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Admission Date: [**2170-6-22**] Discharge Date: [**2170-7-2**]
Date of Birth: [**2092-6-12**] Sex: M
Service: SURGERY
Allergies:
Cipro / Morphine
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Local recurrence of [**First Name3 (LF) 499**] cancer and new metastatic disease to
the liver.
Major Surgical or Invasive Procedure:
1. Placement of right ureteral stent by Dr. [**Last Name (STitle) **].
2. Laparotomy and lysis of adhesions.
3. Resection of previous colorectal anastomosis.
4. Primary coloproctostomy, stapled number 31.
5. Small bowel resection en bloc with local recurrence
specimen.
6. Diverting end ileostomy with local mucous fistula.
7. Segmental resection of three liver lesions by Dr. [**Last Name (STitle) **].
Past Medical History:
HTN
CAD
[**Last Name (STitle) 499**] cancer
BPH
Past surgical: L ureteral stent, colectomy x 2, coronary
atherectomy + angioplaty
Social History:
The patient works as an optometrist in [**Doctor Last Name 26532**]. He is married. He used to smoke 1 pack a day for 30
years, but quit in [**2149**]. He occasionally has a glass of beer,
does not use any other drugs.
Family History:
He had a paternal uncle with [**Name2 (NI) 499**] cancer.
Father with [**Name2 (NI) 499**] cancer at age 57 and CAD. He died at 72 from
coronary artery disease. Mother had pancreatic cancer. Sister
is healthy and two sons that are healthy.
Physical Exam:
Vitals: 98.4, 52, 158/60, 20, 96% on 2L, 82-84% on RA
GEN: NAD, A/Ox3
CV: RRR, no m/r/g
RESP: CTAB, no W/R/R
ABD: soft, ND, slightly TTP, +BS
Incison: midline abdominal OTA with staples
Ostomy: stoma pink & viable, liquid brown effluence
Extrem: no c/c/e
Pertinent Results:
[**2170-6-30**] 08:25AM BLOOD WBC-7.0 RBC-3.19* Hgb-8.9* Hct-28.3*
MCV-89 MCH-28.0 MCHC-31.6 RDW-15.8* Plt Ct-287
[**2170-6-29**] 02:49AM BLOOD WBC-4.9 RBC-2.96* Hgb-8.5* Hct-26.6*
MCV-90 MCH-28.7 MCHC-31.9 RDW-15.1 Plt Ct-237
[**2170-6-28**] 02:13AM BLOOD WBC-5.4 RBC-2.97* Hgb-8.7* Hct-26.7*
MCV-90 MCH-29.2 MCHC-32.5 RDW-15.0 Plt Ct-200
[**2170-6-22**] 03:12PM BLOOD WBC-11.2*# RBC-4.21* Hgb-12.4* Hct-37.6*
MCV-89 MCH-29.4 MCHC-32.9 RDW-15.6* Plt Ct-223
[**2170-6-30**] 08:25AM BLOOD Glucose-110* UreaN-32* Creat-1.6* Na-144
K-3.7 Cl-111* HCO3-24 AnGap-13
[**2170-6-29**] 02:49AM BLOOD Glucose-114* UreaN-29* Creat-1.8* Na-145
K-3.7 Cl-115* HCO3-19* AnGap-15
[**2170-6-30**] 08:25AM BLOOD ALT-94* AST-33 AlkPhos-104 TotBili-1.0
[**2170-6-28**] 02:13AM BLOOD ALT-176* AST-68* AlkPhos-75 TotBili-1.8*
[**2170-6-24**] 01:30AM BLOOD CK-MB-11* MB Indx-0.5 cTropnT-0.02*
[**2170-6-23**] 04:19PM BLOOD CK-MB-15* MB Indx-0.6 cTropnT-<0.01
[**2170-6-22**] 03:12PM BLOOD CK-MB-4 cTropnT-<0.01
[**2170-6-30**] 08:25AM BLOOD Albumin-2.9* Calcium-7.8* Phos-3.0
Mg-2.7*
Brief Hospital Course:
Mr. [**Known lastname 78636**]' operative course was complicated by increased blood
pressure and difficult extubation. Surgical procedure was
otherwise unremarkable. Patient transferred to ICU for closer
monitoring on ventilator. Secretions sent for culture, positive
for Klebsiella. Treated accordingly with antibiotics. Patient
also required hemodynamic support due to elevated blood pressure
while in ICU.
.
Once hemodynamically stable, transferred to Stone 5 for routine
post-op care. Ileostomy teaching provided. Diet advanced once
ostomy began to put out stool & gas. Tolerated regular diet.
Medications switched to oral. Blood pressure remained elevated
on home dose of Norvasc. Clonidine 0.2mg daily added to regimen
with some effect. SBP's in 140-150 range. Pain well controlled
with Tylenol. Activity progressed to baseline. Physical Therapy
consulted. No PT needs at home.
.
Continued to require supplemental oxygen to maintain sats over
95%. Has H/O emphysema and sleep apnea. Sats on RA after walking
between 82-84%. Supplemental Oxygen arranged for home. VNA
arranged for continued teaching/management of ostomy care,
respiratory and cardiovascular assessment.
.
Attempted to contact patient's PCP, [**Last Name (NamePattern4) **].[**First Name (STitle) **], unable to reach
because office closed. Clonidine discontinued at discharge.
Patient instructed to follow-up with PCP [**Last Name (NamePattern4) **] 1 week to re-assess
blood pressure and respiratory status. In addition, he will
follow-up with Dr. [**Last Name (STitle) 1120**] in a few weeks for staple removal. He
agreed with this plan.
Medications on Admission:
amlodipine 7.5mg [**Hospital1 **], lipitor 10mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 325mg QD
Discharge Medications:
1. Amlodipine 2.5 mg Tablet Sig: Three (3) Tablet PO twice a
day.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
4. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain for 2 weeks: Do not exceed 4000mg in 24hrs.
5. Home Oxygen Therapy
Home oxygen 1-2 liters via nasal cannula
Titrate oxygen for saturations >88%
Discharge Disposition:
Home With Service
Facility:
Visiting Nurse Service of Greater [**Doctor Last Name **]
Discharge Diagnosis:
Local recurrence of [**Doctor Last Name 499**] cancer and new metastatic disease to
the liver.
post-op respiratory distress-difficult extubation
post-op respiratory infection-cultures positive for Klebsiella
post-op hypertension-treated with Clonidine & Norvasc
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled with oral medications.
Requiring oxygen during day (room air oxygen saturation after
ambulation between 82-84%), CPAP at night ambulating with
assistance
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* New or worsening cough or wheezing/shortness of breath.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow up appointment.
-Steri-strips will be applied and will fall off on their own.
Please remove any remaining strips 7-10 days after application.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter (contact Dr. [**Last Name (STitle) 1120**], take 4mg of
Imodium, repeat 2mg with each episode of loose stool. Do not
exceed 16mg/24 hours.
Followup Instructions:
Scheduled Appointments :
***Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 78637**] in 1 week to re-assess you lungs, oxygen
saturation, and blood pressure.
1. Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2170-7-31**] 1:00
2. Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD,PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2170-8-2**] 11:00
3. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 15105**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2170-8-2**] 11:00
Completed by:[**2170-7-2**]
|
[
"2762",
"2767",
"4019"
] |
Admission Date: [**2163-6-21**] Discharge Date: [**2163-6-28**]
Date of Birth: [**2083-10-2**] Sex: M
Service: SURGERY
Allergies:
Dilaudid / Iodine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Juxtarenal abdominal aortic
aneurysm.
Major Surgical or Invasive Procedure:
[**2163-6-21**] Resection and repair of abdominal aortic aneurysm with
20-mm Dacron tube graft.
History of Present Illness:
This 79-year-old gentleman has a 5.5-cm infrarenal abdominal
aortic aneurysm that has been enlarging. The aneurysm has no
neck and is unsuitable for endovascular repair and he is
undergoing open repair.
Past Medical History:
CAD MI in [**2155**] s/p right coronary stents, hypercholesterolemia
prostate cancer s/p TURP and radiation c/b radiation cystitis
with recurrent episodes of hematuria weekly
Social History:
Prior to admission was living with wife independently.
Family History:
Family history is notable for coronary artery disease in both
his mother and father who passed from myocardial infarctions.
There is no family history of any aneurysmal disease.
Physical Exam:
On Discharge:
AFVSS 98.8 HR: 87 BP: 123/63 RR: 16 Spo2: 94%
Gen: NAD, Alert and oriented x3
CVS: RRR
Pulm: CTA bilaterally no resp distress
Abd: S/AT/ND C/D/I
Extremities: Mild BLE edema
Pertinent Results:
[**2163-6-21**] 01:17PM BLOOD WBC-6.9 RBC-3.40* Hgb-10.0* Hct-30.0*#
MCV-88 MCH-29.5 MCHC-33.5 RDW-15.3 Plt Ct-85*
[**2163-6-22**] 03:10AM BLOOD WBC-8.9 RBC-3.24* Hgb-9.8* Hct-28.8*
MCV-89 MCH-30.2 MCHC-33.9 RDW-15.5 Plt Ct-71*
[**2163-6-23**] 02:33AM BLOOD WBC-14.0*# RBC-3.79* Hgb-11.1* Hct-32.9*
MCV-87 MCH-29.4 MCHC-33.8 RDW-16.9* Plt Ct-67*
[**2163-6-24**] 03:56AM BLOOD WBC-16.0* RBC-3.71* Hgb-10.8* Hct-31.6*
MCV-85 MCH-29.0 MCHC-34.1 RDW-16.8* Plt Ct-96*
[**2163-6-25**] 04:00AM BLOOD WBC-12.6* RBC-3.60* Hgb-10.7* Hct-31.9*
MCV-89 MCH-29.8 MCHC-33.7 RDW-16.7* Plt Ct-94*
[**2163-6-26**] 09:20AM BLOOD WBC-12.6* RBC-4.22* Hgb-12.0* Hct-37.1*
MCV-88 MCH-28.5 MCHC-32.5 RDW-16.3* Plt Ct-145*#
[**2163-6-27**] 06:25AM BLOOD WBC-8.4 RBC-3.93* Hgb-11.2* Hct-34.6*
MCV-88 MCH-28.6 MCHC-32.5 RDW-16.2* Plt Ct-145*
[**2163-6-21**] 08:06PM BLOOD Neuts-90.2* Lymphs-5.0* Monos-4.0 Eos-0.1
Baso-0.0
[**2163-6-21**] 01:17PM BLOOD Plt Smr-LOW Plt Ct-85*
[**2163-6-24**] 03:56AM BLOOD PTT-28.0
[**2163-6-21**] 01:17PM BLOOD Glucose-155* UreaN-17 Creat-0.9 Na-140
K-4.1 Cl-109* HCO3-25 AnGap-10
[**2163-6-27**] 06:25AM BLOOD Glucose-99 UreaN-34* Creat-1.5* Na-142
K-3.0* Cl-104 HCO3-29 AnGap-12
[**2163-6-21**] 08:06PM BLOOD Calcium-7.9* Phos-4.0 Mg-1.4*
[**2163-6-27**] 06:25AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.0
[**2163-6-21**] 11:23AM BLOOD Type-ART pO2-261* pCO2-38 pH-7.40
calTCO2-24 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED
[**2163-6-21**] 12:16PM BLOOD Type-ART pO2-258* pCO2-51* pH-7.29*
calTCO2-26 Base XS--2 Intubat-INTUBATED Vent-CONTROLLED
[**2163-6-21**] 01:47PM BLOOD Type-ART FiO2-50 pO2-136* pCO2-40 pH-7.41
calTCO2-26 Base XS-1 -ASSIST/CON Intubat-INTUBATED
[**2163-6-21**] 05:30PM BLOOD Type-ART Rates-/11 PEEP-5 FiO2-40 pO2-88
pCO2-51* pH-7.34* calTCO2-29 Base XS-0 Intubat-INTUBATED
[**2163-6-21**] 08:25PM BLOOD Type-MIX
[**2163-6-22**] 03:25AM BLOOD Type-ART pO2-78* pCO2-46* pH-7.33*
calTCO2-25 Base XS--1
[**2163-6-22**] 06:36PM BLOOD Type-ART pO2-56* pCO2-27* pH-7.45
calTCO2-19* Base XS--2 Intubat-INTUBATED
[**2163-6-23**] 02:48AM BLOOD Type-[**Last Name (un) **] pH-7.44
[**2163-6-21**] 11:23AM BLOOD freeCa-1.09*
[**2163-6-23**] 02:48AM BLOOD freeCa-1.14
Brief Hospital Course:
The patient was admitted to the surgery service after having
Resection and repair of abdominal aortic aneurysm with 20-mm
Dacron tube graft.
Neuro: The patient received and epidural with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications Tramadol.
CV: Post-operatively the patients blood pressure was managed
with IV labetolol drip and nitroprusside. On discharge the was
stable from a cardiovascular standpoint; vital signs were
routinely monitored. He is currently on Metoprolol for beta
blockage with good blood pressure management.
Pulmonary: On discharge patient was stable from a pulmonary
standpoint; vital signs were routinely monitored. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout this hospitalization. He did have a CXR
on [**6-23**] which revealed opacities and pneumonia could not be
excluded. He will be discharged with levo/flagyl for suspect
pneumonia for a 2 week course.
GI/GU/FEN:
Post operatively, the patient was made NPO with IVF.
The patient's diet was advanced when appropriate, which was
tolerated well.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. He will be discharged
with levo/flagyl for suspect pneumonia for a 2 week course.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly. Sliding
scale to be continued.
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, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
Accupril,Amoxicillin,Atenolol,ASA,Axid,Rosovastatin,
Fluticasone, Casodex, Eligard
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 2 weeks: PNA treatment.
2. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks: PNA treatment.
3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day): New medication
.
4. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): per sheet.
6. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
8. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
12. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
13. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
14. Axid 150 mg Capsule Sig: One (1) Capsule PO once a day.
15. Flonase 50 mcg/Actuation Spray, Suspension Sig: [**1-29**] Nasal
once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] skilled nursing center
Discharge Diagnosis:
Juxtarenal abdominal aortic aneurysm
PMH:
CAD
Hypercholesterolemia
Prostate cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**7-5**]
weeks
?????? You should get up out of bed every day and gradually
increase your activity each day
?????? 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 incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**3-2**]
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
?????? You should get up every day, get dressed and walk,
gradually increasing 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 (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 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow
or green drainage from incisions
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2163-7-11**] 12:30
Completed by:[**2163-6-28**]
|
[
"486",
"5119",
"41401",
"2720",
"496",
"2859"
] |
Admission Date: [**2161-3-10**] Discharge Date: [**2161-3-14**]
Date of Birth: [**2107-5-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
E-Mycin / Amoxicillin
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest discomfort
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x 3 [**2161-3-10**]
closed thoracostomy right [**2161-3-10**]
History of Present Illness:
This 53 year old white male with known coronary artery disease,
s/p multiple stents to RCA and LAD. Developed chest discomfort
described as a "warmth" over the past 1-2 weeks, the worst
episode occurring when he carried bags through the
airport. He underwent cardiac catheterization which revealed
severe
triple vessel disease.
Past Medical History:
coronary artery disease
NSTEMI- [**2148**], s/p stent of PDA
[**2153**] Coronary PCI
[**2154**] Coronary PCI
Hyperlipidemia
benign prostatic hyperplasia
Social History:
Lives with: [**Doctor First Name 22483**] girlfriend
Occupation:District manager for a retail company
Tobacco: 1 [**11-22**] ppd x 30yrs
ETOH: socially
Family History:
mother/father with CAD in their 40s
Physical Exam:
Admission:
Pulse: 66SR Resp: 13 O2 sat: 97%RA
B/P Right: 129/91 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA x EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR x[] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] no Edema or
Varicosities
Neuro: Grossly intact x
Pulses:
Femoral Right: cath Left: 1+
DP Right: doppler Left: doppler
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no bruits appreciated
Pertinent Results:
Conclusions
PRE-BYPASS: The left atrium is mildly 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 and cavity
size are normal. There is moderate regional left ventricular
systolic dysfunction with moderate anterior and antero-septal
hypokinesis. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-45 %). The right ventricular cavity
is mildly dilated with mild 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. The mitral valve leaflets are mildly
thickened. Torn mitral chordae are present. Trivial mitral
regurgitation is seen. There is no pericardial effusion.
POST CPB:
1. Improved global and focal LV and RV function with inotropic
support (Epinephrine)
2. N o change in valve structure and function.
3. Intact aorta
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2161-3-10**] 15:44
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
Operating Room on [**2161-3-10**] where he underwent coronary artery
bypass. Overall the patient tolerated the procedure well
weaning from bypass on low dose Epinephrine transiently.
Post-operatively he was transferred to the CVICU in stable
condition for recovery and invasive monitoring. The immedaite
postoperative CXR revealed a small right pneumothorax which
enlarged on a subsequent film off the ventilator. A right CT
was placed uneventfully. Cefazolin was used for surgical
antibiotic prophylaxis. POD 1 found the patient extubated,
alert and oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued
without complication. The patient was evaluated by the physical
therapy service for assistance with strength and mobility.
