27**]. Given 3 day
course of cipro.
.
10. HIV test sent on [**2119-10-28**], she was informed that the test was
negative.
.
11) CXR -
Patient with interstitial findings on CXR. Likely [**1-25**]
resolving pna but could be drug toxicity. Will need follow up
CXR once pna completely resolved.
.
12. Prophylaxis: She was maintained on pneumoboots, heparin SC,
PPI and a bowel regimen. miconazole to groin rash. fall
precautions, one-to-one sitter.
*
Access: A right subclavian and a right A-line were place. The
femoral line was removed. Right A-line d/ced and Left A-line
placed on [**10-19**]. L A line d/ced by patient on [**10-25**]. R
subclavian d/ced [**10-24**]. PICC placed at bedside on [**10-24**].
*
Code: Full
.
Dispo: pt going to [**Location (un) 16662**] [**Location (un) 16663**]
Medications on Admission:
Meds at home:
AMOXICILLIN 500MG--One tablet three times a day x 10 days
EFFEXOR XR 37.5MG--3 by mouth every day
FLONASE 50MCG--One spray each nostril every day
GABAPENTIN 300MG--Take one tablet at bedtime
IBUPROFEN 600 MG--One tablet by mouth q 6 hours as needed
NAPROSYN 500MG--Take two pills by mouth every morning and one
pill by mouth every evening as needed for for pain with food
PEGYLATED INTERFERON --As directed by gi
SEROQUEL 25MG--3 by mouth at bedtime
.
Meds on transfer:
Tequin, Pepcid, Vancomycin, unasyn, Hydrocort, Fluorinef, MSO4
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous Q
12H (Every 12 Hours) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 16662**] - [**Street Address(1) **]
Discharge Diagnosis:
Streptococcal pneumoniae and bacteremia
Discharge Condition:
Stable.
Discharge Instructions:
Please call your doctor or return to the ER if you experience
any shortness of breath, persistent cough or fevers /chills.
Followup Instructions:
You have an appointment to see the nurse practitioner at Dr. [**Name (NI) 16664**] office, [**Doctor Last Name **] Brain [**2119-11-7**] 10:40am. Phone:[**Telephone/Fax (1) 250**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2119-12-12**] 1:0
Patient will need follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**]
within 1-2 weeks.
|
[
"51881",
"5845",
"5990",
"99592"
] |
Admission Date: [**2155-4-7**] Discharge Date: [**2155-4-13**]
Date of Birth: [**2085-11-17**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
abd pain/dizziness
Major Surgical or Invasive Procedure:
1. Percutaneous access obtained into the left peripheral hepatic
ducts. Placement of external 8 French modified biliary drain to
external bag drainage.
2. ERCP with brushings
History of Present Illness:
69y F w/ known choledochal cyst who presents w/abd
discomfort and pre-syncopal episode the prior evening. She had
initially presented to [**Hospital3 **] hospital approximately 2 weeks
prior after experiencing actute onset of abdominal pain. Imaging
revealed a choledochal cyst w/both intra- and extrahepatic
components. She was discharged after an uneventful hospital
course and refered to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] for evaluation and had
seen him the week prior. She was subsequently advised to
follow-up with Dr. [**Last Name (STitle) **] this coming week. She is currently
without significant complaints. She denies fever,
nausea/vomiting, change in bowel habits, cough/cold/congestion,
chest pain, shortness of breath, headache. She does relay a
history of poor PO intake and decreasd appetite since her
presentation 2 weeks prior.
Past Medical History:
PMH: HTN
PSH: Breast cyst resection x2
Meds: prilosec, [**Last Name (un) 6722**] anti-htn
SH: widowed, lives with current fiance
FH: no family history of biliar disease
Social History:
SH: widowed, lives with current fiance
Family History:
FH: no family history of biliary disease
Physical Exam:
Temp:98.3 HR:119 BP:132/69 Resp:18 O(2)Sat:97 normal
gen: NAD
heent; trachea midline, neck supple, no cervical/supraclavicular
adenopathy
cv: sinus tachycardia
resp: CTAB
abd: soft, non-distended, mild discomfort RUQ/epigastric, no
rebound
ext: no c/c/e
Pertinent Results:
On Admission: [**2155-4-7**]
WBC-16.4* RBC-3.65* Hgb-11.6* Hct-34.0* MCV-93 MCH-31.8
MCHC-34.1 RDW-12.1 Plt Ct-553*
PT-12.3 PTT-24.6 INR(PT)-1.0
Glucose-136* UreaN-12 Creat-0.7 Na-137 K-4.2 Cl-103 HCO3-25
AnGap-13
ALT-343* AST-559* AlkPhos-194* TotBili-1.5 Lipase-195*
Albumin-3.8 Calcium-9.0 Phos-3.9 Mg-2.1
CEA-2.6 AFP-7.0 CA [**64**]-9- 224
At Discharge: [**2155-4-12**]
WBC-5.8 RBC-3.37* Hgb-10.8* Hct-31.5* MCV-94 MCH-32.0 MCHC-34.2
RDW-12.2 Plt Ct-460*
Glucose-97 UreaN-7 Creat-0.8 Na-140 K-4.0 Cl-103 HCO3-26
AnGap-15
ALT-87* AST-53* AlkPhos-211* Amylase-77 TotBili-1.0
Lipase-142* Albumin-3.5
Brief Hospital Course:
69 y/o female admitted with abdominal pain and dizziness. She
has a known choledochal cyst who presents w/abd discomfort and
pre-syncopal episode the prior evening.