By the time of discharge on POD #4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged in good condition with
appropriate follow up instructions and VNA.
Medications on Admission:
atenolol 25', diltiazem SR 120', prasugrel 10' (60mg on [**2161-2-27**]),
crestor 20', flomax 0.4', Vit C 500', asa 325', zinc 50',
cranberry
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain for 1 months.
Disp:*90 Tablet(s)* Refills:*0*
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
NSTEMI- [**2148**], s/p stent of PDA
[**2153**] and [**2154**] Coronary angioplasty
postoperative pneumothorax
Hyperlipidemia
benign prostatic hyperplasia
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2161-4-15**], 1pm
Please call to schedule appointments
Primary Care: Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 275**] ([**Telephone/Fax (1) 6699**]) in [**11-22**]
weeks
Cardiologist: Dr. [**Last Name (STitle) 7047**] ([**Telephone/Fax (1) 8725**]) in [**11-22**] weeks
Please call cardiac surgery if need arises for evaluation or
readmission to hospital [**Telephone/Fax (1) 170**]
Completed by:[**2161-3-14**]
|
[
"41401",
"2724",
"412",
"V4582"
] |
Admission Date: [**2112-9-29**] Discharge Date: [**2112-10-3**]
Date of Birth: [**2058-4-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
54F MR, tracheomalacia s/p tracheostomy in [**2107**], PVD, multiple
aspiration pneumonias, DM2 among other conditions who had low
oxygen saturations at her nursing facility
Patient is not able to provide further history, but denies pain.
Patient was succioneed by EMS with improvement in saturation;
however, she was found to have electrolyte abnormalities and a
drop in her HCT, and as such as admited. Per report, she was
guiaic negative in the ED.
In the ED, initial VS were: 98 98 102/43 18 98% 10L
On transfer, 96.1 ??????F (35.6 ??????C) (Axillary), Pulse: 72, RR: 17,
BP: 121/48, O2Sat: 100, O2Flow: (Room Air).
Labs were notable for Na 121, K 5.3, Cl 81, Bicarb 43, BUN 21,
Cr 1, HCT 25.4.
EKG showed NSR at 75, with TWI in V1.
CXR showed on prelim atelectasis vs. pna.
On arrival to the floor, she is in NAD, but only verbalizes
yes/no answers
REVIEW OF SYSTEMS:
(+) Unable to obtain [**1-14**] poor historian
Past Medical History:
Past Medical History:
Mental retardation
tracheomalacia s/p tracheostomy
h/o aspiration pneumonia
E.Coli bacteremia [**10-23**]
diabetes mellitus
h/o C. difficile infection
glaucoma
hypertension
HLD
osteoarthritis
depression/anxiety,
constipation
psychosis
PAST SURGICAL HISTORY:
Tracheostomy and PEG [**2107**],
R total knee replacement
R hip replacement
Right common iliac artery stent placement and right external
iliac recanalization with stent placement x2. [**1-/2111**]
Social History:
lives at nursing home
Father and Brother are [**Name2 (NI) **]-guardians
Family History:
unable to obtain
Physical Exam:
ADMISSION EXAM:
===================================
VS - T 98 BP 150/1 HR 86 RR 22 96% on 60% trach mask
General: would state shake head "yes or no" to questions, also
says "yes" and "no"
[**Name2 (NI) 4459**]: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD, poor dentition
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops although exam limited due to coarse breath sounds
Lungs: diffuse coarse breath sounds, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly. PEG tube located in LUQ
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact although disconjugate gaze especially
with right eye
LABS: Please see attached
DISCHARGE EXAM:
=====================================
VS - T 97.4 BP 138/52 HR 102 RR 24 98% on 40% trach mask
General: Responds to name, no acute distress, baseline MR
[**Last Name (Titles) 4459**]: Sclera anicteric, MM dry, EOMI
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Bronchial breath sounds
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley
Ext: Cool hands, but otherwise warm, well perfused, 2+ pulses,
no clubbing. Bilateral hands/feet with edema.
Neuro: Answers yes/no questions. Intermittently follows
commands.
Pertinent Results:
ADMISSION LABS:
===============================
[**2112-9-29**] 01:00AM BLOOD WBC-9.4 RBC-2.72* Hgb-8.8* Hct-25.4*
MCV-93 MCH-32.5* MCHC-34.8 RDW-17.3* Plt Ct-291#
[**2112-9-29**] 01:00AM BLOOD Neuts-49.7* Lymphs-33.8 Monos-13.3*
Eos-2.6 Baso-0.6
[**2112-9-29**] 07:20AM BLOOD Ret Aut-8.4*
[**2112-9-29**] 01:00AM BLOOD Glucose-164* UreaN-21* Creat-1.0 Na-121*
K-5.3* Cl-81* HCO3-43* AnGap-2*
[**2112-9-29**] 07:20AM BLOOD TotProt-5.6* Albumin-2.8* Globuln-2.8
Calcium-8.6 Phos-3.5# Mg-2.1 Iron-44
[**2112-9-29**] 07:20AM BLOOD calTIBC-352 Hapto-141 Ferritn-304*
TRF-271
[**2112-9-29**] 01:02AM BLOOD Lactate-1.3
IMAGING:
=========================
CXR [**2112-9-29**]
FINDINGS: AP and lateral views of the chest. Tracheostomy tube
is seen in place. Mild cardiomegaly is unchanged. There are
bibasilar opacities that may represent atelectasis; however,
aspiration or pneumonia cannot be ruled out. Correlate
clinically. No large pleural effusion or pneumothorax.
IMPRESSION: Mild interstitial edema. Bibasilar opacities are
likely chronic. CT can be done to assess for subtle changes.
[**2112-10-1**] CHEST (PORTABLE AP): Tracheostomy tube remains in
satisfactory position. Overall, cardiac and mediastinal
contours are difficult to assess given marked patient rotation,
but are likely stable. Lungs remain low lung volumes with
overall improvement in aeration, suggesting that interstitial
edema has resolved. Basilar patchy opacities are unchanged and
may reflect chronic changes. No large pneumothorax, although
the sensitivity for detecting pneumothorax is somewhat
diminished given supine technique.
[**2112-10-1**] BILAT LOWER EXT VEINS: Limited study due to the
overlying edema. No DVT is seen in the common femoral veins or
proximal superficial femoral veins bilaterally. Flow was seen
in the superficial femoral veins and popliteal veins bilaterally
but technical limitations did not allow adequate assessment.
Other than the right posterior tibial veins which are patent,
the calf veins are not well visualized.
Microbiology:
=========================
[**2112-9-30**] GRAM STAIN (Final [**2112-9-30**]):
[**10-6**] 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.
RESPIRATORY CULTURE (Final [**2112-9-30**]):
TEST CANCELLED, PATIENT CREDITED.
[**2112-10-1**] MRSA SCREEN (Final [**2112-10-2**]): POSITIVE
[**2112-10-1**] Blood Culture, Routine (Pending):
[**2112-10-2**] Blood Culture, Routine (Pending):
[**2112-10-1**] URINE CULTURE (Final [**2112-10-2**]): NO GROWTH.
[**2112-10-1**] SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2112-10-1**]):
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ <=1 S
DISCHARGE LABS
============================
[**2112-10-3**] 03:00AM BLOOD WBC-6.7 RBC-2.59* Hgb-8.2* Hct-25.3*
MCV-98 MCH-31.8 MCHC-32.4 RDW-17.0* Plt Ct-190
[**2112-10-1**] 02:06AM BLOOD PT-9.4 PTT-26.1 INR(PT)-0.9
[**2112-10-3**] 03:00AM BLOOD Glucose-66* UreaN-23* Creat-1.3* Na-139
K-3.7 Cl-103 HCO3-30 AnGap-10
[**2112-10-3**] 03:00AM BLOOD Calcium-7.7* Phos-3.9# Mg-2.6
[**2112-10-2**] 03:40AM BLOOD Lactate-1.2
Brief Hospital Course:
54F MR, tracheomalacia s/p tracheostomy in [**2107**], PVD, multiple
aspiration pneumonias, DM2 among other conditions who had low
oxygen saturations at her nursing facility
.
# Hypoxemia - Pt initially was admitted due to low oxygen
saturations at her nursing home. It was initially felt this
could possibly due to infection and antibiotics were started.
However, later in her hospital course, her presentation seemed
more consistent with mucous plugging, and so antibiotics were
stopped. She was started on guaifenesin and NAC. She had a
hypoxic event where she desatted to 50% which brought her to the
MICU and she was put on the ventilator. Her improvement was
rapid and she was satting 98% on 40% face mask upon discharge.
PE was considered as a possible etiology of her hypoxia, and
LENIs were obtained which did not show evidence of clot, though
this was a limited study. Additionally, given her rapid
improvement on the ventilator, this was not felt to be a likely
etiology. Sputum culture showed pseudomonas, but this was felt
to be colonization rather than infection, and so antibiotics
were discontinued (as stated above). She was seen by IP given
her history of tracheobronchomalacia and it was decided that
intervention was not necessary. Overall, her etiology of hypoxia
was felt to be secondary to mucous plugging.
# Hyponatremia: Upon admission, patient has serum Na of 120
which improved with fluid resuscitation. Likely hypovolemic
hyponatremia; this is supported by exam, BUN/Cr ratio elevated
above 20, and metabolic alkalosis, which could very well be
contraction. Her Na improved to 129 with fluids supporting the
diagnosis of hypovolemic hypnatremia. As per nursing home, was
same as reported from [**8-29**] labs from facility. Her sodium upon
discharge was 139.
# Anemia: Patient has normal HR and BP, and per report was
guiaic negative. It was concerning for hemolysis versus anemia
of chronic inflammation. Her reticulocyte index indicates that
her bone marrow is responding appropriately. Her hemolysis labs
did not suggest hemolysis as the cause of her anemia. Fe studies
were only notable for elevated ferritin, which makes most likely
diagnosis of her Anemia to be anemia of chronic inflammation.
She did not require blood transfusions during this
hospitalization.
# Hyperkalemia: Upon presentation, patient had mild hyperkalemia
(5.3) which is likely secondary to decreased intravascular
volume, which caused a mild [**Last Name (un) **], possibly precipitating hyper K.
No EKG changes to suggest cardiac effects. Potassium improved to
4.7 from 5.3 with IVF. Her potassium was 3.7 upon discharge.
# Metabolic alkalosis: Likely contraction in the setting of
volume depeltion. There is also a possibility that this is a
compensatory metabolic alkalosis from a respiratory acidosis [**1-14**]
to mucus plugging of trach. Her alkalosis improved with IVF,
lending credence to the idea that it is secondary to volume
depletion with contraction alkalosis.
# DM: Pt was initially continued on her home regimen of 56 units
lantus qHS and insulin sliding scale. However, on the day of
discharge, she became hypoglycemic to 32 that increased to 213
with 1.5 amps of D5. Therefore, her home lantus was cut in half
to 28 units to start tonight and depending on what her sliding
scale requirements are, this should be titrated as necessary.
Chronic Problems:
====================================
#Hypothyroidism: she was continued on home levothyroxine
#H/o psychosis: cont on how valproate/seroquel.
#HTN: She was initially continued on home amlodipine/metoprolol,
but these were held upon transfer to the ICU. However, it is
felt safe to re-start these medications, as her BP was 130/67
upon discharge.
TRANSITIONAL ISSUES
=================================
# Pt has two blood cultures 10/20 and [**10-2**] that are pending
upon discharge that need to be followed-up on
# Pt's home lantus was decreased to 28 units qHS (down from 56
units qHS) due to hypoglycemia. Her insulin sliding scale
requirements should be monitored given this decreased dose of
lantus and be used to increase her lantus as necessary.
# Code Status: FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. valproic acid (as sodium salt) *NF* 500 mg/10 mL (10 mL) Oral
Daily
2. Vitamin D 400 UNIT PO DAILY
3. Amlodipine 10 mg PO DAILY
Hold for SBP <100, HR <60
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Metoprolol Tartrate 150 mg PO BID
Hold for SBP <100, HR <55
6. Glargine 56 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
7. Aspirin 325 mg PO DAILY
8. fenofibrate *NF* 54 mg Oral Daily
9. lactobacillus acidophilus *NF* 1 tablet Oral Daily
10. multivitamin with minerals *NF* 9 mg/15 mL iron Oral Daily
11. Polyethylene Glycol 17 g PO DAILY
12. Quetiapine Fumarate 200 mg PO TID
13. Quetiapine Fumarate 50 mg PO TID
14. valproic acid (as sodium salt) *NF* 750 mg Oral QHS
15. Albuterol 0.083% Neb Soln 1 NEB IH [**Hospital1 **]
16. latanoprost *NF* 0.005 % OU Daily
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Acetylcysteine 20% 1-10 mL NEB Q2H:PRN mucus
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Guaifenesin [**4-21**] mL PO Q6H
7. Heparin 5000 UNIT SC TID
8. valproic acid (as sodium salt) *NF* 500 mg/10 mL (10 mL) Oral
Daily
9. valproic acid (as sodium salt) *NF* 750 mg Oral QHS
10. Vitamin D 400 UNIT PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. multivitamin with minerals *NF* 9 mg/15 mL iron Oral Daily
13. Metoprolol Tartrate 150 mg PO BID
Hold for SBP <100, HR <55
14. latanoprost *NF* 0.005 % OU Daily
15. lactobacillus acidophilus *NF* 1 tablet Oral Daily
16. fenofibrate *NF* 54 mg Oral Daily
17. Albuterol 0.083% Neb Soln 1 NEB IH [**Hospital1 **]
18. Amlodipine 10 mg PO DAILY
Hold for SBP <100, HR <60
19. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
20. Quetiapine Fumarate 200 mg PO TID
21. Quetiapine Fumarate 50 mg PO TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
- mucous plug
- hypovolemic hyponatremia
- anemia of inflammation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 69887**],
It was a pleasure taking care of your here at [**Hospital1 771**].
You came into the hospital because you were having a hard time
breathing. We believe this was from mucus that was stuck in your
trach. You have been started on guaifenesin and acetylcysteine
to help prevent mucous plugging. It is important to make sure
you are breathing through humdified air to help prevent the
mucous clot from clogging your airways.
You were also found to have some electrolytes to be abnormal.
These were most likely from being dehydrated. They were normal
after you received some intravenous fluids.
You were also found to be slightly anemic. You have a history of
anemia and this is thought to be due to inflammation.
The following changes were made to your medications
*DECREASED your lantus to 28 units qHS (down from 56 units qHS)
*ADDED guaifenesin to help decrease mucous plugging
*ADDED acetylcysteine to help decrease mucous plugging
*ADDED heparin subq to help prevent clots while you are
bedbound.
*ADDED glucagon and dextrose to be administered per the insulin
sliding scale depending on your glucose levels
Followup Instructions:
Please have your extended care facility arrange follow up with a
MD.
Completed by:[**2112-10-4**]
|
[
"2761",
"5849",
"25000",
"V5867",
"2724",
"2449",
"4019",
"2767"
] |
Admission Date: [**2107-7-24**] Discharge Date: [**2107-7-28**]
Date of Birth: [**2028-3-14**] Sex: F
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
sp cardiac arrest/colitis
Major Surgical or Invasive Procedure:
sp Left subclavian CVL placement
sp Right femoral CVL placement
History of Present Illness:
79F Pmhx CHF,COPD, found down at home, pulseless- CPR initiated
w/conciousness regained on scene. At OSH ABG 7.19/94/110, BiPAP
started. Pt found to be hypothermic w/ WBC 17 (pt on steroids)
pnuemobilia and thickening of sigmoid. Currently on Nasal
cannula 02 + hemodymamically stable.
Past Medical History:
CHF (EF 25%, mod AS,AR, mod MR, CAD,PAF, angina, COPD (O2
dependent-2 L) PVD, recurrent UTI's, Chronic bronchitis, ?h/o
DM,
sp L ax-bifem, L fem-[**Doctor Last Name **], ERCP '[**04**], T+A, Appy, CEA, L4-L5
laminectomy.
Social History:
ex tobacco
denies [**Hospital **]
nursing home resident
Family History:
NC
Physical Exam:
thin, A&O X 1
IRRR
Decreased BS bilaterally
soft, mild tenderness R and L lower quadrants-not reproducible
visible fem-fem graft
ext warm, + 1 edema
Pertinent Results:
[**2107-7-24**] 04:20AM BLOOD WBC-13.8* RBC-3.17* Hgb-8.9* Hct-28.4*
MCV-90 MCH-28.2 MCHC-31.4 RDW-15.0 Plt Ct-185
[**2107-7-26**] 03:15AM BLOOD WBC-6.8 RBC-2.86* Hgb-7.7* Hct-25.9*
MCV-91 MCH-27.0 MCHC-29.9* RDW-15.1 Plt Ct-178
[**2107-7-27**] 02:41AM BLOOD WBC-5.3 RBC-2.94* Hgb-8.2* Hct-27.4*
MCV-93 MCH-27.9 MCHC-29.9* RDW-15.0 Plt Ct-194
[**2107-7-25**] 03:07AM BLOOD PT-14.0* PTT-30.1 INR(PT)-1.2*
[**2107-7-24**] 04:20AM BLOOD Glucose-86 UreaN-18 Creat-0.8 Na-144
K-3.7 Cl-101 HCO3-40* AnGap-7*
[**2107-7-26**] 09:36AM BLOOD Glucose-202* UreaN-25* Creat-1.1 Na-139
K-3.9 Cl-100 HCO3-37* AnGap-6*
[**2107-7-27**] 02:41AM BLOOD Glucose-122* UreaN-31* Creat-1.3* Na-139
K-4.1 Cl-99 HCO3-35* AnGap-9
[**2107-7-24**] 04:20AM BLOOD ALT-51* AST-86* CK(CPK)-638* AlkPhos-65
Amylase-120* TotBili-0.4
[**2107-7-24**] 12:38PM BLOOD CK(CPK)-1086*
[**2107-7-24**] 09:45PM BLOOD CK(CPK)-972*
[**2107-7-27**] 02:41AM BLOOD CK(CPK)-218*
[**2107-7-24**] 04:20AM BLOOD cTropnT-0.18*
[**2107-7-24**] 12:38PM BLOOD CK-MB-18* MB Indx-1.7 cTropnT-0.17*
[**2107-7-24**] 09:45PM BLOOD CK-MB-14* MB Indx-1.4
[**2107-7-25**] 04:26AM BLOOD CK-MB-10 MB Indx-1.4 cTropnT-0.12*
[**2107-7-27**] 02:41AM BLOOD CK-MB-5 cTropnT-0.10*
[**2107-7-24**] 04:20AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0
[**2107-7-27**] 02:41AM BLOOD Calcium-8.2* Phos-5.3* Mg-1.9
[**2107-7-25**] 07:36AM BLOOD Vanco-16.2*
[**2107-7-26**] 10:26AM BLOOD Type-ART pO2-105 pCO2-95* pH-7.19*
calTCO2-38* Base XS-4
[**2107-7-26**] 11:05AM BLOOD Type-[**Last Name (un) **] pO2-35* pCO2-107* pH-7.17*
calTCO2-41* Base XS-5
[**2107-7-26**] 11:31AM BLOOD Type-ART pO2-144* pCO2-80* pH-7.23*
calTCO2-35* Base XS-3
[**2107-7-26**] 07:42PM BLOOD Type-ART pO2-127* pCO2-105* pH-7.16*
calTCO2-40* Base XS-4
[**2107-7-26**] 09:19PM BLOOD Type-ART pO2-76* pCO2-85* pH-7.26*
calTCO2-40* Base XS-7
[**2107-7-27**] 01:50AM BLOOD Type-ART pO2-47* pCO2-105* pH-7.15*
calTCO2-39* Base XS-3
[**2107-7-27**] 02:54AM BLOOD Type-ART pO2-64* pCO2-91* pH-7.23*
calTCO2-40* Base XS-6
CT CSpine: No evidence of cervical spine fracture. Cervical
spondylosis as described above.
CXR post CVL placement [**7-25**]:
A left subclavian vascular catheter terminates in the superior
vena cava. Several skin folds are present in the left hemithorax
but there is no pneumothorax. There are bilateral moderate
pleural effusions, both of which have increased in size since
the previous study. New perihilar and basilar opacities may
reflect pulmonary edema sparing the upper lobes in the setting
of emphysema, but it is difficult to exclude underlying
aspiration or infectious pneumonia in the lung bases. Surgical
clips are present in the left axilla.
[**7-27**] CXR: Interval development of large left pneumothorax with
almost complete collapse of the left lung.
Brief Hospital Course:
79F w/ a multiple medical problems including CHF (EF20%), COPD
(on home O2), found down at home, pulseless- CPR initiated
w/conciousness regained on scene. At OSH ABG 7.19/94/110, BiPAP
started. Pt found to be hypothermic w/ WBC 17 (pt on steroids)
pnuemobilia and thickening of sigmoid. Pt was transferred to
[**Hospital1 18**] for further management with wishes from the pt and family
to reverse DNR/DNI status if surgery was indicated. On
transfer, the pt had VSS with a mildly tender abdomen without
peritoneal signs. It was decided to treat her conservatively
with bowel and IV antibiotics. She improved and was tolerating
PO's without difficulty after passing a swallow study. Her
Cpine was clearly with both a negative CT Cspine and clinical
exam. Her groin CVL was DC'd after a L SC SVL was palced. CXR
confirmed good position and no PTx.
Overnight on HD 3, pt became mildly agitated and an ABG was
drawn which showed a severe resp acidosis and BiPAP was
initiated. The pt subsequently developed severe hypoxia with
hypotension. A CXR was obtained which showed complete collapse
of the L lung thought to be a result of bursting a bleb
associated with her severe COPD. Family did not want a chest
tube placed and decided to make the pt [**Name (NI) 3225**] measures.
On HD 4 pt continued to show a severe respiratory acidosis, was
continued on a morphine drip, and was difficult to arouse. At
6pm pt's respiratory status worsened and she died.
Medications on Admission:
coreg 6.25", captopril 12.5", effexor 150', colace 100" prn,
calcium ", lasix 40', KCL 20', Pred 5', opscal', protonix 40',
diamoxx 250', albuterol prn, darvocet prn, senekot, trazadone
25'
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
respiratory failure
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2107-7-29**]
|
[
"51881",
"4280",
"496",
"5849"
] |
Admission Date: [**2122-2-27**] Discharge Date: [**2122-3-5**]
Service: MEDICINE
Allergies:
Heparin Sodium / Shellfish
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
Right hip fracture
Major Surgical or Invasive Procedure:
Right hip fracture repair (ORIF)
History of Present Illness:
87M with MMP including DM (last HbA1c 6.7), AFib on coumadin,
CAD s/p CABG/stents, CHF (EF 25-30%), s/p pacemaker/ICD, porcine
AVR/MVR, BPH (chronic foley) presented after mechanical fall
found to have right sub-trochanteric fracture. He was at home,
woke up at 7.25AM and found his foley bag to be full. He tried
to reach the foley bag and accidentally hit the power button of
his nearby motorized wheelchair. He subsequently fell backwards.
He denies having hit anything else except his buttock and right
hip. He specifically did not hit his head. He felt pain ([**11-18**]
in severity) in his right hip and could not move without
excruciating pain. He next called 911 and was brought into the
ED.
.
Patient denies any dizziness or special events preceding the
fall, but he is known to have a very poor sense of balance since
childhood. According to the patient, he has a brain cyst since
birth responsible for his poor balance.
.
ROS: He denies any F/C/N, CP, SOB (beyond his baseline from
COPD), abdominal pain, N/V/D, bloody stools or urine, or urinary
symptoms.
.
ED: In the ED, his VS were stable. He was given Tylenol PO and
morphine 2mg iv x 2 for pain control. Hip films, Head CT and CT
C-spine were performed. They revealed no acute findings except
for a right displaced, subtrochanteric fracture. Ortho evaluated
the patient and decided to operate him in the morning after
medical clearance. His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2450**], also saw the patient in
the ED and it was decided to admit the patient to the medicine
service for pre-OP clearance given his multiple cardiac risk
factors.
Past Medical History:
1. Atrial fibrillation, on coumadin (INR goal 2.0-2.5 per PCP)
2. s/p pacemaker, AICD
3. CAD s/p CABG, stents (placed 16 yrs ago) - last [**Last Name (STitle) **] [**3-16**]
showing moderate fixed inferior defect
4. CHF - last echo [**12-15**] EF 20-25%
5. COPD / Emphysema (70+ yrs of smoking)
6. Type II diabetes mellitus (last HbA1c 6.7 in [**10/2121**])
7. s/p porcine MVR/AVR in [**2105**]
8. hyperlipidemia
9. BPH - chronic foley (being changed q6weeks)
10. h/o nephrolithiasis
11. CRI - baseline creat 1.1-1.2
12. Chronic anemia (possibly ACD per PCP, [**Name10 (NameIs) **] worked up)
13. Large porencephalic cyst within right parietal/occipital
area (since birth per patient)
14. Hypothyroidism (on replacement therapy)
15. Left inguinal hernia
Social History:
Lives with his wife. Difficult home situation per PCP. [**Name10 (NameIs) **] is
also wheelchair bound. Has meals on wheels, uses a motorized
scooter/walker. Smokes 2-5cigs/day x 70 years. Rare EtOH, no
IVDU.
Family History:
Non-contributory
Physical Exam:
VS: Temp: 97.3, BP: 132/70, HR: 66, RR: 22, O2sats: 95% on RA,
weight: 138.6 lbs
GEN: pleasant, talkative, comfortable, elderly man in NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no upper
teeth
NECK: supple, no LAD, JVP 13cm
RESP: coarse BS, No rhales, rhonchi or wheezes
CV: PMI laterally displaced, RR, S1 and S2 wnl, no m/r/g
ABD: +BS, soft, ND, no masses or hepatosplenomegaly, deep RLQ
palpation causes right hip pain, but no abdominal tenderness
EXT: no c/c/e, wasted muscles, warm legs, 2+ DP/TP pulses, R leg
externally rotated, decreased ROM of R hip [**3-13**] pain, mild
swelling over R hip noted, TTP over R hip and femur
SKIN: no jaundice, old bruise over R forearm (pt hit his arm
accidentally the day prior to his fall)
NEURO: A&O x3, CN II-XII intact, decreased strength of RLE [**3-13**]
hip pain
RECTAL: deferred given immobility of patient
UGT: L groin bulge TTP, approximately egg-sized (known inguinal
hernia), foley in place
Pertinent Results:
[**2122-2-27**] 08:25AM WBC-6.5 RBC-3.65* HGB-11.4* HCT-32.8* MCV-90
MCH-31.2 MCHC-34.8 RDW-13.3
[**2122-2-27**] 08:25AM NEUTS-60.0 LYMPHS-20.5 MONOS-5.7 EOS-12.9*
BASOS-0.9
[**2122-2-27**] 08:25AM PLT COUNT-184
[**2122-2-27**] 08:25AM PT-18.7* PTT-26.7 INR(PT)-1.8*
[**2122-2-27**] 08:25AM GLUCOSE-151* UREA N-32* CREAT-1.0 SODIUM-139
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-24 ANION GAP-12
.
EKG: NSR with LBBB (old), old Q in III, no acute changes
.
[**2-27**] Right hip and knee film:
1. Obliquely oriented fracture of the proximal right femur
extending from the lesser trochanter distally and laterally into
the proximal femoral diaphysis with foreshortening and
displacement.
2. Degenerative changes of the lower lumbar spine.
.
[**2-27**] CT Head: No acute hemorrhage. No shift of midline
structures. Large porencephalic cyst within right
parietal/occiptal area unchanged compared to [**2120-4-12**]. No
hydrocephalus.
.
[**2-27**] CT C-spine: No significant malalignment. No fracture. Mild
retrolisthesis of C4 on C5. Mild- moderate degenerative disease.
.
ECHO [**2121-12-29**]: LA is moderately dilated. Mild symmetric LVH. The
left ventricular cavity size is normal. There is severe global
left ventricular hypokinesis. Overall left ventricular systolic
function is severely depressed (20-25%). The ascending aorta is
mildly dilated. A bioprosthetic aortic valve prosthesis is
present. The transaortic gradient is normal for this prosthesis.
No aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present. The transmitral gradient is normal for
this prosthesis. No mitral regurgitation is seen.
.
CXR AP [**2-27**]: A dual-chamber pacer is present with its leads
overlying the right atrium and ventricle. Median sternotomy
sutures are present. Rightward shift of the trachea which is
likely secondary to atherosclerotic changes and enlargement of
the aortic knob. The lungs are clear. No pleural effusions
present. Mild cardiomegaly is stable. Prosthetic mitral valve in
place.
.
CXR AP [**2-28**]: Increased interstitial markings, which may
represent edema. Change in course of atrial pacer lead. Is there
evidence that this may become dislodged or has it been removed?
.
Hip XR [**2-28**]: Three views. Comparison with the previous study
done [**2122-2-27**]. A comminuted fracture of the proximal femur is
again demonstrated. Major fracture fragments are transfixed by a
screw and intramedullary rod. A small butterfly fragment at the
lateral aspect of the fracture site is displaced laterally.
There is no evidence of dislocation.
.
[**3-3**] Abdomen supine & erect: Mild gaseous distention of the
stomach. Moderate amount of stool within the rectum and colon
without evidence of obstruction.
Brief Hospital Course:
87M with MMP including DM (last HbA1c 6.7), AFib on coumadin,
CAD s/p CABG/stents, CHF (EF 25-30%), s/p pacemaker/ICD, porcine
AVR/MVR, BPH (chronic foley) presented after mechanical fall
found to have right displaced, sub-trochanteric fracture, went
for ORIF, was transiently in MICU for prolonged intubation and
AICD interrogation after tachycardic runs, then stable on floor
again.
.
1. R subtrochanteric fx: Seen by Ortho in ED. Displaced on XR.
ORIF was planned on day of admission but given scheduling
issues, deferred until 7AM the next day. Patient has medium to
high risk for cardiac complications but was overall stable and
cleared for surgery based on clinical exam, stable EKG, CXR, and
labs. Plavix and coumadin were held. Pt was transiently on
Heparin drip prior surgery. Needed 1U pRBC pre-OP for transient
drop in his hematocrit. Operation went without any major
surgical events. However, patient required prolonged intubation
post-OP and thought to have VT run peri-OP. Was briefly in MICU
until extubated. EP interrogated AICD. Runs were likely not VT
but SVT with bundle branch block. Stable since transfer to
floor. Pain control initially with PCA post-OP, then with
Tylenol PO and Morphine IV. Eventually transitioned to PO
oxycodone. Patient only had two transient episodes of Afib with
RPR that postponed discharge by one day. Otherwise, he had an
uneventful hospital course after transfer to the medical floor
except for a small post-Op hematoma around the right waist and
hip. Post-OP Lovenox was discontinued once patient was
therapeutic on coumadin again. Patient needs followup
appointment with Orthopedics four weeks after the operation.
Staples need to be taken out two weeks post-OP ([**2122-3-14**]).
.
2. CAD s/p CABG/stents: Stable throughout most of his hospital
stay. Pt denied any CP or increased SOB on admission. EKG was
without any acute changes. Per PCP, [**Name Initial (NameIs) 109162**]/IIIa inhibitors were
tried in the past, but discontinued due to severe hematuria.
Patient was continued on ASA, statin, betablocker, Nitro SL prn
CP. Plavix was held preoperatively and restarted post-OP at
regular dose.
.
3. Rhythm: Patient has known AFib, is on coumadin and s/p
pacemaker/AICD. Patient was kept on telemetry throughout his
hospital stay. INR goal 2.0-2.5 per PCP. [**Name10 (NameIs) **] coumadin prior
surgery. Was briefly heparinized pre-OP. Received FFPs x2 and
Vit K sc x1 shortly prior surgery. Went for surgery in AM of
[**2-28**]. Had two runs of ?VT peri-OP and AICD did not function. EPS
interrogated AICD and read tachycardic runs as SVT with bundle
branch block as opposed to VT. Patient only had two transient
episodes of Afib with RPR that postponed discharge by one day.
His BB dose was increased to 37.5mg [**Hospital1 **] for better rate control.
Coumadin was restarted post-OP. INR was 1.9 on [**3-3**], and 2.2 on
day of discharge. INR should be checked 2-3 days after discharge
to ensure therapeutic range.
.
4. Systolic CHF: EF 20-25% on last Echo ([**12-15**]). CHF seemed
stable. No LE edema, lungs clear, no increased SOB, no CP. Pt
appeared euvolemic on exam. Patient was continued on his BB and
Nitro SL prn CP. Lasix was restarted upon discharge.
.
5. DMII: Last HbA1c 6.7 in 9/[**2121**]. Glyburide was held during
hospital stay and restarted upon discharge. RISS during peri-op
period.
.
6. COPD: Known emphysema, 70+ years of smoking. Continued home
inhalers (albuterol, ipratroprium prn). Sputum from [**3-1**] grew
only OP flora.
.
7. CRI: Likely [**3-13**] DM. Baseline creat 1.1-1.2. Creat of 1.0 on
admission. Remained stable throughout hospital course.
.
8. Anemia: Hct baseline 27-34. Stable on admission with Hct of
32. Ferritin of 76, iron of 90, folate 17.6, B12 437 in 4/[**2121**].
Unclear etiology but possibly ACD per PCP. [**Name10 (NameIs) **] workup as
outpatient recommended. Hct dropped overnight ([**2-27**]) prior
surgery from 32.8 to 25.6. Stools were guaiac'd and foley
checked for hematuria. Patient received 1U pRBC, Hct came up to
29.4. Pt went to surgery. Post-OP Hct remained stable around
27-29 until discharge.
.