On admission she underwent an ERCP which showed an anomalous
pancreaticobiliary junction. There was a 2cm tight distal CBD
stricture noted. A guidewire was advanced successfully beyond
the stricture, and the proximal common bile duct was grossly
dilated to 20mm, consistent with a choledochal cyst. Brushings
were obtained and were reported as negative for malignant cells.
She was started on Unasyn periprocedurally for the ERCP then
given 3 days of Vanco and Zosyn.
On [**4-8**] she underwent Percutaneous access obtained into the left
peripheral hepatic ducts with cholangiogram which demonstrated
markedly dilated common bile duct
consistent with known choledochal cyst. Also noted is moderately
irregular,
slightly beaded appearance to nondilated intrahepatic bile duct,
particulary
on the left. These findings could represent the sequelae of
cholangitis. Another consideration would be an associated
choledochal variant.
Bile cultures were sent which grew out 3 different strains of
pan-sensitive E coli.
Her peak temperature was 100.5 on the day of the cholangiogram
and then she was afebrile throughout the rest of her stay. Blood
and urine cultures were all no growth.
Her abdominal pain decreased greatly on exam and she was feeling
much improved. She was ambulating and tolerating her diet after
a brief spike in her amylase and lipase.
She will be discahrged to home on PO cipro and one drain in
place, capped.
She is requested to make an outpatient cardiology appointment
for surgery clearance.
She has followup scheduled with Dr [**Last Name (STitle) **] as well in
anticipation of surgery.
Medications on Admission:
Amlodipine 5 mg daily
NKDA
Discharge Medications:
1. Outpatient Lab Work
[**2155-4-17**]
cbc, chem 10, ast, alt, alk phos, t.bili, albumin
fax to [**Telephone/Fax (1) 22248**] attention [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**],
2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
vna of [**Hospital3 635**]
Discharge Diagnosis:
choledochal cyst, CBD stricture, cholangitis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Call for follow-up with Dr. [**Last Name (STitle) **]. You may resume your prior
diet and activity as tolerated. If you notice any of the
following call Dr.[**Name (NI) 8584**] office for an appointment;
redness/drainage/swelling around catheter site, change in the
color/character/volume of drainage, jaundice, fever >101 or
progressive itching. If you experience any of the following go
directly to the emergency deparment; chest pain, shortness of
breath, severe pain not relieved by medication, intractable
nausea/vomiting, or any other concerning symptoms. You may
shower with the drain, be sure to keep it covered, do not soak
or take tub baths.
Followup Instructions:
[**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2155-4-24**] 1:40
Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] test in
preparation for surgery
Completed by:[**2155-4-18**]
|
[
"4019",
"2859",
"42789"
] |
Admission Date: [**2188-1-10**] Discharge Date: [**2188-1-17**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary Artery Bypass Graft x3 (Left internal mammary artery ->
Left anterior descending, saphenous vein graft -> obtuse
marginal, Saphenous vein graft -> right coronary artery), Atrial
Septal defect closure [**2188-1-11**]
History of Present Illness:
83 year old female with exertional chest pain for the last two
years. The chest pain has been progressively increasing and is
now limiting normal physical activities and referred for further
work up
Past Medical History:
Coronary Artery Disease
Atrial Septal defect
Elevated cholesterol
GERD
Arthritis
Anemia
Anxiety
Appendectomy
Tonsillectomy
varicose vein ligation
Social History:
Lives with spouse
Retired, worked for MDC
Tobacco 4 pack year history - quit 35 years ago
ETOH 3 drinks per week
Family History:
Father deceased at 54 from MI
brother deceased in 50's from MI
Physical Exam:
Admission
Vitals HR 77 RR 18 B/P 151/72, wt 57.2kg
General no acute distress
Skin unremarkable
HEENT unremarkable
Chest CTA bilaterally anteriorly
Heart RRR
Abdomen Soft NT, ND, +BS
Ext: warm well perfused no edema
Varicosities: bilat lower ext
Neuro: grossly intact
Pertinent Results:
[**2188-1-17**] 07:10AM BLOOD WBC-6.8 RBC-3.21* Hgb-10.0* Hct-28.6*
MCV-89 MCH-31.1 MCHC-35.0 RDW-15.7* Plt Ct-328#
[**2188-1-17**] 07:10AM BLOOD Plt Ct-328#
[**2188-1-13**] 03:30AM BLOOD PT-12.8 PTT-30.3 INR(PT)-1.1
[**2188-1-14**] 06:50AM BLOOD Glucose-108* UreaN-13 Creat-0.6 Na-136
K-4.2 Cl-101 HCO3-28 AnGap-11
[**2188-1-16**] 06:10AM BLOOD UreaN-16 Creat-0.6 K-3.6
Brief Hospital Course:
Admitted for cardiac catherization which revealed coronary
artery disease and was referred to cardiac surgery for
evaluation. She underwent preoperative workup and was
transferred to the operating [****] for coronary artery
bypass graft and atrial septal defect closure, please see
operative report for for further details. She was then
transferred to the cardiac surgery recovery unit for hemodynamic
monitoring on vasopressor and propofol. She did well and in the
first 24 hours was weaned from sedation, awoke neurologically
intact, and was extubated with out incidence. She was weaned
from pressors and started on betablockers and diuresis. She was
ready for transfer to the floor on POD 2. Continued to
improving, diuresis was increased, and she continued to increase
her physical activity. She was ready for discharge to home on
[**1-17**].
Medications on Admission:
Imdur 60mg daily
Atenolol 25mg daily
[**Doctor First Name **] 18mg daily
Protonix 40 mg daily
Iron 65 mg daily
MVI
ASA 325mg daily
Nitroquick prn
Vitamin C 500mg 2 tabs daily
Tylenol 500mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*120 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 weeks: 40mg [**Hospital1 **] x2 wk then 40mg QD x1 wks.