9. BPH: Chronic foley. Being changed q6weeks in urology clinic.
Per PCP, [**Name10 (NameIs) **] to bleed easily from bladder. Ucx from [**2-28**] grew
GNR (10-100K), 2 colonies. No rx.
.
10. Hypothyroidism: continued Levoxyl.
.
11. Hyperlipidemia: continued statin.
.
12. FEN: Diabetic, cardiac diet. Repleted electrolytes as
needed. Patient had poor PO intake post-OP. Supplemented with
Ensure.
.
13. Prophylaxis: Coumadin for Afib. Lovenox post-OP until INR
therapeutic, then stopped given post-OP hematoma around right
waist and hip. Bowel regimen with senna prn and colace standing.
.
14. Code Status: Full
Medications on Admission:
coumadin 1mg M-W-F, 2mg T-T-S
plavix 75mg qday
ASA 352mg qd
metoprolol 25mg po bid
Atorvastatin 10mg qday
Folate 1mg po qday
albuterol inh 1-2 puffs q6 prn
ipratropium inh 1 puff q6h prn
lasix 10mg qday
glyburide 1.25mg qday
Levoxyl 50 mcg qd
Nitro SL 0.4mg prn CP
Discharge Medications:
1. Outpatient Lab Work
Your INR should be checked two to three days after discharge.
Please have have the results faxed to your PCPs office at ([**Telephone/Fax (1) 109163**]. Your coumadin should be adjusted if necessary.
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB, wheezing.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for SOB,
wheezing.
7. Glyburide 1.25 mg Tablet Sig: One (1) Tablet PO once a day.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed for pain.
16. Prochlorperazine 5 mg Tablet Sig: One (1) Tablet PO Q4-6H
PRN () as needed for nausea.
17. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
18. Furosemide 20 mg Tablet Sig: [**2-10**] Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Health and Rehab
Discharge Diagnosis:
Primary Diagnosis:
1. Right subtrochanteric fracture, s/p ORIF
2. AFib with RPR, on coumadin
3. Acute blood loss, requiring blood transfusion
.
Secondary Diagnosis:
1. CAD, s/p CABG, stents
2. Systolic CHF (EF 20-25%)
3. DM type II
4. COPD
5. CRI
6. Chronic anemia
7. Hypothyroidism
8. BPH
Discharge Condition:
Afebrile. Hemodynamically stable. Tolerating PO.
Discharge Instructions:
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
spontaneous bleeding or any other concerning symptoms.
.
Please take all your medications as directed. Your beta blocker
has been increased to 37.5mg twice daily. Your INR should be
checked two to three days after discharge. Your coumadin should
be adjusted if necessary. Please have have the results faxed to
your PCPs office at ([**Telephone/Fax (1) 109164**].
.
Please keep your follow up appointments as below.
.
You should have your staples removed at the rehabilitation
center on [**2122-3-14**].
Followup Instructions:
Please follow up with your primary care doctor ([**Last Name (LF) **],[**First Name3 (LF) **] T.
[**Telephone/Fax (1) 250**]) in [**2-10**] weeks after rehab. You should have your
staples removed on [**2122-3-14**] at rehab.
.
You have an appointment to see Dr. [**First Name (STitle) **] from Orthopedics on
Tuesday, [**4-7**] at 10:45am on the [**Location (un) 1773**] of the
[**Hospital Ward Name 23**] building on the [**Hospital1 18**] [**Hospital Ward Name **].
.
In addition, please follow up with:
.
Provider: [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) 15351**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2122-5-14**] 1:20
Provider: [**Name Initial (NameIs) 10081**]/EXERCISE LAB Phone:[**Telephone/Fax (1) 1566**]
Date/Time:[**2122-6-9**] 10:30
|
[
"42731",
"9971",
"496",
"2851",
"V5861",
"V4581",
"V4582",
"2449",
"2724"
] |
Admission Date: [**2154-2-7**] Discharge Date: [**2154-2-14**]
Date of Birth: [**2102-3-25**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Tetracycline
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
tracheal stenosis
Major Surgical or Invasive Procedure:
balloon dilation of trachea
History of Present Illness:
HPI: 51 yoF w/ widely metastatic NSCLC ([**Last Name (LF) 500**], [**First Name3 (LF) **], liver,
kidney) p/w tracheal narrowing. She presented to her oncologist
this a.m. c/o right shoulder pain X 2 days, intermittent
dysphagia (solids >liquids) X 1 week, and "difficulty breathing
in" X 5 days. She was noted to have stridor (concerning for
tracheal compression) and elevated JVP (concerning for early SVC
syndrome) and was admitted for further evaluation/management.
She had a total spine MRI which showed collapse of T1 c/w a
pathological fracture with anterior edema as well as evidence of
metastases at T10, T12, left L5 lamina, and left sacral ala.
However, there was no evidence of significant cord compression
or neural foraminal narrowing. She also had a chest CT which
showed marked progression of disease with a large mass invading
the right aspect of the mediastinal with significant narrowing
of the distal trachea (and possible invasion), encasement of the
lateral aspect of the SVC, esophagus, and right SC vessels, as
well as evidence of lymphagitic spread within the lungs. She
received dexamethasone 10 mg IV X 1 and was admitted to the ICU
for close monitoring to ensure airway stability prior to planned
bronchoscopy/tracheal stenting in a.m.
In [**Location 31038**] rigid bronch [**2-13**] vertebral issues, and no flex
bronch-trach stent given nickel allergy(stent is nickel),
therefore had balloon dilatation. Ortho-spine
following---recommended brace, intervention only if neuro
changes, no signs cord compression now.
Past Medical History:
PMHx:
1) Metastatic NSCLC: dx [**7-15**]; mets to brain (right parietal,
left parietal, right pontine, right subfalcine), liver (caudate
with biliary compression/dilitation), [**Month/Year (2) 500**] (spinal, left ileum,
right proximal femur)
-- s/p carboplatin & taxol X 2 cycles; Iressa X 5 weeks,
Navelbine X 1 cycle (held last week for low blood counts)
2) Arthritis
3) Sciatica
4) MVP
5) Right hip pathologic fx s/p ORIF
Social History:
Former payroll assistant in a high school, 1-1.5 ppd x 20 yrs,
social etoh, married, 2 daughters
Family History:
Mother and brother with DM and CAD
Physical Exam:
VS: 98 80 127/74 18 97% RA
GEn: chronically ill-appearing, comfortable, without stridor
HEENT: PERRL, EOMI, pale conjunctiva, + JVD to angle of jaw
Cardiac: RRR, 2/6 SEM at apex
Lungs: CTA bilaterally
Abd: NABS, soft, nt/nd, no masses
Extr: no c/c/e, 2+ DP bilaterally
Pertinent Results:
Labs on admission:
[**2154-2-7**] 11:39PM PH-7.54*
[**2154-2-7**] 11:39PM freeCa-1.10*
[**2154-2-7**] 10:19PM GLUCOSE-192* UREA N-7 CREAT-0.5 SODIUM-138
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
[**2154-2-7**] 10:19PM ALT(SGPT)-20 AST(SGOT)-17 LD(LDH)-315* ALK
PHOS-114 TOT BILI-0.2
[**2154-2-7**] 10:19PM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-2.9
MAGNESIUM-1.8
[**2154-2-7**] 10:19PM WBC-2.6*# RBC-6.41*# HGB-17.9*# HCT-54.4*#
MCV-85 MCH-28.0 MCHC-33.0 RDW-15.4
[**2154-2-7**] 10:19PM NEUTS-83.7* LYMPHS-11.7* MONOS-4.1 EOS-0.2
BASOS-0.3
[**2154-2-7**] 10:19PM PLT COUNT-275#
[**2154-2-7**] 10:19PM PT-13.4 PTT-30.0 INR(PT)-1.1
Brief Hospital Course:
A/P: 51 yo female, with widely metastatic non-small cell lung
cancer, presenting with tracheal narrowing and ?cord
compression, no invervention tried, pt eventually made CMO and
passed away.
1. Metastatic Lung cancer: On presentation, she had ?cord
compression and tracheal narrowing. Steroids were initially
administered for ?cord compression (no definite evidence on
spinal MRI). She had balloon dilation of her trachea, but
flexible and rigid bronchoscopy with stenting could not be
performed. Rigid could not be performed [**2-13**] spinal disease, and
flexible could not be performed [**2-13**] nickel allergy to stent that
would be used. Radiation oncology was consulted for possible
radiation of the trachea for the narrowing. The decision was
made, however, to make the patient DNR/DNI and CMO (made by her
family). She was then put on a morphine drip with the dose
titrated up as necessary. Scolopamine patch was also used. She
passed away on [**2154-2-14**] at 1:35 pm. As per her husband, autopsy
will be performed.
Medications on Admission:
Meds on admission:
Ativan
MS [**First Name (Titles) **]
[**Last Name (Titles) 31039**]
B12
[**Name (NI) **]
Sonata
Celebrex
ASA
Percocet
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic lung cancer
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"4240"
] |
Admission Date: [**2185-6-22**] Discharge Date: [**2185-7-2**]
Date of Birth: [**2118-11-11**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Status post fall, facial abrasions
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67 yo male with long standing history of alcohol abuse,
depression, and anxiety. Found at bottom of several stairs with
altered mental status/obtundation. Multiple facial abrasions
were noted. He was hemodynamically stable with no evidence of
hypoxia. He was then sent from the referring institution for
further workup of his possible traumatic injuries and altered
mental status.
Past Medical History:
Alcohol abuse
Depression
Anxiety
Hypertension
Social History:
married, not employed currently, +tobacco, [**3-10**] EtOH/liquor
drinks Q24hr
Family History:
N/C
Physical Exam:
T 97.0 HR 68 BP 150/70 RR 20 SpO2 98%
HEENT- anicteric, MMM, no JVD, no thyromegaly, no bruit
Cor- RRR, no m/r/g
Pulm- CTA b/l
Abd- soft, ND, NT, no hernia/scar
Ext- no c/c/e/ct
Pertinent Results:
[**2185-6-21**] 11:30PM WBC-16.0* RBC-4.17* HGB-12.9* HCT-36.1*
MCV-87 MCH-31.0 MCHC-35.8* RDW-15.3
[**2185-6-21**] 11:30PM UREA N-27* CREAT-1.2
[**2185-6-22**] 01:28AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2185-6-21**] 11:30PM FIBRINOGE-565*
[**2185-6-21**] 11:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
The patient was transferred to [**Hospital1 18**], intubated for airway
protection at a referring insitution beacuse of altered mental
status. He was HD stable, no hypoxia and was minimally
repsonsive on exam (GCS 5T on admission). His pupillary exam
was normal and he did not have any evidence of
epileptic/myoclonic activity on examination. The patient was
transferred to the T/SICU for further management after a CT
head/Cspine/Torso was unremarkable (admission Cspine CT was
thought to be abnormal at C4/C5, however, MRI/MRA of the Cspine
and consultation w/ Dr. [**Last Name (STitle) 548**] proved that there was no injury).
Over the ensuing 72hrs in the T/SICU, a neurology consult was
obtained and an LP, cultures, tox screens, and EEG did not serve
to prove a diagnosis. Thereafter, he developed high grade
fever, tachycardia, increasing agitation (he emerged from his
obtunded state after 24hrs in the hospital), hypertension and
tachycardia. He was diagnoses w/ Delerium Tremens in the
setting of a possible post-concussive state and this was thought
to explain his initial presentation. Neurology concurred and
ultimately, [**Last Name (un) **] management w/ a CIWA protocol and judicous
Haldol dosing, we were able to extubae the patient. His mental
status and agitation improved thereafter, his BP regimen was
tailored to control his hypertension and thereafter he was
dismissed to home after PT clearance.
Medications on Admission:
klonapin, verapamil, HCTZ, atenolol, seroquel, baclofen
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) for 7 days.
2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 7 days.
Disp:*7 Patch 24 hr(s)* Refills:*0*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Delerium secondary to alcohol withdrawal
Status post fall, facial abrasions
Hypertension
Depression
Anxiety
Discharge Condition:
Stable
Discharge Instructions:
Please return to the hospital if you experience fevers greater
then 101.4, chills, or other signs of infection. Also return to
the hospital if you experience chest pain, shortness of breath,
redness, swelling, or purulent discharge from the incision site.
Return if you experience worsening pain or any other concerning
symptoms.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
.
Please restart all of your home meds as directed.
.
Please follow-up as directed. Please follow-up with your
primary care doctor and psychiatry as soon as possible.
Followup Instructions:
Please follow up with your primary care doctor as soon as
possible. One main reason is that you had high blood pressure
during your hospitalization. You will need to see your doctor
as soon as possible to discuss this with him/her and get
recommendations for optimizing your blood pressure management.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"3051",
"4019"
] |
Admission Date: [**2165-6-5**] Discharge Date: [**2165-6-7**]
Date of Birth: [**2096-5-3**] Sex: F
Service: NEUROSURGERY
Allergies:
IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Elective admit for coiling of PComm aneurysm
Major Surgical or Invasive Procedure:
Coiling of R Pcomm aneurysm
History of Present Illness:
Pt is a 69f with previously coiled R Pcomm aneurysm who presents
for elective admission for re-coiling procedure.
Past Medical History:
Right lens implant, asthma, HTN, hypothyroidism, hyperactive
bladder, renal CA with partial nephrectomy 5 years ago- treated.
Social History:
NC
Family History:
NC
Physical Exam:
Non focal
Brief Hospital Course:
Pt was admitted to the neurosurgery service and underwent
elective coiling of R Pcomm aneurysm. She tolerated the
procedure well with no complications. Post operatively she was
transferred to the ICU for further care including SBP control
and a heparin GTT for 24 hours. Her post op exam remained stable
and she had no issues. She was transferred to the floor in
stable condition on [**6-6**]. She was OOB and had no difficulty
voiding on her own or tolerating a PO diet. She was DC'd home in
stable condition on [**6-7**] and will follow up accordingly.
Medications on Admission:
Levothyroxine, norvasc, ASA 325
Discharge Medications:
1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
R Pcomm aneurysm
Discharge Condition:
AOx3. Activity as tolerated. No lifting greater than 10 pounds.
Discharge Instructions:
Medications:
?????? Take Aspirin as you have been prescribed and continue this
until further discussion with Dr. [**First Name (STitle) **] in clinc. Continue all
other medications you were taking before surgery, unless
otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency room.
Followup Instructions:
Please follow up in 1 month with Dr. [**First Name (STitle) **] with an MRI/MRA of
the head. Call [**Telephone/Fax (1) 58980**] for an appt.
Completed by:[**2165-6-7**]
|
[
"4019",
"2449",
"49390"
] |
Admission Date: [**2174-11-3**] Discharge Date: [**2174-11-9**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Increasing SOB and fatigue
Major Surgical or Invasive Procedure:
[**2174-11-3**] Aortic Valve Replacement utilizing a 21mm St. [**First Name5 (NamePattern1) 923**]
[**Last Name (NamePattern1) 9041**] Supra Pericardial Valve and Single Vessel Coronary Artery
Bypass Grafting with Left Internal Mammary Artery to Left
Anterior Descending Artery
History of Present Illness:
Ms. [**Known lastname 9449**] is a lovely woman with severe AS and significant
family history of CAD who has been followed with serial ECHO's
since her cath in [**2170**]. The last was done at [**Hospital3 **]
[**2174-10-21**] (reportedly showed severe AS which was a change from
ECHO done [**5-/2174**] - no report is available). Her primary
cardiologist Dr. [**Last Name (STitle) 39288**] has referred her for cardiac
catheterization as part
of her pre-op work-up for AVR. Currently, she states she has not
had not any chest pain but she has had a significant increase in
SOB and fatigue over the past two months. She is SOB after
walking 40 feet, climbing one flight of stairs and carrying in
empty trash cans from the curb, none of these activities
bothered her over the summer. She denies chest pain and resting
SOB. She has mild swelling in the ankles d/t a broken ankle a
long time ago. Cardiac catheterization on [**10-31**]
confirmed severe AS with mean gradient of 32 mmHg and [**Location (un) 109**] of
0.73 cm2. Selective coronary angiography showed a right dominant
system. There was no true left main coronary artery as the left
coronary ostium only supplied the left anterior descending
artery. The left anterior descending artery had angiographic
evidence of a 40% stenosis in the
proximal vessel. The left circumflex artery arose from a
separate ostium at the right aortic valve cusp. This ostium is
separate from the RCA ostium, but connectsvertically to the
ostium of the RCA. The left circumflex artery does
not have angiographic evidence of coronary artery disease in the
proximal segment. There is angiographic evidence of 40-50%
in-stent
restenosis in the mid-LCX. The right coronary artery had a
proximal [**Doctor Last Name 45655**] crook with a 40% stenosis. There was no
evidence of significant flow limiting stenosis in the mid or
distal RCA. Left ventriculography revealed mildly depressed left
ventricular systolic function. There was severe
hypokinesis/akinesis of the lateral and inferiobasal walls.
There was mild global hypokinesis elsewhere. Based on the above
results, arrangements were made for cardiac surgical
intervention.