Disp:*35 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
3 weeks: 20mEq [**Hospital1 **] x2wk then 20 mEq QD x1 wks.
Disp:*84 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease s/p CABG
Atrial Septal defect s/p closure
PMH:
Elevated cholesterol
GERD
Arthritis
Anemia
Anxiety
Appendectomy
Tonsillectomy
varicose vein ligation
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 44890**] in 1 week ([**Telephone/Fax (1) 68961**]) please call for appointment
Dr [**Last Name (STitle) **] in [**1-26**] week - please call for appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2188-1-17**]
|
[
"41401",
"2859",
"53081"
] |
Admission Date: [**2174-9-2**] Discharge Date: [**2174-9-11**]
Date of Birth: [**2106-12-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Dilaudid / Zofran / Penicillins / Sincalide
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2174-9-5**] s/p Coronary artery bypass graft x 4 (Left internal
mammary artery > left anterior descending, saphenous vein graft
> RAMUS, saphenous vein graft > Obtuse marginal, saphenous vein
graft > posterior descending artery)
History of Present Illness:
67 year old [**Month/Day/Year 8003**] speaking female with known coronary artery
disease, s/p left carotid endarterectomy '[**70**], hypertension,
diabetes mellitus, and
hypercholesterolemia presented to her PCP complaining of dyspnea
on exertion, increased fatigue and throat tightness associated
with activity. Cath in [**State 108**] in [**July 2174**] reported 90%left main,
prox.LAD 90%,prox Circumflex 90%.LV function normal(-results per
PCPs dictation). She was admitted to outside hospital for
symptom relief and transferred to [**Hospital1 18**] for cardiac surgical
revascularization
Past Medical History:
Coronary artery disease
Diabetes Mellitus
Hypertension
Hypercholesterolemia
Carotid stenosis s/p Left CEA [**2170**]
Social History:
Lives with her brother and sister-in law
[**Name (NI) 8003**] speaking only, Finished 8th grade in [**First Name4 (NamePattern1) 1056**]
[**Last Name (NamePattern1) 1139**]: denies
Family History:
Mother died at age 75(?), Father died age 83 from prostate
cancer. 4
brothers, 2 sisters-1 brother (+)CABG-living,1 sister(+)CAD.High
family incidence of diabetes mellitus.1 Brother died with kidney
disease and peripheral vascular disease.
Physical Exam:
[**9-3**]
98.4, 80 sinus rhythm 112/58 14 98% room air
General no acute distress
Neuro alert and oriented x3, non focal
Cardiac RRR no murmur/rub/gallop
Respiratory CTA bilaterally
Abdomen soft, NT, ND +BS
Extremities no CCE
Pertinent Results:
[**2174-9-2**] 07:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2174-9-2**] 07:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2174-9-2**] 08:20PM PT-11.3 PTT-28.5 INR(PT)-0.9
[**2174-9-2**] 08:20PM PLT COUNT-352
[**2174-9-2**] 08:20PM WBC-6.1 RBC-3.85* HGB-11.4* HCT-35.1* MCV-91
MCH-29.6 MCHC-32.5 RDW-13.6
[**2174-9-2**] 08:20PM %HbA1c-6.5*
[**2174-9-2**] 08:20PM ALBUMIN-4.5 CALCIUM-10.3* MAGNESIUM-2.3
[**2174-9-2**] 08:20PM LIPASE-13
[**2174-9-2**] 08:20PM ALT(SGPT)-20 AST(SGOT)-22 LD(LDH)-253* ALK
PHOS-63 AMYLASE-55 TOT BILI-0.2
[**2174-9-2**] 08:20PM GLUCOSE-175* UREA N-18 CREAT-0.7 SODIUM-138
POTASSIUM-5.2* CHLORIDE-100 TOTAL CO2-30 ANION GAP-13
[**2174-9-9**] 04:38AM BLOOD WBC-8.4 RBC-3.45*# Hgb-10.0*# Hct-30.7*
MCV-89 MCH-29.0 MCHC-32.6 RDW-15.0 Plt Ct-295
[**2174-9-9**] 04:38AM BLOOD Plt Ct-295
[**2174-9-9**] 04:38AM BLOOD Glucose-85 UreaN-15 Creat-0.6 Na-142
K-4.1 Cl-103 HCO3-32 AnGap-11
===============================
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82986**] (Complete)
Done [**2174-9-5**] at 1:55:51 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2106-12-9**]
Age (years): 67 F Hgt (in): 66
BP (mm Hg): / Wgt (lb): 205
HR (bpm): BSA (m2): 2.02 m2
Indication: Intra-op TEE for CABG
ICD-9 Codes: 786.05, 440.0
Test Information
Date/Time: [**2174-9-5**] at 13:55 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 32862**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW000-0: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Aorta - Ascending: 3.3 cm <= 3.4 cm
Findings
LEFT ATRIUM: Normal LA size. No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dynamic interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Mild regional LV
systolic dysfunction. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal ascending aorta diameter. Normal aortic arch
diameter. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). Mildly thickened
aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Trivial MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Results were
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-Bypass:
The left atrium is normal in size. No mass/thrombus is seen in
the left atrium or left atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. Overall left ventricular systolic
function is mildly depressed (LVEF= 40-45 %). with normal free
wall contractility. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No aortic
regurgitation is seen. Trivial mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
Post-Bypass:
All finding are consistent with pre-bypass findings. Left
ventricular systolic function is mildly depressed with an
EF=45%. Aorta is intact post-decannulation. All findings
communicated with surgical team.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2174-9-6**] 11:03
====================================
[**Known lastname **],[**Known firstname **] I [**Medical Record Number 82987**] F 67 [**2106-12-9**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2174-9-8**] 8:53
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 12611**] FA6A [**2174-9-8**] 8:53 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 82988**]
Reason: eval for pleural effusions in pt with dropping Hct s/p
CABG
Final Report
INDICATION: 47-year-old female status post CABG.