Past Medical History:
Aortic stenosis, Coronary artery disease - s/p coronary
stenting, Hypertension, High Cholesterol, Diabetes mellitus,
Hypothyroidism, History of Kidney Stones, s/p TAH/BSO, Hard of
Hearing
Social History:
Widowed two years ago. Now lives with her daughter. She has six
children.
Family History:
Significant for premature CAD. Father had MI at age 61. Older
sister died of MI at age 56. [**Name (NI) **] sister died of [**University/College **] at age
62. Brothers had nonfatal MI at ages 62 and 36. One daughter had
MI with stent at age 39.
Physical Exam:
Vitals: BP 150/70, HR 69, RR 14, SAT 96% on room air
General: eldeerly female in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD, transmitted murmur to carotid noted
Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2174-11-9**] 07:30AM BLOOD WBC-9.7 RBC-3.28* Hgb-10.6* Hct-29.1*
MCV-89 MCH-32.4* MCHC-36.5* RDW-14.1 Plt Ct-197
[**2174-11-9**] 07:30AM BLOOD Plt Ct-197
[**2174-11-9**] 07:30AM BLOOD Glucose-135* UreaN-15 Creat-0.8 Na-138
K-4.4 Cl-102 HCO3-26 AnGap-14
[**2174-11-6**] 08:06AM BLOOD Mg-1.8
[**2174-11-4**] CXR
There has been interval removal of a left-sided chest tube. No
evidence of pneumothorax. Swan-Ganz catheter is again seen with
tip in the right pulmonary artery. Endotracheal tube has been
removed. There is atelectasis in the left lower lobe and small
left-sided pleural effusion are again seen. Osseous structures
are stable.
[**2174-11-3**] EKG
Sinus rhythm. Left bundle-branch block. Since the previous
tracing of [**2174-10-31**] the left bundle-branch block is new.
Brief Hospital Course:
Mrs. [**Known lastname 9449**] was admitted and underwent an aortic valve
replacement utilizing a 21mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 9041**] Supra Pericardial
Valve and single vessel coronary artery bypass grafting on
[**11-3**]. The operation was uneventful and she transferred
to the CSRU on minimal inotropic support. Within 24 hours, she
awoke neurologically intact and was extubated without incident.
She weaned from pressor support without difficulty and
transiently required a Nipride drip for hypertension. Beta
blockade was resumed. She gradually weaned from intravenous
therapy and transferred to the step down unit on postoperative
day three. She was noted to have intermittent episodes of
paroxysmal atrial fibrillation for which her beta blockade was
advanced as tolerated. She otherwise continued to make clinical
improvements. Her rhythm was observed for several days and
episodes of paroxysmal atrial fibrillation continued. Coumadin
was thus started for anticoagulation. Mrs. [**Known lastname 9449**] continued to
make steady progress and was discharged to home on postoperative
day six. At discharge, her oxygen saturations were 98% on room
air with a chest x-ray showing a small left sided pleural
effusion. She was in a normal sinus rhythm at 68 with a BP of
130/60. All surgical wounds were clean, dry and intact.
Medications on Admission:
Atenolol 25 qd, Lisinopril 40 qd, Lipitor 40 qd, Levoxyl 88mcg
qd, Aspirin 325 qd, Metformin 1000 qam and 500 qpm
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. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
3. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): 1000mg qam and 500mg qpm.
Disp:*75 Tablet(s)* Refills:*2*
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once: on[**11-9**]
then per dr. .
Disp:*30 Tablet(s)* Refills:*2*
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aortic stenosis, Coronary artery disease - s/p coronary
stenting, Hypertension, High Cholesterol, Diabetes mellitus,
Hypothyroidism, History of Kidney Stones, s/p TAH/BSO, Hard of
Hearing, Postop Atrial Fibrillation
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) **] in [**2-22**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15942**] in [**12-23**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) 39288**] in [**12-23**] weeks.
Completed by:[**2174-11-9**]
|
[
"4241",
"9971",
"42731",
"41401",
"4019",
"25000",
"2720",
"2449"
] |
Admission Date: [**2152-11-3**] Discharge Date: [**2152-11-14**]
Date of Birth: [**2075-1-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bactrim / Lipitor
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Right Mid-Line Placement
History of Present Illness:
77 y o F with bronchiectasis, severe COPD with baseline 2L 02
requirement, tracheobronchomalacia s/p Y-stent admitted to MICU
with Influenza A on [**11-3**].
As per patient, her symptoms began on [**10-31**] with sore throat,
headache, cough and SOB. Denied any fevers, chills, myalgias or
other systemic symptoms at the time. In ED, initial VS: 98.5,
71, 127/70, R=38, 96% 2LNC. Pt received methyprednisolone 125 mg
x 1, albuterol and ipratropium nebs x1, ativan, and IV
ciprofloxacin. She was placed on BIPAP 10/5 with FIO2 30% and
sent to MICU.
Patient was unable to tolerate BiPAP secondary to inability to
clear upper airway secretions; but was able to maintain
saturations on nasal cannula alone although she remained
tachypnic. In MICU, the patient was started on oseltamivir for
influenza and azithromycin. MICU course was complicated by low
urine output with a FeNa < 1% which resolved with 500 cc bolus.
Also found to have dysuria with positive urinalysis: started
empirically on ciprofloxacin prior to transfer to floor.
On transfer to the floor, VS 98.2 146/77 67 18 96% on RA. Still
complains of dyspnea greated than baseline, although notes an
improvement in initial symptoms of headache and sore throat.
Her cough is at baseline and she denies any increase in
purulence or quantity of sputum. Review of systems is otherwise
negative besides that noted in HPI.
Past Medical History:
COPD/TBM s/p Y stent placement [**2152-1-18**]. 3 other admissions and
9 therapeutic bronchoscopies since Y stent placement.
bronchiectasis
HTN
GERD
hypothyroid
hyperlipidemia
anxiety
recurrent UTI
anemia
hysterectomy at 33yo from anemia
b/l cataract sx
total knee replacement 2yrs ago
bladder sling
Social History:
Lives alone at home, attends pulmonary rehab 3x/week. Has 4
children, all live locally. Worked as a store clerk, retired 3
years ago, volunteered at [**Hospital3 3583**] until 3 mo ago.
Drinks wine infrequently. No h/o tobacco or illicit drug use.
Husband smoked until ~22 yrs ago. Daughter is a nurse. Reports
decreased appetite and enthusiasm for eating in past year,
markedly decreased activity and exercise tolerance, weight loss.
Family History:
Mother had MI, brother died from heart disease and had minor
stroke. No family history of lung disease/COPD/asthma. 4
children and 7 grandchildren are generally healthy; grandaughter
has spherocytosis and was just hospitalized for 5 days with flu
Physical Exam:
GENERAL: thin, elderly female in mild respiratory distress
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Purses lips during
expirations Neck Supple, No LAD, No thyromegaly.
CARDIAC: Distant heart sounds. Regular rhythm, normal rate.
Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**].
LUNGS: dyspneic with speech; using accessory muscles of
respiration with substernal retractions and scalene muscle use;
scattered rhonchi, limited air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No clubbing/ cyanosis/ edema or calf pain, 2+
dorsalis pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2152-11-3**] 11:42PM URINE BLOOD-TR NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2152-11-3**] 11:42PM URINE RBC-0-2 WBC-[**11-10**]* BACTERIA-NONE
YEAST-NONE EPI-[**2-24**]
[**2152-11-3**] 06:50PM TYPE-[**Last Name (un) **] PO2-54* PCO2-60* PH-7.32* TOTAL
CO2-32* BASE XS-2 COMMENTS-GREEN TOP
[**2152-11-3**] 05:05PM GLUCOSE-136* UREA N-17 CREAT-0.8 SODIUM-132*
POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-28 ANION GAP-14
[**2152-11-3**] 05:05PM WBC-12.5* RBC-4.98 HGB-13.3 HCT-41.3 MCV-83
MCH-26.7* MCHC-32.2 RDW-13.6
[**2152-11-3**] 05:05PM NEUTS-73.0* LYMPHS-23.4 MONOS-2.7 EOS-0.5
BASOS-0.3
[**2152-11-3**] 05:05PM PLT COUNT-238
[**2152-11-3**] 05:05PM PT-12.3 PTT-27.1 INR(PT)-1.0
[**2152-11-10**] 06:11AM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2152-11-10**] 06:11AM URINE RBC-8* WBC-245* Bacteri-MOD Yeast-NONE
Epi-2 TransE-1
[**2152-11-10**] 06:11AM URINE WBC Clm-RARE Mucous-RARE
Microbiology Data:
POSITIVE FOR INFLUENZA A VIRAL ANTIGEN. [**2152-11-3**]
Positive for Swine-like Influenza A (H1N1) virus by
RT-PCR at
State Lab.
GRAM STAIN (Final [**2152-11-11**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final [**2152-11-13**]):
HEAVY GROWTH Commensal Respiratory Flora.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
[**2152-11-10**] 6:11 am URINE Source: CVS.
**FINAL REPORT [**2152-11-13**]**
URINE CULTURE (Final [**2152-11-13**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
EKG: [**2152-11-3**]
Baseline artifact is present. Sinus rhythm. The axis is
indeterminate.
Non-specific ST-T wave changes. Compared to the previous tracing
voltage has improved in the limb leads.
CXR: [**2152-11-3**]
The lungs are massively hyperexpanded but stable from prior
exam.
This likely indicates underlying obstructive lung disease. No
consolidation or edema is evident. There is a markedly tortuous
aorta with calcified plaque at the arch. The cardiac silhouette
is within normal limits for size. No effusion or pneumothorax is
seen. There is blunting of the right costophrenic angle,
presumably due to scarring. The osseous structures are grossly
unremarkable.
IMPRESSION: Underlying COPD. No acute pulmonary process
CXR: [**2152-11-10**]
Cardiac size is normal. The aorta is tortuous. The lungs are
hyperinflated
but clear. There is no evidence of pneumothorax. If any, there
is a small
left pleural effusion. Cardiomediastinal contours are unchanged,
with cardiac size top normal. The patient has known bibasilar
and right middle lobe bronchiectasis.
Brief Hospital Course:
Mrs. [**Known lastname **] is a 77 yo woman with severe COPD, severe
bronchiectasis, tracheobronchomalacia s/p Y-stent placed [**12-31**]
who was admitted with H1N1 influenza on [**2152-11-3**], stabilized in
the MICU on BiPAP for a few hours and transferred to the floor
on [**2152-11-5**].
1. Influenza A: Confirmed H1N1 by state lab. Pt received a
course of 5 day course of oseltamivir 75 mg [**Hospital1 **] beginning
[**2152-11-3**]. Pt was placed on droplet precautions and given
symptomatic relief PRN.
2. SOB/respiratory distress: Throughout her stay, pt sat in the
tripod position and breathed with pursed lips, with varying
amounts of superimposed respiratory distress. Her cough was
typically productive of green sputum.
Pt received home nebs (ipratropium, levalbuterol,
acetylcysteine) as well as guaifenesin. Her COPD exacerbation
was treated with 5 days of prednisone 40 mg followed by a
prolonged prednisone taper as well as 5 days of azithromycin.
She received chest PT regularly beginning on [**11-8**]. Her
respiratory status fluctuated throughout her stay, with
respiratory rate ranging from 24-40. HCO3 was in the high 20s
on admission and the low to mid 30s through most of the
hospitalization, climbing as high as 37 on [**11-8**] before
decreasing to 33 by discharge. ABG on [**11-9**] showed a mild
metabolic alkalosis (pH 7.46, pCO2 49) likely consistent with
acutely improved ventilation overlying chronic metabolic
compensation for respiratory acidosis. Respiratory status on
discharge had not yet improved to her baseline: saturating
94-96% on 3LNC.
3. UTI: History of frequent UTIs. Complained of dysuria, found
to have sterile pyuria on admission. She was started on Cipro
500 mg [**Hospital1 **] which was discontinued after 3 doses given resolving
symptoms and negative cultures. She developed new dysuria and
mild leukocytosis on [**11-9**] and was begun on Cipro again on [**11-10**]
when her UA showed positive nitrite, 245 WBC, and moderate
bacteria. Urine culture grew ESBL e.coli so patient was started
on meropenem. Finally antibiotics were switched to ertapenem on
day of discharge for ease of administration: instructed to
complete 10 day course (9 additional days) with repeat
urinalysis and urine culture upon completion.
4. Anxiety: Pt received lorazepam 0.25 mg [**Hospital1 **] while in house,
which she takes at home.
5. HTN: Pt was maintained on home dose atenolol 50 mg daily.
SBP 130s to 180s throughout, likely due to stress state and
increased steroid dose.
6. Hypothyroidism: Pt maintained on home dose levothyroixine 112
mcg daily
Medications on Admission:
simvastatin 20 mg qHS
ASA 81 mg daily
atenolol 50 mg daily
mucomyst nebs 3 mL q8hr
albuterol inhaler q 2h PRN
levalbuterol neb q 6-8 hr PRN
tiotropium 18 mcg daily
fluticasone 50-100 mcg daily
prednisone 5 mg every other day
flovent 110mcg, 4 puffs [**Hospital1 **]
mucinex 1200 mg [**Hospital1 **]
citalopram 50 mg daily
mirtazapine 7.5 mg qHS
lorazepam 0.5 mg [**Hospital1 **] PRN
levothyroxine 112 mcg daily
methenamine hippurate 1 g [**Hospital1 **]
omeprazole 40 mg [**Hospital1 **]
sucralfate ACHS
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
2. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO bid ().
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety.
7. Acetylcysteine 20 % (200 mg/mL) Solution Sig: One (1) ML
Miscellaneous Q 8H (Every 8 Hours).
8. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation PRN (as needed) as needed
for see below: please use when giving mucinex.
12. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation Q4H (every 4 hours) as needed for wheezing,
dyspnea.
13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO QD () for 3
days.
14. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QD () for 3
days.
15. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QD () for 3
days.
16. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous daily
() as needed for complicated UTI for 9 days.
17. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
18. Citalopram 10 mg Tablet Sig: Five (5) Tablet PO once a day:
total dose of 50mg.
19. Methenamine Hippurate 1 gram Tablet Sig: One (1) Tablet PO
twice a day.
20. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QCHS.
21. Outpatient Lab Work
please repeat urinalysis and urine culture on [**2152-11-22**]; after
completing antibiotic course
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
H1N1 Influenza
COPD exacerbation
Urinary tract infection
Discharge Condition:
hemodynamically stable; respiratory status near baseline:
tripods, uses accessory muscles of respirations, intermittent
tachypnea to 30s, saturating 94-96% on 3 LNC
Discharge Instructions:
You were admitted to the hospital with increased shortness of
breath and cough and were diagnosed with H1N1 influenza. Your
breathing was briefly supported with a mask ventilator in the
intensive care unit. You were treated with oseltamivir
(Tamiflu) for your influenza and prednisone and azithromycin
(antibiotics) for your COPD flare, along with your usual oxygen
and nebulizers. You were treated with Cipro for a possible
urinary tract infection which seemed to go away; you developed a
urinary tract infection after the Cipro was stopped; it was
re-started on [**2152-11-10**].
Please limit your exertion while you are getting over your
influenza and continue your usual routine of nebulizer
treatments and pulmonary rehab appointments.
Please call your doctor or go to the emergency room if you
develop new fevers, chills, increased difficulty breathing,
cough up blood, chest pain, bloody urine, or any other symptom
that you find concerning.
Followup Instructions:
Please make an appointment with your primary car physician
[**Name Initial (PRE) 176**] 1-2 weeks of your discharge from rehab.
-Dr. [**First Name4 (NamePattern1) 2398**] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 250**]
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
[
"5990",
"53081",
"4019",
"2859",
"2449"
] |
Admission Date: [**2199-12-9**] Discharge Date: [**2199-12-22**]
Date of Birth: [**2130-4-10**] Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Ceftazidime / Fosamax
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Blood transfusions
Electrophysiology ablation
History of Present Illness:
Pt is a 69 yo female with a history of 3VD CAD, s/p CABG in [**2169**]
and awaiting repeat, mixed systolic/diastolic CHF with EF
40-45%, who presented with 10 days of progressive dyspnea. 10
days prior to admission, pt felt dyspneic and a decrease in how
far she could walk. + new 2 pillow orthopnea. + subjective "low
grade fever," though did not measure it at home. + cough
productive of white frothy sputum. +2 pillow orthopnea, whereas
normally can lay flat. No PND. No LE edema.
Recent Cardiac cath [**2199-9-10**] showed diffuse 3 vessel disease,
severe mitral regurgitation, and mild systolic and diastolic
ventricular dysfunction. ECHO [**2199-8-27**] also showed severe MR [**First Name (Titles) **] [**Last Name (Titles) 75827**]y reduced LV and RV systolic function. Pt is followed by
Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] of CT [**Doctor First Name **] at [**Hospital1 112**], and is to get repeat
CABG/MVR in near future once cleared by Dr. [**Last Name (STitle) 497**] for her esoph
varices (to have repeat EGD [**2198-12-17**] after recent banding), and
once her R axillary LAD etiology is determined (had negative
dissection with bx 1y PTA, was to have another recently but did
not make the appt because of her current illness.
Pt was admitted to the MICU as she was found to be in atrial
fibrillation with RVR, tachypnic, confused, and with a new renal
failure. She was initially on a diltiazem gtt for her atrial
fibrillation. She was seen by cardiology, and despite increasing
beta blocker and diltiazem, was persistently in afib with RVR.
Pt underwent ibutilide cardioversion with success on [**2199-12-11**].
On transfer to the regular medicine service, pt feels well. No
CP/SOB. No F/C/N/V.
Past Medical History:
1. CAD, CABG x3 at age 39 at [**Hospital1 112**]
2. Congestive heart failure, EF 40-50% ([**8-19**]), moderate-severe
MR.
3. Paroxysmal atrial fibrillation
4. Upper GI bleed with esophageal varicies diagnosed in [**Month (only) 216**]
[**2192**], most recent EGD showing grade III esophageal varices,
status post banding [**11-18**]
5. Ascites secondary to [**Month/Year (2) 32004**] vein thrombosis, [**2188**].
6. Idiopathic thrombocytopenic purpura s/p splenectomy in [**2188**]
(in the setting of chemotherapy treatment for breast cancer).
7. Sarcoidosis - diagnosed in [**2164**]
8. Left breast cancer diagnosed in [**2188**], status post lumpectomy,
chemotherapy and radiation treatment. Was on tamoxifen until
[**2194-3-15**].
8. Hypercholesterolemia
9. Osteoporosis
10. IBS
11. Hyperparathyroidism
12. Depression
13. Lactose intolerance
14. Status post cholecystectomy in [**2190**]
15. Stable AAA - 4.2 x 3.9 cm
16. Right axillary dissection and neck exploration for enlarged
right adenopathy
Social History:
Married, formerly worked at a department store. H/o tobacco use
(1 ppd quit 14 years ago) Denies EtOH, IVDA
Family History:
F: died of CHF
M: CAD
S: DM2
Physical Exam:
VS: T: 97.4 (98.0); BP: 122/85 (117-134/54-85); P: 60s-70s; RR:
22; O2: 96 ; I/O 350/475; 14 hr: 620/350
General: Older female speaking in full sentences, though has to
take a breath mid-sentence. Mildly tachypnic
HEENT: Sclera anicteric; EOMI; OP clear
Neck: Right EJ in place. JVD to angle of jaw?
CV: RRR S1S2. II/VI systolic murmur at apex
Chest: Rales at left base. Otherwise clear
Abd: +BS. +fluid wave. Soft, nt, ND
Ext: No edema
Neuro: A&O x 3. Reflexes: biceps, bracio, patellar all [**1-16**]. MS
[**4-18**] throughout. CN II-XII tested and intact.
Pertinent Results:
Labs on admission:
[**2199-12-9**] 11:50AM BLOOD WBC-13.1* RBC-4.04* Hgb-11.7* Hct-35.3*
MCV-87 MCH-28.9 MCHC-33.1 RDW-17.2* Plt Ct-124*
[**2199-12-9**] 11:50AM BLOOD Neuts-59.0 Lymphs-32.0 Monos-6.2 Eos-1.1
Baso-1.7
[**2199-12-9**] 12:53PM BLOOD PT-15.0* PTT-28.2 INR(PT)-1.5
[**2199-12-9**] 11:50AM BLOOD Glucose-147* UreaN-46* Creat-2.9*# Na-140
K-7.9* Cl-108 HCO3-13* AnGap-27*
[**2199-12-9**] 11:59AM BLOOD ALT-33 AST-105* CK(CPK)-137 AlkPhos-128*
Amylase-57 TotBili-1.0
[**2199-12-9**] 11:59AM BLOOD CK-MB-3 cTropnT-0.17*
[**2199-12-9**] 08:52PM BLOOD Ammonia-<6
[**2199-12-9**] 09:26PM BLOOD Lactate-2.2*
_______________________
Cardiac Labs:
[**2199-12-9**] 11:59AM BLOOD CK-MB-3 cTropnT-0.17*
[**2199-12-9**] 03:00PM BLOOD CK-MB-3 cTropnT-0.23*
[**2199-12-9**] 08:52PM BLOOD CK-MB-3
[**2199-12-10**] 05:02AM BLOOD CK-MB-NotDone cTropnT-0.23*
[**2199-12-11**] 05:47AM BLOOD proBNP-4003*
[**2199-12-14**] 01:15PM BLOOD CK-MB-NotDone cTropnT-0.31*
[**2199-12-14**] 07:25PM BLOOD CK-MB-NotDone cTropnT-0.32*
[**2199-12-15**] 06:45AM BLOOD CK-MB-1 cTropnT-0.22*
_______________________
Other Labs:
[**2199-12-15**] 06:45AM BLOOD calTIBC-311 Ferritn-68 TRF-239
[**2199-12-12**] 06:33AM BLOOD C3-98
_______________________
Labs on discharge:
[**2199-12-22**] 05:41AM BLOOD WBC-12.5* RBC-3.54* Hgb-9.7* Hct-29.5*
MCV-83 MCH-27.4 MCHC-32.9 RDW-16.1* Plt Ct-223
[**2199-12-22**] 05:41AM BLOOD Glucose-112* UreaN-36* Creat-1.5* Na-138
K-4.0 Cl-103 HCO3-23 AnGap-16
[**2199-12-22**] 05:41AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.8
_______________________
Radiology:
Chest AP 12/26/06-1. Cardiomegaly with mild CHF.
2. Biapical scarring unchanged. By report, the patient has a
history of sarcoid.
3. No focal infiltrate identified.
4. Small nodular density left mid zone. See comment above.
- - - - - - - - - - - -
Abdominal ultrasound with dopplers [**2200-12-9**]
1. Redemonstration of [**Month/Day/Year 32004**] vein thrombosis.
2. No evidence of liver mass or ascites.
3. IVC enlargement and increased dynamic flow in the hepatic
veins consistent with patient's history of known CHF.
- - - - - - - - - - --
Echo [**2200-12-10**]-There is mild regional left ventricular systolic
dysfunction. Tissue velocity imaging E/e' is elevated (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg). Resting regional wall motion abnormalities
include basal to mid inferior and distal septal hypokinesis.
Right ventricular chamber size is normal. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. The
left ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. There is mild pulmonary
artery systolic hypertension.
Compared with the prior study (tape not available) of [**2199-8-27**],
overall left ventricular systolic function is probably similar
(however distal septal hypokinesis noted in the current study
but not in the prior report). Mitral regurgitation is now less
prominent. There is now a restrictive left ventricular filling
pattern.
- - - - - - - - - - - - -
Chest PA/LAT [**2199-12-17**]-IMPRESSION: Cardiomegaly, interstitial
edema, and small left pleural effusion unchanged.
EKG on admission: Atrial fibrillation, rate ~140s. Left axis.
New STD II,III, AvF, V4-V6.
Brief Hospital Course:
Pt is a 69 yo female with h/o 3VD CAD, s/p CABG in [**2169**] and
awaiting repeat, mixed systolic/diastolic CHF with EF 40-45%,
who presents with 10 days of progressive dyspnea, found to have
a fib with RVR, ARF, and increased ascites. She is s/p
cardioversion with ibutilide and had an EP ablation.
1. Cardiovascular:
a. [**Name (NI) 9520**] Pt was in Afib/Aflut and is s/p ibutilide conversion
to sinus rhythm when she was in the ICU. She was being rate
controlled with PO metoprolol which was being uptitrated but she
went back in to aflutter with RVR on HD 10. She maintained her
pressure and was put on a diltiazem drip, uptitrated to 15
units/hour. She spontaneously converted to normal sinus on HD 12
and had an EP study with ablation that day. Metoprolol was
continued and she was discharged on 50 mg tid.
It was decided not to anticoagulate this patient with varices
after speaking with liver as she is an extreme risk of bleeding.
b. CAD- known 3VD. Pt had new inferolateral ST depressions which
got better on subsequent EKGs. We continued ASA and beta
blocker.
c. Pump/BP- Known mixed systolic, diastolic heart failure.
Repeat echo here showed EF 40-45%. Additionally, it appeared on
physical exam and based on chest xray with b/l pleural effusions
that pt was in CHF exacerbation likely secondary to the RVR. She
was diuresed 1-2 L/day with lasix and her spironolactone was
initially held but slowly uptitrated. While she was in rapid
afib, diuresis was held as we wanted to maintain her pressures.
Hydralazine and isosorbide were held as pressures were
borderline and we wanted to diurese her. Isosorbide was able to
be restarted post-ablation. Strict I/Os were kept, pt was on a
fluid restriction, and a low sodium diet. Wt on discharge was
61.5 kg and likely represents her dry weight.
2. ARF-baseline cr 0.9-1.0, was 3.0 at peak and slowly came
down. It was thought to be a prerenal state from CHF, less
likely afib with RVR as time correlation between the two was a
few days to resolve. Urine Eos were negative, and C3 was normal
therefore it unlikely artheroembolic. Renal u/s showed no
evidence of obstruction or hydronephrosis. As pt was diuresed,
her creatinine came down. On discharge her creatinine was
1.5-1.7 and this likely represents a new baseline for her.
3. [**Name (NI) 1621**] Pt was dyspneic in the first half of her
hospitalization. It was likely [**1-16**] CHF, anxiety, worsening
ascites. As she was diuresed, and with ativan, pt became less
dyspneic. Also, at the end of hospitalization, pt was ambulation
and satting in the mid-upper 90s.
4. Leukocytosis- Peak WBC of 18.8 and Low grade temperatures in
upper 99s. There were no signs of infection and pt was
pancultured multiple times. U/As were negative. BCx x 2 were
negative, UCx were negative.
5. Hepatology/[**Name (NI) **] Pt with [**Name (NI) 32004**] vein thrombosis that is
chronic. We did not anticoagulate her afib/flutte [**1-16**] varices,
and an extremely high risk of bleeding. Aldactone was initially
held when pt went back in to afib/flutter which was restarted
and uptitrated after the EP ablation. In terms of varices,
stools were gauaiced and negative. An active T&S was kept at all
times. Sucralfate and PPI were continued. She will need repeat
banding as an outpt.
6. Anemia- As above. Iron studies were consistent with anemia of
chronic disease (Iron 12, TIBC, ferritin nl). Pt was given 2
units of pRBC, one each on HD6 and HD 7.
7. F/E/N-renal, cardiac, low salt diet. Electrolytes were
checked and repleted prn.
8. Prophylaxis-Pt was on pneumoboots (given risk of bleeding),
PPI, sucralfate
9. Access- 2 PIVs.
10. [**Name (NI) 8410**] Pt was Full Code.
Medications on Admission:
Propranolol 80 mg daily
Aldactone 100 mg daily
Protonix 40 mg daily
Lovastatin 40 mg daily
Centrum Silver one tablet daily
Medications on transfer:
ASA 325 mg po qday
Atorvastatin 40 mg qday
Benzonatate 100 mg tid
MVI
Colace 100 mg [**Hospital1 **]
Anzemet 12.5 mg prn nausea
Guafenesin with codeine q 6 prn
Hydralazine 10 mg po q6 hours
Isosorbide dinitrate 10 mg [**Hospital1 **]
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
4. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
6. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary diagnosis:
Atrial flutter with rapid ventricular rate
S/P ablation
Congestive heart failure
Acute renal failure
Anemia
Secondary Diagnosis:
Coronary artery disease
Esophageal Varices
Discharge Condition:
Better. Pt is in sinus rhythm at a normal rate. She is
ambulating and her oxygen saturation is good.
Discharge Instructions:
Low sodium diet (2 grams)
Fluid restriction [**2193**] ml
Please call your doctor or go to the emergency room if you have
chest pain, shortness of breath, worsening breathing, weakness,
lightheadedness, or any other health concern.
Please make note that you have many medication changes.
Followup Instructions:
-Please call Dr.[**Name (NI) 60978**] Office for followup in the next few
weeks. You will need repeat banding of your varices. The number
is [**Telephone/Fax (1) 7091**].
-You will need follow up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] at [**Hospital1 3372**]. YOu should call him this week. Additionally,
you can get a copy of your discharge summary by calling medical
records at [**Telephone/Fax (1) 2806**]. It should be ready in ~1 week.
-You will need to follow up with electrophysiology per their
recommendations. Their number is [**Telephone/Fax (1) 99417**].
-You will need to call Dr.[**Name (NI) 2935**] office at [**Telephone/Fax (1) 2936**].
You should have follow up in the next 7-10 days.
-You will need to get your right axiallary lymph nodes followed
up as you know about.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"5849",
"4280",
"2762",
"2767",
"496",
"41401",
"4240",
"4019",
"V4581"
] |
Admission Date: [**2154-1-27**] Discharge Date: [**2154-1-31**]
Date of Birth: [**2110-4-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
altered mental status, sob, decreased urine output, chest
burning
Major Surgical or Invasive Procedure:
none
History of Present Illness:
43 year-old woman with multiple medical problems, including CAD
s/p MI [**2141**], CHF with diastolic dysfunction, TIDM c/b
gastroparesis, [**Year (4 digits) **]/scleroderma, restrictive lung disease,
Gerd, s/p retinal hemorrhage [**1-26**], presents today with
decreased urine output, shortness of breath, mental status
changes, and chest burning. She also reports a month long
history of diarrhea that resolved 4 days ago. She reports
decreased appetite, po intake, and now with no bowel movement
for 4 days. Two days prior to presentation she developed
worsening dyspnea at rest associated with nonradiating chest
burning sensation, and increasing abdominal and lower extremity
swelling. She also noted onset of a rash in the bilateral lower
extremities that is not painful or itching. She was recently
started on standing Reglan as treatment for gastroparesis one
week prior to presentation. Additionally in the past week
prednisone was tapered off. She also had noted a hemorrhage in
her right eye one day PTA.
In the ED, hypotensive at 90/50. Treated with 3L NS, CTX dose
and 100mg hydrocortisone and transferred to [**Hospital Unit Name 153**].
Past Medical History:
CAD s/p MI and LAD/RCA stents [**2141**]
CHF w/ EF 57% 9/02
DM1 (IDDM) w/ triopathy
Scleroderma
[**Year (4 digits) **] syndrome (Lupus overlap)
Restrictive lung dz
H/o flash pulmonary edema
+ antiphospholipid antibody syndrome on coumadin
S/p PE [**1-/2142**]
GERD
Hiatal hernia
gastroparesis
Hypothyroidism
CRI
Migraines
Gout
s/p appy and ccy
Social History:
Lives w/ husband and daughter, prior [**6-11**] pk yr tob hx, quit 10
yr ago. Does not work. Denies EtOH.
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3707**] [**Telephone/Fax (1) 20792**]
Cardiologist: [**First Name8 (NamePattern2) 5987**] [**Last Name (NamePattern1) 13114**] [**Telephone/Fax (1) 25520**]
Endocrinologist: [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 26643**]
Pulmonary: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 23427**] [**Telephone/Fax (1) 93113**]
Nephrologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10083**] [**Telephone/Fax (1) 3637**]
Ophthalmologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 28100**]
Rheumatologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2226**]
Gastroenterologist: [**Telephone/Fax (1) 21732**]
Family History:
Mom w/ scleroderma/[**Telephone/Fax (1) **], multiple myeloma
Physical Exam:
T 97.6 HR 98 BP 99/43 RR 16 92%4Lnc
Gen: lying in bed, comfortable, speaking in full sentences, NAD
HEENT: PERRL, anicteric, conjunctiva pink, MMM
Neck: supple, no LAD
CV: RRR with distant heart sounds, no mrg, 1+DP pulses B
Resp: bibasilar crackles
Abd: obese, soft, NT, mildly distended, no masses, no fluid
wave
Ext: erythematous with 2+ pitting edema bilaterally
Skin: erythema anterior aspect of B legs, no telangiectasias,
no raynoud's
Neuro: A&Ox3, CNII-XII intact, strenth [**6-6**] throughout,
decreased sensation to fine touch B distal LE, +asterixis
Pertinent Results:
[**2154-1-27**] 01:00PM URINE HOURS-RANDOM UREA N-318 CREAT-197
SODIUM-31
[**2154-1-27**] 01:00PM URINE OSMOLAL-316
[**2154-1-27**] 01:00PM PT-23.2* PTT-45.6* INR(PT)-3.4
[**2154-1-27**] 01:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2154-1-27**] 01:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2154-1-27**] 01:00PM URINE RBC->50 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**4-6**]
[**2154-1-27**] 01:00PM URINE AMORPH-FEW
[**2154-1-27**] 01:00PM URINE EOS-NEGATIVE
[**2154-1-27**] 11:41AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2154-1-27**] 11:41AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2154-1-27**] 11:41AM URINE RBC->50 WBC-[**7-12**]* BACTERIA-FEW
YEAST-NONE EPI-21-50
[**2154-1-27**] 11:18AM LACTATE-2.3*
[**2154-1-27**] 11:17AM GLUCOSE-111* UREA N-110* CREAT-6.5*#
SODIUM-134 POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-30* ANION GAP-15
[**2154-1-27**] 11:17AM ALT(SGPT)-22 AST(SGOT)-17 CK(CPK)-56 ALK
PHOS-91 AMYLASE-42 TOT BILI-0.5
[**2154-1-27**] 11:17AM cTropnT-0.04*
[**2154-1-27**] 11:17AM CK-MB-NotDone
[**2154-1-27**] 11:17AM ALBUMIN-3.7 CALCIUM-9.3 PHOSPHATE-3.2
MAGNESIUM-3.1*
[**2154-1-27**] 11:17AM WBC-10.2 RBC-2.80* HGB-8.7* HCT-26.0* MCV-93
MCH-31.0 MCHC-33.4 RDW-15.2
[**2154-1-27**] 11:17AM NEUTS-84.5* LYMPHS-11.7* MONOS-3.6 EOS-0.1
BASOS-0.2
[**2154-1-27**] 11:17AM PLT COUNT-282
.