TECHNIQUE: AP upright portable chest x-ray.
COMPARISON: Portable chest x-ray from [**2174-9-7**].
FINDINGS: There is increased left lower lobe retrocardiac
opacity, consistent with worsening atelectasis. Slightly
increased left pleural effusion. Mild cardiomegaly without
evidence of pulmonary venous hypertension. Unchanged slight
widening of the mediastinum as expected status post CABG. The
sternal wires are intact and aligned. The hila are normal.
IMPRESSION: Worsening left lower lobe atelectasis and slightly
increased left pleural effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 13617**]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: [**Doctor First Name **] [**2174-9-8**] 4:34 PM
============================================
Brief Hospital Course:
Transferred from outside hospital for surgical evaluation. She
underwent preoperative workup including dental consult which no
acute signs of infection but will require follow up after
surgery for comprehensive dental care. On [**2174-9-5**] she was
brought to the operating room and underwent coronary artery
bypass graft surgery. See operative report for further details.
In summary she had CABG x4 with LIMA-LAD, SVG-Ramus, SVG-OM,
SVG-PDA. Her bypass time was 86 minutes with a crossclamp of 61
minutes. She tolerated the operation well and was transferred
from the operating room to the cardiac surgery ICU in stable
condition. She received vancomycin for perioperative
antibiotics. In the first twenty four hours she was weaned from
sedation, awoke neurologically intact and extubated without
complications. On post operative day one she was started on
beta blockers and diuretics. She remained in intensive care
unit for an extra day for blood glucose management. Physical
therapy worked with her on strength and mobility. She was
transfered to the floor on post operative day two and continued
to progress slowly.
On POD 4 it was decided she would benefit from a short
rehabilitation stay. She was screened and transferred to rehab
at [**Hospital1 2670**] Wood Mill in [**Hospital1 487**].
Medications on Admission:
Amitriptyline 125 mg qHS
ASA 81 mg daily
Zantac 150 mg twice a day
Insulin-Novolin 70/30- 45units Q AM,35 units Q PM
Imdur 15mg twice a day
Lisinopril 20 mg daily
Metformin 500 mg twice a day
Lopressor 12.5 daily
MVI
Prilosec 20 mg daily
Simvastatin 40 mg daily
Verapamil 180 mg daily
NTG 0.4mg SL prn
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever/pain.
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. Amitriptyline 50 mg Tablet Sig: One [**Age over 90 **]y Five (125)
Mgs PO HS (at bedtime).
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-21**] Sprays Nasal Q
8H (Every 8 Hours).
7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
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. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itchiness.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane Q4H (every 4 hours) as needed for cough/sore
throat.
12. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day: hold for SBP<100
HR<60.
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
14. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Pepcid 20 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
17. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: as directed below units Subcutaneous twice a day: 45 units
QAM
35 units QPM.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Diabetes Mellitus
Hypertension
Hypercholesterolemia
Carotid stenosis s/p Left CEA [**2170**]
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 29070**] in [**1-21**] weeks - please call for appointment
Dr [**Last Name (STitle) **], [**Known firstname **] in [**2-22**] weeks-please call for appointment
Completed by:[**2174-9-9**]
|
[
"41401",
"4019",
"25000",
"2720"
] |
Admission Date: [**2156-7-3**] Discharge Date: [**2156-7-8**]
Date of Birth: [**2084-3-11**] Sex: F
Service: MEDICINE
Allergies:
Aspirin / Aleve / Codeine / Depakote
Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 13224**] is a 72F with a PMH s/f ESRD, chronic right sided HF,
congestive hepatopathy, persistent hypoglycemia, and
afib/flutter on digoxin who was found unresponsive at her NH for
up to one hour. EMS was called, and the patient was found to be
bradycardic to 30s, with a blood pressure of 80/palp. Per the
patient's family, she had no new fevers, mental status changes,
and had her usual chronic cough.
In the emergency department the patients vitals were:97.6,
80/palp, 46, 40, 92% on 4LNC. She was intubated, and a right
femoral line was placed. Her EKG showed a junctional
bradycardia at 48, which was thought to be consistent with
digoxin toxicity. A level was drawn, and the patient was
administered 4 vials of digibind. She was noted to have a
hematocrit of 21 (her baseline is 27-30), and a lactate of 8.
She was started on levophed and given 750mg levofloxacin, 2g of
cefepime, 1g of vancomycin, and 500mg of flagyl IV for presumed
sepsis of unknown etilogy. Her blood sugars were in the 20s,
for which the patient recieved two amps of D50.
Past Medical History:
1. Chronic Gastric Angiodysplasia (GAVE)
2. DM type II: c/b nephropathy and neuropathy - currently not on
diabetic meds secondary to persistent hypoglycemia
3. ESRD: HD MWF has fistula L arm
4. CAD
5. CHF: R-sided, diastolic EF 50-55% with 4+ TR 2+ MR [**8-/2155**]
TTE
6. Anemia: multifactorial (ESRD + iron deficiency [**12-27**] GIB)
7. Gout
8. Chronic pleural effusions s/p thoracentesis [**8-/2153**] negative
cytology,
9. H/O C. diff colitis
10. Atrial fib/flutter: currently undergoing amiodarone load,
also on digoxin
11. Congestive Hepatopathy
12. Persistent hypoglycemia
13. Seizure disorder
Social History:
Pt lives at [**Location **]. No ETOH, tobacco, or drugs. Four children
involved in her care.
Family History:
[**Name (NI) 1094**] son and daughter have DM. Her son also has HTN. Her mother
had an MI in her 80s.
Physical Exam:
T=95.5 rectally... BP=112/60s... HR=90s... RR=23
GENERAL: Intubated, sedated
HEENT: NCAT, Pupils minimally reactive bilaterally, +scleral
icterus. Dry mucous membranes. No JVD appreciated.
CARDIAC: Irregularly irregular rhythm, normal rate, no murmurs
LUNGS: Coarse ventilated breath sounds, diminished at the left
base
ABDOMEN: Distended with an umbilical hernia. +BS, No HSM.
EXTREMITIES: Cachectic extremities, non-palpable pulsed on BL
LE's, 2+ pulses in radial arteries.
Brief Hospital Course:
Ms [**Known lastname 13224**] is a 72F with a PMH s/f ESRD, congestive hepatopathy,
and afib/aflutter on digoxin who was found unresponsive at her
NH. Admitted to the ICU on pressors and broad spectrum abx for
presumed sepsis and dig toxicity (given digibind in ED), pt. was
difficult to wean off pressors, given significant
co-morbidities, a decision was made to focus on comfort.
- continued morphine prn for pain/discomfort
- sarna lotion for pruritis.
Pt on [**Hospital1 **] Medicine service for one day, expired on [**2156-7-8**].
Medications on Admission:
Digoxin 125 mcg QOD
Amiodarone 400mg daily until [**7-10**], then 200mg daily
Levetiracetam 250 mg [**Hospital1 **]
Dextrose 600mg TID
Actonel 35mg weekly
Advair [**Hospital1 **]
Albuterol prn
ASA 81mg daily
Combivent 18/103, two puffs q8H
Fluoxetine 20mg daily
Lasix 20mg daily
Metoprolol tartrate 12.5mg [**Hospital1 **]
Olanzapine 2.5mg daily
Tylenol, sarna, miconazole powder prn
Discharge Medications:
-
Discharge Disposition:
Expired
Discharge Diagnosis:
Cardiopulmonary arrest secondary to end stage heart, kidney and
liver failure
Discharge Condition:
deceased
Discharge Instructions:
-
Followup Instructions:
-
Completed by:[**2156-7-8**]
|
[
"0389",
"51881",
"42789",
"4280",
"42731"
] |
Admission Date: [**2134-2-6**] Discharge Date: [**2134-2-22**]
Date of Birth: [**2134-2-6**] Sex: M
Service: NEONATOLOGY
HISTORY OF THE PRESENT ILLNESS:
[**First Name9 (NamePattern2) 48114**] [**Known lastname 46825**] is the former 2.11 kg product of a 35 and
[**2-6**] week gestation pregnancy, born to a 41-year-old, G5, P0
woman. Prenatal screens: Blood type B-, antibody positive
for anti-D, rubella immune, RPR nonreactive, hepatitis B
surface antigen negative, group beta strep status unknown.
RhoGAM was administered at 28 weeks gestation.
[**Hospital 37544**] medical history significant for chronic
hypertension. This pregnancy was complicated by preterm
labor and a marginal placenta previa. She was delivered by
cesarean section due to the preterm labor. The infant
emerged with good cry. He received blow-by oxygen only.
APGARs were 8 at one minute and 8 at five minutes. He was
admitted to the Neonatal Intensive Care Unit for treatment of
prematurity and respiratory distress.
PHYSICAL EXAM: Upon admission to the Neonatal Intensive
Care Unit weight was 2.11 kg, length 45.5 cm, head
circumference 31 cm. General: Nondysmorphic preterm infant.
Skin: No rashes. Head, ears, eyes, nose and throat:
Anterior fontanelles flat. Positive red reflex bilaterally.
Palate intact. No neck masses. There is a left pinpoint
ear pit noted adjacent to the left ear. (The mother has the
same thing.) Chest: Breath sounds clear but significant
grunting, flaring and retraction. Cardiovascular: Regular
rate and rhythm, normal S1 and S2, +2 femoral pulses, no
murmur. Abdomen: Soft, no hepatosplenomegaly, no masses.
Genitalia: Normal male, testes descended bilaterally. Patent
anus. Spine straight with intact sacrum. Extremities: Hips
without clicks. Neurologic: Moving all extremities. Normal
tone and reflexes.
HOSPITAL COURSE BY SYSTEMS: Including pertinent laboratory
data.
1. Respiratory: [**Hospital 48114**] was placed on continuous positive air
pressure shortly after admission for his respiratory
distress. He continued on the continuous positive air
pressure until day of life number two when he weaned to room
air. His presentation and clinical course were consistent
with retained fetal lung fluid. He has not had any episodes
of spontaneous apnea and bradycardia. At the time of
discharge he is breathing comfortably in room air with
respiratory rates in the 30s to 50s.
2. Cardiovascular: [**Hospital 48114**] has maintained normal heart rates
and blood pressures. A soft murmur has been noted
intermittently and remains present at the time of discharge.
The murmur is heard over the axilla and back and is consistent
with peripheral pulmonic stenosis. Femoral pulses are equal
and normal. His color is pink and well perfused.
3. Fluids, electrolytes, nutrition: [**Hospital 48114**] was initially
n.p.o. and maintained on intravenous fluids. Enteral feeds
were started on day of life number two and gradually advanced
to full volume. At the time of discharge he was taking
breast milk or Enfamil fortified to 26 calories per ounce
with additional 2 calories as corn oil, and the breast milk
with 4 calories of Enfamil powder. Weight at the time of
discharge is 2.13 kg with a head circumference of 32 cm and a
length of 45.5 cm. Serum electrolytes were checked twice in
the first week of life and were within normal limits. Hi
slast set of electrolytes on [**2-19**] were Na 135, K 5.6, Cl 100,
CO2 23.