CXR: no acute cardiopulmonary process
ECG: 85bpm, nsr, nml intervals, nml axis, no st/t changes
[**2154-1-28**] RENAL ULTRASOUND: The right kidney measures 11.0 cm.
The left kidney measures 11.2 cm. There is no evidence of
hydronephrosis, masses or stones. A Foley catheter is identified
within a decompressed bladder
Brief Hospital Course:
43 year-old woman with h/o CAD s/p MI [**2141**], CHF with diastolic
dysfunction, TIDM c/b gastroparesis, [**Year (4 digits) **]/scleroderma,
restrictive lung disease, Gerd, s/p retinal hemorrhage [**2154-1-26**],
presents today with decreased urine output, increased LE edema,
shortness of breath, mental status changes, and chest burning.
Laboratory analysis suggestive of ARF on CRI. During
hospitalization the following problems were addressed:
1. ARF: Patient with CRI, baseline creatinine around 2.2, but
very labile, presented with creatinine 6.5. Renal ultrasound
showed no hydronephrosis. FENA 0.8% suggestive of prerenal
azotemia. Renal consulted, spun urine with no sediment noted.
Etiology thought to be prerenal secondary to hypovolemia with
diarrhea. Initial presentation concerning for uremia given
fluid overload, rash, asterixis on exam, but creatinine improved
to 4.8 by day #2 and patient did not want hemodialysis and her
electrolytes were stable. All nephrotoxic medications held; [**Last Name (un) **]
held. Initially treated with ivf's, went into diastolic heart
failure, and treated with lasix. She thereafter continued to
autodiurese.
2. Hypotension: likely due to hypovolemia, intravascular
depletion as pressure responded well to IVFs. Baseline SBP
100s, presented with SBP 90. No evidence of infection or other
source of sepsis. [**Month (only) 116**] have benefitted from [**Last Name (un) 104**] stim test given
recent steroid course, but steroids dosed in ED. No further
steroids given and blood pressure remained within normal range.
Antihypertensives were initially held. Beta-blocker resumed as
blood pressure came up and as she has diastolic failure.
3. Mental status changes: ddx: uremia as described above vs
hypoglycemia as pt reports baseline bl sugar 180s and symptoms
develop with bl sugar 80, presented to ED with bl glucose 108.
Mental status now improved back to baseline.
4. ? PNA vs viral syndrome: In [**Hospital Unit Name 153**], patient treated with CTX
-> then switched to levoaquin monotherapy, and had rapid
improvement with stabilization of pressures and marked diuresis
and start of resolution of ARF on CRI. She was put on a 7 day
course of levaquin.
5. Coagulopathy: patient on coumadin for h/o antiphospholipid
antibody syndrome. Anticoagulation held as pt supratherapeutic
with INR 3.7 on presentation; may be d/t antibiotic use causing
decreased metabolism of coumadin vs nutritional losses. Pateint
received 10mg SQ vitamin K and INR came down to 1.7. She was
put on heparin and switched to lovenox as a bridge and coumadin
was restarted at home dose of 3mg QHS.
6. CAD: pt presented with chest pain not c/w previous
ischemia, no ECG changes, normal cardiac enzymes. B-blocker and
[**Last Name (un) **] were initially held with hypotension; continued on lipitor.
Pt is not on ASA at baseline.
7. CHF: pt with h/o diastolic dysfunction, nml EF (>55%) on
echo [**2151**] and more recently by report from pt's cardiologist.
No evidence of pulmonary edema on initial CXR, but with pulm
edema on day #2 after IVF load. Treated on day #2 with lasix
with good response. No longer short of breath, and beta-blocker
resumed.
8. type I DM: On home insulin pump. Patient is followed at
[**Last Name (un) **].
9. Gastroparesis: complication of DM; reglan held as it is a
new medication and patient with MS changes and ARF in patient
with h/o urinary retention. Once renal function improved,
reglan restarted.
10. Sciatica: d/t disc herniation; s/p steroid course and
taper, treated in house with oxycodone prn for pain control per
home regimen
11. Hypothyroidism: continued on home synthroid
12. Diarrhea: seems to be resolved now; may be have been
antibiotic associated; was likely the etiology of her metabolic
alkalosis as diarrheal dehydration causing contraction alkalosis
13. Gout: holding allopurinol [**3-5**] nephrotoxicity
14. R retinal hemorrhage: followed by ophthalmology, and
thought to be a preretinal hemmorhage with no contraindication
to anticoagulation. She also has known proliferative diabetic
retinopathy s/p PRP OU, which has resulted in decreased
peripheral visual fields. Outpatient followup recommended.
Medications on Admission:
Warfarin Sodium 3 mg PO HS
Atorvastatin 80 mg PO QD
Losartan Potassium 50 mg PO once a day
Nifedipine ER 30 mg Sustained Release PO once a day.
Betaxolol HCl 20 mg PO once a day.
Verapamil HCl 120 mg Sustained Release PO once a day.
Levothyroxine Sodium 150 mcg PO QD
Desipramine 75mg PO QD
Allopurinol 200 mg PO QD
Hydrochlorothiazide 50 mg PO QD
Calcitriol 0.25 mcg PO QD
Furosemide 80 mg 2-4 times a day
Omeprazole 20 mg PO twice a day
Gabapentin 300 mg PO BID
iron supplement
Zolpidem Tartrate 5-10 mg PO HS PRN
Tigan 250 mg once a day PRN migraine.
Midrin prn
Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H PRN.
oxycodone prn
Metoclopramide 5 mg PO QIDACHS
Provigil 100mg prn
Multivitamin once a day
Cipro for bacterial overgrowth d/c'd one week ago
Flagyl 500mg PO TID for bacterial overgrowth d/c'd 1 week ago
Prednisone taper d/c'd 4-5 days ago
Hyoscyamine 0.125-0.250 mg QID PRN RUQ pain
Discharge Medications:
1. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
4. Warfarin Sodium 2 mg Tablet Sig: 1.5 Tablets PO HS (at
bedtime).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
7. Betaxolol HCl 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Verapamil HCl 120 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Desipramine HCl 75 mg Tablet Sig: One (1) Tablet PO once a
day.
10. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
11. Hyoscyamine Sulfate 0.125 mg Tablet Sig: 1-2 Tablets PO [**3-7**]
times daily.
12. Neurontin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
14. Insulin Pump Eng/French R1000 Misc Miscell.
15. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
16. Lovenox 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous once
a day: take this while your INR is less than 2.5.
Disp:*7 syringes* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnoses
1. Acute Renal Failure with uremia
2. Hypotension
3. Congestive heart failure
4. Mental status changes
5. R retinal hemorrhage
6. Pneumonia
7. Diarrhea
Secondary diagnoses:
8. type I DM
9. Gastroparesis
10.Chronic renal insufficiency
11. Hypothyroidism
12. Sciatica
13.Gout
14. antiphospholipid antibody syndrome
14. scleroderma/[**Company **] syndrome
Discharge Condition:
stable and improved without difficulty and with improving
creatinine. Last creatinine was 2.9.
Discharge Instructions:
Please call your doctor if you experience fever greater than
100.5, shaking chills, shortness of breath, chest pain, severe
nausea, vomiting or abdominal pain, inability to urinate, or
worsening diarrhea.
Have your creatinine and INR checked on Monday.
Weigh yourself at least three times daily. Do not take lasix or
hydrochlorothiazide for now. You can start lasix once a day if
you gain more than two pounds in a day.
You can resume all your other outpatient medications.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 3707**], your PCP, [**Name10 (NameIs) 176**] one week of
discharge to have your creatinine and INR checked.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2154-4-23**] 2:00
|
[
"5849",
"4280",
"486",
"2449"
] |
Admission Date: [**2199-7-15**] Discharge Date: [**2199-7-20**]
Date of Birth: [**2126-2-5**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This 73-year-old male with a
long history of heart murmur was diagnosed with mitral valve
prolapse and then mitral regurgitation. Serial echo's showed
worsening MR with increasing LV dimensions and decreasing
ejection fraction. He now has new onset of paroxysmal atrial
fibrillation in [**2199-2-26**] prior to admission. Cath in
[**2199-5-29**] showed clean coronaries without any hemodynamic
obstruction. He has been relatively asymptomatic with no
chest pain, syncope, presyncope; but he did complain of some
mild dyspnea on exertion. Cath performed at [**Hospital3 1280**] prior
to admission showed severe mitral regurgitation. No coronary
artery disease. Ejection fraction was 60% in a right-dominant
system. Echo performed in [**2199-1-29**] showed severe mitral
valve prolapse with severe MR, dilated left atrium, trace
aortic insufficiency, and ejection fraction of 60%. Cardiac
MR performed in [**2199-2-26**] showed affected forward left
ventricular ejection fraction of 32%, a partially flailed
posterior leaflet, moderate-to-severe MR, mild TR, and an
increase in the LV cavity size.
PAST MEDICAL HISTORY:
1. Mitral valve prolapse/mitral regurgitation.
2. Benign prostatic hypertrophy.
3. Migraine headaches.
4. Paroxysmal atrial fibrillation.
5. Hypertension.
PAST SURGICAL HISTORY: Includes TURP in [**2194**].
MEDICATIONS PRIOR TO ADMISSION: Detrol 5 mg once a day,
Toprol XL (patient was unsure of the dose), MetroGel, and
amoxicillin p.r.n. for dental procedures.
ALLERGIES: He had no known allergies. He receives dental
clearance prior to surgery.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: He is a former elementary school principal
who is now widowed and the father of 4. [**Name2 (NI) **] lives alone. He
denies any use of alcohol or tobacco and denied any use of
recreational drugs.
PHYSICAL EXAMINATION: On exam he was 5 feet 11 inches tall,
175 pounds, blood pressure right 132/66, blood pressure left
132/70. His ENT exam was benign. He had multiple nevi and
keratoses over his body but no rash. His neck was supple with
no JVD. His lungs were clear bilaterally. His heart was
regular in rate and rhythm with normal S1/S2 tones and a
grade 3/6 systolic murmur best heard at the apex. His abdomen
was soft, nontender and nondistended with normal bowel
sounds. He had no extremity edema. He appeared to have lower
extremity varicosities. He was alert and oriented x 3 with no
focal deficits, 5/5 strength, moving all extremities. He had
2+ bilateral femoral, DP, PT and radial pulses. He had no
carotid bruits.
PREOPERATIVE LABORATORY DATA: White count of 5.2, hematocrit
of 40.7, platelet count of 178,000. PT of 12.1, PTT of 29.4,
INR of 1.0. Urinalysis was negative. Sodium of 141, K of 4.8,
chloride of 104, bicarbonate of 30, BUN of 21, creatinine of
1.1, with a blood sugar of 70. ALT of 17, AST of 26, alkaline
phosphatase of 59, total bilirubin of 0.7, total protein of
6.6, albumin of 4.2, globulin 2.4. Cholesterol of 161, HbA1C
of 5.4%, triglycerides of 313, with a cholesterol/HD ratio of
4.6. CRP was 0.9.
RADIOLOGIC AND OTHER STUDIES: Preop chest x-ray showed no
significant abnormalities, no CHF, with minimal biapical
pleural thickening. Please refer to the official report dated
[**2199-7-10**].
Preop EKG showed a sinus rhythm at a rate of 66 with no
ischemic changes.
HO[**Last Name (STitle) **] COURSE: On [**7-15**] - the day of admission - the
patient underwent mitral valve repair with a 28-mm
angioplasty ring, and a quadrangular resection, and a PFO
closure by Dr. [**Last Name (Prefixes) **]. He was transferred to the
cardiothoracic ICU in stable condition on a Neo-Synephrine
drip at 0.5 mcg/kg/min and a propofol drip that was titrated.
He was extubated later that afternoon and was doing well. His
insulin drip - which had been started for blood sugar
coverage - was turned off. His white count was 14 postop,
with a hematocrit of 27, K of 4.7, BUN of 17, creatinine of
1.0 postoperatively. He had a cardiac index of 3.2. He was
alert and oriented with a nonfocal neuro exam. His lungs were
clear bilaterally. His sternal incision was clean, dry, and
intact. His heart was regular in rate and rhythm. No
cyanosis, clubbing, edema of his extremities. His chest tubes
were pulled, and he was transferred out to the floor. He was
transitioned to p.o. Percocet's for pain. He was seen and
evaluated by case management and started his ambulation with
the nurses and physical therapists to increase his activity
level. He had no events overnight. He continued with Lasix
diuresis. Wires were left in. His creatinine was stable
postoperatively at 1.0 the following day. He continued with
his perioperative antibiotics. His exam was unremarkable. His
B12 was restarted also on postoperative day 2. His INR rose
slightly to 1.8 and he continued with diuresis and increasing
his ambulation. He continued to make excellent progress. He
was transfused 2 units of blood for his hematocrit of 25. He
was also seen by his cardiologist on consultation for his
development of atrial fibrillation which recurred on
postoperative day #2 which then converted back to sinus
rhythm at 75.
On postoperative day 3 he did have the episode of atrial
fibrillation with a single pause. He was on 12.5 of Lopressor
twice a day. His Lopressor was increased. His pacing wires
were discontinued after the EP consult. His exam was
unremarkable. His central venous line had been removed, and
he was saturating well at 98% on room air. Went in and out of
atrial fibrillation briefly once more during the day but was
back in sinus rhythm with a couple of runs of AFib and PVCs.
He was given 1 gram of magnesium sulfate for repletion and
remained asymptomatic. Was put back on 2 liters nasal oxygen,
and on the 23rd was seen by EP again who recommended
continuing his beta blockade and increasing it to 50 b.i.d.
and to follow up as an outpatient with cardiologist as he was
asymptomatic from his AFib/A-Tach with 1 episode for 3 beats
which might have been VT or an aberrant atrial fibrillation
rhythm. At the time of exam he was back in sinus rhythm at 82
with a blood pressure of 110/57. Lopressor was increased that
day. Hematocrit remained stable at 31.5. Magnesium was 1.9.
He was saturating 95% on room air and back in sinus rhythm on
the day of discharge and was discharged to home with VNA
services on [**2199-7-20**] with the following discharge
diagnoses.
DISCHARGE DIAGNOSES:
1. Status post mitral valve repair with patent foramen ovale
closure.
2. Atrial fibrillation.
3. Benign prostatic hypertrophy.
4. Migraine headaches.
5. Hypertension.
6. Status post transurethral resection of the prostate in
[**2194**].
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. twice a day.
2. Detrol 2 mg p.o. once a day.
3. Enteric coated aspirin 81 mg p.o. once a day.
4. Metoprolol 50 mg p.o. twice a day.
5. Percocet 5/325 1 to 2 tablets p.o. p.r.n. q.4.h. (for
pain).
DISCHARGE STATUS: The patient was discharged in stable
condition to home with VNA services on [**2199-7-20**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2199-7-31**] 12:34:37
T: [**2199-7-31**] 16:32:46
Job#: [**Job Number 57711**]
|
[
"4240",
"42731",
"4019"
] |
Admission Date: [**2135-4-2**] Discharge Date: [**2135-4-7**]
Date of Birth: [**2084-5-28**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Enalapril
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 50M with ESRD secondary to amyloidosis, on HD as well
as multiple other medical problems presenting with CP and
hypotension. He began having chest pain this evening while at
rest: SSCP, nonradiating, +SOB, +nausea, lasted 30-60 minutes,
resolved spontaneously. No history of similar pain in the past.
He also has had a nonproductive cough recently, but denies F/C.
.
EMS was called by his rehab facility because of this chest pain.
EMS reported that K was 7.9 today, initially though to be
post-HD (now seems more likely to have been pre-HD). He was
reportedly hypotensive in transit. On arrival, BP 80/55 -->
53/44. Multiple attempts were made to place a central line.
Although RIJ and L femoral arteries were easily cannulated, they
were unable to advance the wire. In the meantime, BP increased
to 90s SBP.
.
Labs revealed K 3.4 and elevated WBC. A PIV was eventually
placed for access. A 250cc bolus of NS was given. He was also
given aspirin, morphine, and a dose of cefepime and levofloxacin
(given the cough and elevated WBC, and ?infiltrate on CXR).