4. Infectious disease: Due to the unknown group beta strep
status of the mother and the respiratory distress, [**Name (NI) 48114**] was
evaluated for sepsis. A CBC showed a white blood cell count
of 9,900, with a white blood cell differential of 60 percent
neutrophils, 3 percent bands. A blood culture was obtained
prior to starting antibiotics. The blood culture was no
growth at 48 hours and the antibiotics were discontinued.
5. Gastrointestinal: [**Name (NI) 48114**] required treatment for
unconjugated hyperbilirubinemia with phototherapy. His peak
serum bilirubin occurred on day of life number five with a
total of 14.0/0.3 mg per dl direct. He receive phototherapy
for approximately 72 hours. Rebound bilirubin was 8.2
total/0.3 direct.
6. Hematological: Hematocrit at birth was 50.8 percent.
[**Name (NI) 48114**] did not receive any transfusions of blood products.
7. Endocrine: A state newborn screen was sent on day of
life number three and reported results showed a
17-OH-progesterone level of 91.2 ng/ml with a reference range
for normal below 60 ng/ml. A repeat screen was sent on
[**2134-2-19**]. Serum electrolytes were also checked and were
within normal limits. There has been no notification of
abnormal results on the second screen to date. Premature
infants often have abnormal 17-OH-progesterone screening
results. HIs clinical course and recent electrolytes do not
suggest congenital adrenal hyperplasia or CAH. The screening
sent on [**2134-2-20**] will need to be followed.
8. Sensory, audiology: hearing screening was performed with
automated auditory brain stem responses. [**Date Range 48114**] passed in
both ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: [**Name6 (MD) 52890**] [**Name8 (MD) **], M.D., [**Street Address(2) 52891**], [**Location (un) **], [**Numeric Identifier 52892**], telephone number: [**Telephone/Fax (1) 31979**],
fax: [**Telephone/Fax (1) 52893**].
RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: Ad lib breast feeding or bottle-feeding.
Fortified mother's milk to 26 calories per ounce with one
teaspoon of Enfamil powder per 100 cc plus 2 calories per
ounce of corn oil.
2. No medications.
3. Car seat position screening was performed. [**Telephone/Fax (1) 48114**] was
observed in his car seat for two and a half hours without any
episodes of oxygen desaturation or bradycardia.
4. State newborn screen: As previously noted. Done on
[**2134-2-9**] with abnormal 17-OH-P results, repeat specimens
done on [**2134-2-19**].
5. Immunizations: No immunizations administered. Mother's
request is to the have the hepatitis B administered in the
primary pediatrician's office.
6. Immunizations recommended:
A. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria. First, born at less than 32 weeks; second, born
between 32 and 35 weeks with two or three of the following:
day care during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school age
siblings; thirdly, with chronic lung disease.
B. Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age, the family
and other caregivers should be considered for immunization
against influenza to protect the infant.
7. Follow-up appointment recommend with Dr. [**Last Name (STitle) **] within
two - three days of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 35 and 2/7 weeks gestation.
2. Respiratory distress due to retained fetal lung fluid.
3. Suspicion for sepsis ruled out.
4. Pinpoint right ear pit noted.
5. Unconjugated hyperbilirubinemia.
6. Elevated 17-OH-P level on state screen.
7. Cardiac murmur consistent with peripheral plmonic stenosis
(PPS).
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 43348**]
MEDQUIST36
D: [**2134-2-22**] 04:40
T: [**2134-2-22**] 05:04
JOB#: [**Job Number 52894**]
|
[
"7742",
"V290"
] |
Admission Date: [**2125-6-3**] Discharge Date: [**2125-6-19**]
Date of Birth: [**2056-4-9**] Sex: F
Service: SURGERY
Allergies:
Red Dye / Shellfish
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
1. Abdominal pain
Major Surgical or Invasive Procedure:
[**2125-5-29**]: Primary left total knee replacement for osteoarthritis
and arthrofibrosis.
History of Present Illness:
69F s/p L TKR [**5-29**] by Dr [**Last Name (STitle) **] had abd pain and distension after
the surgery. She threw up at least once. She comes in because
of worse abd pain. It becomes [**9-11**] after she eats. Currently
[**7-12**]. She has been throwing up everything she tries to eat. She
did pass gas this am but has not had a bm since surgery. She
does not have a h/o of constipation. She has never had abd
surgery. No fevers. Pain is diffuse.
Past Medical History:
1. Crohn's- stable for 6-7 years on sulfasalazine
2. Atrial fibrillation/flutter since [**2098**], on anticoagulation
since
[**2116-3-5**] s/p TEE-DCCV [**3-2**]
3. HTN
4. H/O Idiopathic dilated cardiomyopathy (resolved)
5. s/p RLE DVT [**2116**]
Social History:
Lives alone in Mission park. No alcohol or smoking. Former
administrative assistant for Lucent bur retired x7yrs.
Family History:
father w/ MI before age 59, mother w/ MI at 75
Physical Exam:
99.7 77 99/42 18 97
Sitting in bed, NAD
RRR
CTAB
Abd - distended, soft, minimally ttp, no scars, no hernias
Rectal - vault empty, no blood
Ext - 2+ pulses, no edema
Pertinent Results:
[**2125-6-3**] 05:50PM PT-31.0* PTT-36.8* INR(PT)-3.1*
[**2125-6-3**] 05:50PM PLT SMR-NORMAL PLT COUNT-230#
[**2125-6-3**] 05:50PM PLT SMR-NORMAL PLT COUNT-230#
[**2125-6-3**] 05:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-OCCASIONAL
[**2125-6-3**] 05:50PM NEUTS-67 BANDS-20* LYMPHS-8* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-1*
[**2125-6-3**] 05:50PM WBC-12.2* RBC-3.08* HGB-10.3* HCT-31.4*
MCV-102* MCH-33.3* MCHC-32.7 RDW-15.2
[**2125-6-3**] 05:50PM ALBUMIN-3.3*
[**2125-6-3**] 05:50PM LIPASE-17
[**2125-6-3**] 05:50PM ALT(SGPT)-27 AST(SGOT)-43* ALK PHOS-114* TOT
BILI-0.7
[**2125-6-3**] 05:50PM GLUCOSE-129* UREA N-56* CREAT-4.1*#
SODIUM-136 POTASSIUM-3.9 CHLORIDE-95* TOTAL CO2-21* ANION GAP-24
[**2125-6-3**] 11:14PM LACTATE-2.6*
[**2125-6-16**] 02:04PM BLOOD Hct-28.6*
[**2125-6-19**] 06:06AM BLOOD PT-34.3* INR(PT)-3.5*
[**2125-6-18**] 06:53AM BLOOD PT-28.7* INR(PT)-2.8*
[**2125-6-17**] 08:11AM BLOOD PT-21.5* PTT-113.1* INR(PT)-2.0*
[**2125-6-10**] 05:03PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2125-6-4**] 12:34AM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.021
[**2125-6-10**] 05:03PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012
[**2125-6-10**] 05:03PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2125-6-3**]:
[**2125-6-3**] 11:00 pm BLOOD CULTURE
**FINAL REPORT [**2125-6-11**]**
Blood Culture, Routine (Final [**2125-6-11**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
DOXYCYCLINE AND Tigecycline REQUESTED BY DR. [**Last Name (STitle) **]
AND DR
[**Last Name (STitle) **].
Tigecycline Sensitivity testing performed by Etest ,
DOXYCYCLINE
sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
Tigecycline = 0.19 MCG/ML, SENSITIVE. DOXYCYCLINE =
RESISTANT.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final [**2125-6-4**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 99236**] @ 2136 ON [**6-4**] -
CC6C.
GRAM NEGATIVE ROD(S).
[**2125-6-7**]: ABD CT:
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Diffuse multifocal bilateral airspace disease. Given the
presence of
interlobular septal thickening, small bilateral pleural
effusions and
cardiomegaly, CHF is the top consideration. Differential does
include ARDS
and multifocal pneumonia.
3. Resolution of portal venous gas and pneumatosis with
enhancement of the
small bowel wall. Findings are consistent with improvement of
the small bowel
ischemia. The persistent diffuse small bowel dilation and
additional focal
areas of small bowel and colonic wall thickening are likely
related to the
recent ischemic event to the bowel. Note that the dilation is
diffuse and
small-bowel obstruction is not favored.
4. Hypoperfusion of the pancreatic tail and spleen likely due to
complete
occlusion of the celiac axis. Also note marked attenuation of
the SMA, though
it does fill with contrast.
5. Multiple bilateral acute renal infarctions noting severe
attenuation of
the bilateral renal arteries.
6. Large left-sided thyroid mass which can be evaluated in the
future with
ultrasound as the clinical condition warrants.
[**2125-6-7**]: CARDIAC ECHO:
IMPRESSION: Mild to moderate global left ventricular systolic
dysfunction. Mild mitral regurgitation. Moderate tricuspid
regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2125-6-4**], LV
function has declined. TR severity has slightly increased. The
other findings are similar.
Brief Hospital Course:
General Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. She was admitted in ICU on [**6-4**]:
Admitted to SICU for SBO.
[**6-5**]: D/c from SICU
[**6-6**]: Re-admitted to SICU [**3-6**] afib with RVR. Cardiology
consulted. Flagyl re-started. Pt tachypneic, failed BiPAP,
intubated. CT torso negative for PE, looks like ARDS picture.
Started on Amio bolus/gtt, rate controlled in PM however with
episode of asystole for 3-4 seconds, continues on pressors
(started after intubation)
[**6-7**]: Unstable Afib with RVR, hypotensive, recieved 200J shock X
2, then shock x 3 (100J-->50 J-->50J) CE cycled, cards
[**Name (NI) 653**], esmolol gtt improved rate, x 1 ffp. Drop in Plts,
sent off HIT antibodies and changed out catheter to
non-heparinized line, Knee tap by ortho showing WBC=2278, gram
stain pending. Repeat TTE
[**6-8**]: Platelet drop leveling off. No signs of active bleeding.
[**6-10**]: Nurses noted stool from vagina, flexiseal placed, had
transient episode of tachypnea which responded with suctioning
(happened after pt was turned). On Lasix gtt for CHF on CXR.
[**6-11**]: Heparin gtt started. Bronch negative, U/S of lungs showed
no pleural effusions, extubated without problem
[**6-12**]: d/c NGT
CV: Given that she is not likely to be taking PO medications in
the near future and was previously rhythm-controlled on sotalol,
would favor short term use of
amiodarone to control heart rate and rhythm.
- can give 150mg IV x 1 followed by 1mg/min IV infusion x 6
hours
followed by 0.5mg/hour x 18 hours
- please maintain INR between [**3-7**] if no evidence of bleeding;
with heparin bridge if coumadin must be held or reversed for
surgery
- plan to discontinue amiodarone and resume sotalol once
surgically stable and able to take POs. Patient was restarted on
Sotalol and Atenolol. Coumadin was started on [**6-14**], patient INR
on [**6-19**] was 3.5, we hold her Coumadin. Please rechaeck INR on
[**6-20**] prior restarting Coumadin.
Pulmonary: Patient was extubated on [**6-11**] without problem, daily
CXR showed resolution of her pneumania. Volume overload was
treated with Lasix IV. Continue to use 1 L O2 via nasal cannula.
GI: Patient was NPO with TPN for nutrition. Her diet was
advanced to clears when tolerated and advanced further to
regular.
GYN: In ICU fecal content visualized by [**Name8 (MD) **] RN around the foley
catheter. GYN consulted and they performed vaginal exam. Vaginal
apex fully visualized. No fecal material visualized. Small
amount of bleeding noted from trauma from speculum.
Scolpette placed without fecal material visualized. Vaginal
cul-de-sacs visualized and no fecal material visualized.
Assessment: No macroscopic evidence of recto-vaginal fistula on
speculum exam at this time.
ID: Patient's blood cultured revealed E.coli infection. She was
started on Ceftriaxone, which was changed to Meropenem on [**6-12**]
for two weeks total.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: Admission labs were further significant for a
macrocytic anemia
(received 1 unit PRBCs on [**6-4**]) and an elevated INR which
continued to rise despite her Coumadin being on hold. On [**6-7**] she
had a rather acute platelt drop from 220 to 88, it is now in the
20's. She has no signs of bleeding.
She received FFP on [**6-7**] b/c INR 9.0. It seems that on [**6-6**] she
had been receiving s.c. Heparin as well as Heparin flushes for
her line. After her TKR she had been on
therapeutic Lovenox for at least 4 days. She has now worsening
thrombocytopenia and an elevated INR despite holding her
Coumadin.
(1) coagulopathy: Her elevated INR is likely secondary to
previous use of Coumadin and current Vitamin K
deficiency(intubated, NPO). Further contributing is the use of
antibiotics. Given her significant thrombocytopenia we recommend
to give
Vitamin K 5 mg i.v. slowly and to provide Vitamin K through her
TPN.
(2) thrombocytopenia: no schistocytes seen on the peripheral
blood smear, she does not have splenomegaly, HIT was ruled out
by negative [**Doctor First Name **]. The most likely explanation is her sepsis. No
further intervention required at this point unless the patient
would start bleeding. Continue to monitor her platelet count and
avoid medications that could cause thrombocytopenia.
(3) macrocytic anemia: chronic but below baseline, possibly
secondary to recent TKR, no RBC abnormailties in peripheral
smear DDX: B12/Folate deficiency, hypothyroidism, MDS check
B12/Folate and TSH
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
Atenolol
100 mg Tablet
1 Tablet(s) by mouth once a day [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 30 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Hydrochlorothiazide
12.5 mg Tablet
0.5 Tablet(s) by mouth once a day [**2124-5-23**]
Renewed [**Location (un) **],
[**Doctor Last Name **] 90 Tablet 3 (Three) [**Last Name (LF) 5263**], [**First Name7 (NamePattern1) 402**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Levothyroxine [Levoxyl]
50 mcg Tablet
1 Tablet(s) by mouth once a day brand name only. NO
SUBSTITUTION.
No Substitution [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 30 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Lisinopril
40 mg Tablet
1 Tablet(s) by mouth once a day [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 30 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Sotalol
80 mg Tablet
1.5 Tablet(s) by mouth twice a day [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 90 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
Sulfasalazine
500 mg Tablet
3 Tablet(s) by mouth twice a day [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 180 Tablet 11 (Eleven) [**Last Name (LF) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], MPH
nr Timolol
Dosage uncertain
(Prescribed by Other Provider) [**2123-11-4**]
Recorded Only [**Location (un) **],
[**Doctor Last Name **] J
nr Travoprost (Benzalkonium) [Travatan]
Dosage uncertain
(Prescribed by Other Provider) [**2123-11-4**]
Recorded Only [**Location (un) **],
[**Doctor Last Name **] J
Warfarin
2 mg Tablet
4 Tablet(s) by mouth per day [**2125-2-26**]
Renewed [**Location (un) **],
[**Doctor Last Name **] J 285 Tablet
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
2. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Four (4) Puff Inhalation QID (4 times a day) as needed for
wheeze.
3. Hydrochlorothiazide 12.5 mg Capsule Sig: 0.5 Capsule PO DAILY
(Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sotalol 120 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day.
8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
9. Sulfasalazine 500 mg Tablet Sig: Three (3) Tablet PO twice a
day.
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Mn,
Tu, We, Th, Sa, Sn
Hold if INR > 3.0
Check INR on [**6-20**] prior restarting pt's Coumadin.
11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day: Give
on Friday
Hold if INR > 3.0
Check INR on [**6-20**] prior resatrting Coumadin.
12. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
14. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
15. Timolol Maleate 0.25 % Drops Sig: One (1) Ophthalmic once a
day.
16. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 6 days: Stop on [**6-26**].
17. Ondansetron 4-8 mg IV Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
1. Small bowel obstruction
2. E. coli bacteremia
3. Persistent atrial fibrillation with rapid ventricular
response
4. Thrombocytopenia and coagulopathy
5. Macrocytic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-11**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3260**], [**MD Number(3) 3261**]:[**Telephone/Fax (1) 1228**]
Date/Time:[**2125-6-29**] 10:00
.
Provider: [**Name10 (NameIs) 1423**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2125-7-4**] 9:30
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2125-8-16**] 9:00
.
Please call [**Telephone/Fax (1) 2998**] to arrange a follow up appointment with
Dr. [**First Name (STitle) 2819**] (General Surgery) in [**3-7**] weeks after discharge.
Completed by:[**2125-6-19**]
|
[
"5849",
"99592",
"78552",
"2875",
"42731",
"4019",
"V5861"
] |
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