.
In addition, he was noted while in the ED to have tachycardia,
at times sinus tach and at times afib with RVR, rates as high as
160s. Given the hypotension, intermittent tachycardia, and
difficulty with access, he was admitted to the MICU.
.
On arrival to the MICU, he is CP free and VS are stable. He
complains of a frontal HA and of being thirsty. Otherwise ROS is
negative.
Past Medical History:
ESRD secondary to amyloidosis -failed LRRT in [**7-5**] now on HD- R
groin line
IVC stent
Sarcoidosis
Pulmonary aspergillosis
DM (diet controlled)
Chronic HCV
Hypertension
Sinusitis,
Paroxysmal atrial fibrillation,
C. difficile [**3-8**]
MRSA line sepsis
Renal osteodystrophy
Adrenal insufficiency
Upper extremity DVT ([**2132**])
Pancreatitis
Bilateral BKA
Right index and fifth finger amputations
Social History:
Smoked 1 ppd X 30 years but quit one year ago. No alcohol.
Previous drug use (IVDU). Girlfriend is involved in his care.
Family History:
Mother, brother with diabetes.
Physical Exam:
PE: On transfer to floor
VS: 97.4, HR: 80s-90s, 100s-120s/60s-70s, 18, 96% on RA.
Gen: Tired-appearing, NAD. Answering all questions
appropriately.
HEENT: PERRL, aniceric, MM slightly dry.
Neck: Supple, no LAD.
Lungs: Few bibasilar crackles R>L. No wheezes.
Heart: RRR, II/VI systolic murmur throughout, loudest at LLSB.
Abd: +BS. Soft, NT/ND.
Extrem: s/p b/l BKA. No edema. R femoral HD catheter, C/D/I, no
drainage, redness, or fluctuance.
Pertinent Results:
[**2135-4-2**] 09:10AM GLUCOSE-57* UREA N-36* CREAT-5.9* SODIUM-142
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-25 ANION GAP-22*
[**2135-4-2**] 09:10AM ALT(SGPT)-17 AST(SGOT)-24 LD(LDH)-229
CK(CPK)-28* ALK PHOS-152* TOT BILI-0.3
[**2135-4-2**] 09:10AM CK-MB-NotDone cTropnT-0.27*
[**2135-4-2**] 09:10AM ALBUMIN-3.7 CALCIUM-11.2* PHOSPHATE-7.6*
MAGNESIUM-2.1
[**2135-4-2**] 09:10AM WBC-12.8* RBC-3.38* HGB-9.8* HCT-31.6* MCV-94
MCH-29.1 MCHC-31.2 RDW-14.8
[**2135-4-2**] 09:10AM PLT COUNT-289
[**2135-4-2**] 06:36AM GLUCOSE-105 UREA N-34* CREAT-5.8* SODIUM-142
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-24 ANION GAP-23*
[**2135-4-2**] 06:36AM CK(CPK)-33*
[**2135-4-2**] 06:36AM CK-MB-NotDone cTropnT-0.25*
[**2135-4-2**] 06:36AM CALCIUM-11.2* PHOSPHATE-7.7*# MAGNESIUM-2.2
[**2135-4-1**] 08:34PM GLUCOSE-343* LACTATE-2.2* NA+-139 K+-3.4*
CL--93* TCO2-28
[**2135-4-1**] 08:30PM UREA N-25* CREAT-4.8*
[**2135-4-1**] 08:30PM estGFR-Using this
[**2135-4-1**] 08:30PM CK(CPK)-17*
[**2135-4-1**] 08:30PM CK-MB-NotDone cTropnT-0.18*
[**2135-4-1**] 08:30PM WBC-12.9* RBC-3.34* HGB-9.9* HCT-31.7* MCV-95
MCH-29.6 MCHC-31.2 RDW-14.9
[**2135-4-1**] 08:30PM NEUTS-77.2* LYMPHS-14.7* MONOS-6.8 EOS-1.2
BASOS-0.2
[**2135-4-1**] 08:30PM PT-14.7* INR(PT)-1.3*
[**2135-4-1**] 08:30PM PLT COUNT-307
.
CXR:HISTORY: 50-year-old man with history of endocarditis,
osteomyelitis, diabetes mellitus, hypertension, end-stage liver
disease and pulmonary aspergillosis with mycetoma by CT. New
having hemoptysis. Please evaluate for interval change.
FINDINGS: The lungs are low in volume. In the lung apices, there
is pleural thickening chronic in nature. On today's examination,
there is a lucency in the right upper lung with a very thin
borders. There is no pleural effusion, however, there is
extensive linear pleural calcification. The heart is not
enlarged. In the hilar and mediastinal areas, are multiple
calcified lymph nodes.
There is a central line approach through the IVC terminating in
the SVC.
The visualized portions of the abdomen demonstrates heavily
calcified kidneys.
IMPRESSION:
1) Over a period of two days, there is abnormal lucency that is
seen only on the frontal radiograph in the right upper lobe with
a thin wall. This could either be an overlying superimposed
shadows vs. a true cavity in keeping with the patient's history
of mycetomas.
2) Pleural calcification likely secondary to asbestos-related
disease.
3) End-stage renal disease characterized by heavy calcification.
Multiple calcified lymph nodes that in general could be
sarcoidosis, occupational lung disease or a sequelae of
granulomatous disease.
.
CT CHEST W/O CONTRAST [**2135-4-3**] 7:40 PM
CT CHEST W/O CONTRAST
Reason: ? PNA
[**Hospital 93**] MEDICAL CONDITION:
50 year old man with increasing WBC, concern for infiltrate on
CXR in context of multiple pulmonary problems (fungal infection,
sarcoid, pleural plaques).
REASON FOR THIS EXAMINATION:
? PNA
CONTRAINDICATIONS for IV CONTRAST: None.
CHEST CT, [**4-3**]
HISTORY: Increasing white count. Rule out pneumonia. Fungal
infections, sarcoid and pleural plaques in the history.
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
images, compared to chest CT scanning, [**2134-10-12**] and
[**2135-1-14**].
FINDINGS:
Extremely heavy calcification in large mediastinal and hilar
nodes, and thickened pleura and pericardium, is all unchanged
since at least [**Month (only) **]. There is no appreciable pleural or
pericardial effusion and no indication of cardiac tamponade. In
the absence of intravenous contrast [**Doctor Last Name 360**] one can also
appreciate extensive mural calcification in the central
pulmonary arteries feature suggesting renal failure and possible
elevation of pulmonary artery pressure.
A large region of consolidation that has been present in the
left lung apex since [**10-13**] continues to decrease in
overall volume, probably clearing pneumonia in a region of
scarring and chronic atelectasis, but at the upper margin of it
there is now the suggestion of a 17 x 8 mm elliptical opacity in
cavity either a mycetoma or an inflammatory phlegmon in the
region of invasive aspergillosis. Right apical atelectasis or
conglomerate fibrosis is more severe. Previous peribronchial
infiltration in the right upper lobe, involving primarily the
axillary subsegments has improved. There are no new areas of
likely pulmonary infection.
IMPRESSION:
1. Interval development of mycetoma in a shrinking area of left
upper lobe consolidation, suggesting either mycetoma or
maturation of invasive aspergillosis.
2. Renal failure, probably explains particularly heavy
dystrophic calcification and granulomatous mediastinal lymph
nodes, pericardium, and bilateral pleural surfaces. No pleural
effusion and no evidence of cardiac tamponade.
3. Previous right upper lobe pneumonia or aspiration, largely
cleared.
Brief Hospital Course:
# Hypotension: Patient had hypotension per report upon
presentation but appeared to improve after small volume
hydration. [**Month (only) 116**] have been artifact secondary to difficulty of
obtaining blood pressure on patient versus hypotension secondary
to excessive volume removal at hemodialysis.
.
# Chest Pain: The patient had chest pain and cough. He was
ruled out for a myocardial infarction with negative enzymes x 3.
There were no changes on his EKG. He had cough and elevated
white count and was treated briefly with ceftriaxone that was
stopped once his CT came back as negative for infiltrate. His
chest pain resolved.
.
# Epistaxis: The patient had an episode of spontaneous
epistaxis that resolved. His hematocrit, platelets, and INR
were normal during the episode.
# Hemoptysis: The patient had hemoptysis x 3 of 5-10cc of dark
red sputum over the course of 48 hours. This occurred after his
epistaxis and may be related to inhaled blood versus his known
aspergillosis. He was evaluated by pulmonary who recommends
outpatient bronchoscopy. A CT showed essentially stable
aspergillosis.
.
# Atrial fibrillation with RVR: The patient has known atrial
fibrillation and had rapid ventricular response. This responded
well to beta blocker therapy.
.
# End-Stage Renal Disease on Hemodialysis: Patient continued
T/H/S hemodialysis while in house.
.
# Hyperkalemia: Patient had hyperkalemia upon admission that
responded to Kayexalate and hemodialysis therapy.
.
# DM: Patient was kept on a regular insulin sliding scale while
in house with appropriate glucose control
.
# Pulmonary aspergillosis: Patient is maintained on
voriconazole.
.
# MRSA/endocarditis/osteomyelitis: The patient was transistioned
from his vancomycin therapy to Bactrim therapy after discussion
with his primary care and ID physicians.
.
# Adrenal insufficiency: Patient continued on home low-dose
steroids.
Medications on Admission:
Megestrol 40 mg/mL Suspension 20 ml PO DAILY
Prednisone 5 mg QAM
Prednisone 2.5 mg QPM
Cinacalcet 60 mg DAILY
Sevelamer HCl 800 mg TID W/MEALS
Ascorbic Acid 500 mg DAILY
Folic Acid 1 mg DAILY
Voriconazole 100 mg Q12H
Sodium Chloride Nasal Spray QID
Metoprolol Tartrate 12.5 mg [**Hospital1 **]
Senna 8.6 mg [**Hospital1 **] as needed.
RISS
Vancomycin 1,000 mg at dialysis.
Vitamin B Complex once a day.
Trimethoprim-Sulfamethoxazole 160-800 mg 1 Tablet PO QHD as
needed for suppress MRSA infection: Give after HD T/Th/Sat each
week.
Pantoprazole 40 mg Q24H
Imodium prn
flagyl 250 tid (schedule to finish on [**2135-03-31**])
kayexelate 15g Sun, Mon, Wed, Fri
tylenol prn
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. B Complex Vitamins Capsule Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO QPM (once a day (in
the evening)).
8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
9. Megestrol 40 mg/mL Suspension Sig: One (1) 10ml PO twice a
day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Voriconazole 50 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours).
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: Four
(4) Tablet PO QHD (each hemodialysis).
16. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit
Subcutaneous ASDIR (AS DIRECTED).
17. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Healthcare-[**Location (un) 86**]
Discharge Diagnosis:
Primary:
Hypotension attributed to hypovolemia
Epistaxis
Hemoptysis
Atrial fibrillation with rapid ventricular response
.
Secondary:
End stage renal disease on hemodialysis
Pulmonary aspergillosis
MRSA endocarditis
adrenal insufficiency
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with low blood pressure, high
potassium, and a fast heart rate from your atrial fibrillation.
All of these symptoms resolved during your stay.
Please continue to take your medications as prescribed. You
have follow-up appointments scheduled with a pulmonologist (lung
doctor) and your infectious disease Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**].
If you develop fevers, start coughing up blood, have a nosebleed
that does not stop or any other concerning symptoms please
contact a physician [**Name Initial (PRE) 2227**].
Followup Instructions:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2135-4-25**] 7:40
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2135-4-25**] 8:00
[**2135-5-2**] 11:00a ID,[**Doctor Last Name **],[**Doctor Last Name **] LM [**Hospital Unit Name **], BASEMENT ID
WEST (SB)
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2135-4-7**]
|
[
"40391",
"42731",
"25000",
"2767",
"V1582"
] |
Admission Date: [**2135-9-10**] Discharge Date: [**2135-9-13**]
Date of Birth: [**2086-1-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD [**2135-9-10**]
History of Present Illness:
49 year old homeless male with PMH of EtOH use (currently [**1-5**]
beers/day) who presents with hematemesis beginning this AM.
Episode occured at 3AM, when he awoke feeling nauseated and
projectile vomited a large amount of reddish brown material with
gross blood. He tried to go back to sleep, but had to go to the
bathroom. When he did, he noted that his stool was dark black
and the consistency of used motor oil. He had repeated similar
bowel movements, up to 15 times, throughout the course of the
night, before he decided to go to the ED. He denies any
associated F/C/abdominal pain/dysuria. Has not been taking any
ASa or NSAIDs. No recent increasing confusion or tremulousness.
BMs had been normal up until this AM. Denies any recent repeated
retching. Last drink was 1 day PTA. Has never had anything like
this before.
.
In the ED: VS 98.4 110 143/96 18 98%RA. Exam showed no abdominal
tenderness or ascites. Was noted to be slightly tremulous and
icteric. Vomited blood and coffee grounds. NGT dropped, with
75cc of BRB. After lavage with 750cc, mostly cleared but some
pink material residual. Labs revealed a normal chemistry, anemia
to 30.9, a WBC count of 13.9, and low platelets at 121. Cardiac
enyzmes were unrevealing. U/A was without infectious parameters.
CXR was unrevealing. EKG was without ischemic changes. Utox
negative. LFTs showed elevated AST/ALT ratio, with elevated
tbili to 8.1. He was crossmatched 2 units, access with 2 18g's
was obtained, and GI was consulted. They recommended an 80mg
bolus of pantoprazole and a drip at 8mg/hr. He received 1 liter
of IVF, a pantoprazole and octreotide bolus, zofran, ativan, and
was admitted to the ICU.
Past Medical History:
Of note, the pt states he hasn't seen a medical professional in
decades.
# EtOH Abuse - denies ever having withdrawn or seized
# 1-time seizure on [**2129-11-30**] in setting of trauma, no subsequent
episodes
# tooth extraction 2 weeks ago - not on anti-inflammatories
Social History:
Endorses ongoing EtOH use x 15 years, previously up to 1 pint of
southern comfort daily. More recently has been drinking 4 beers
and 2 nips per day. Has tried snorting cocaine and heoin before
but adamantly denies IVDU. Homeless, lives on the street/on
porches. Formerly employed at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Life Insurance.
Family History:
Depression in grandmother and mother
Physical Exam:
Vitals: T: 99.3 P: 93 BP: 133/83 RR: 15 SaO2: 98%RA
General: Awake, alert, middle aged male in NAD.
Skin: icteric, no spider angiomata, rahses, or chronic changes
noted
HEENT: NC/AT, PERRL, EOMI without nystagmus, + scleral and
sublingual icterus, MMM, no lesions noted in OP.
Neck: supple, no JVD or carotid bruits appreciated
Chest: No gynecomastia. Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. No fluid wave appreciated.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l. No palmar erythema.
Neurologic: A+O x 3. Able to relate history without difficulty.
cranial nerves: II-XII intact. normal bulk, strength and tone
throughout. No asterixis.
Pertinent Results:
Admission Labs:
[**2135-9-10**] 10:25PM CK(CPK)-260*
[**2135-9-10**] 10:25PM CK-MB-11* MB INDX-4.2 cTropnT-<0.01
[**2135-9-10**] 10:25PM HCT-29.7*
[**2135-9-10**] 06:25PM HCT-29.8*
[**2135-9-10**] 05:59PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2135-9-10**] 05:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2135-9-10**] 03:45PM HCT-29.1*
[**2135-9-10**] 01:31PM GLUCOSE-134* UREA N-20 CREAT-0.7 SODIUM-135
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-26 ANION GAP-15
[**2135-9-10**] 01:31PM ALT(SGPT)-21 AST(SGOT)-97* CK(CPK)-393* ALK
PHOS-325* TOT BILI-8.1*
[**2135-9-10**] 01:31PM LIPASE-59
[**2135-9-10**] 01:31PM CK-MB-17* MB INDX-4.3 cTropnT-<0.01
[**2135-9-10**] 01:31PM ALBUMIN-3.1*
[**2135-9-10**] 01:31PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2135-9-10**] 01:31PM WBC-13.9* RBC-3.26* HGB-10.9* HCT-30.9*
MCV-95 MCH-33.3* MCHC-35.1* RDW-17.5*
[**2135-9-10**] 01:31PM NEUTS-86.3* LYMPHS-8.4* MONOS-4.8 EOS-0.2
BASOS-0.3
[**2135-9-10**] 01:31PM PLT COUNT-121*
[**2135-9-10**] 01:31PM PT-18.2* PTT-34.9 INR(PT)-1.7*
[**2135-9-10**] 01:05PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.024
[**2135-9-10**] 01:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-TR KETONE-15 BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-NEG
.
Labs on discharge:
[**2135-9-13**] 05:10AM BLOOD WBC-9.8 RBC-3.07* Hgb-10.1* Hct-28.7*
MCV-94 MCH-32.8* MCHC-35.1* RDW-17.8* Plt Ct-116*
[**2135-9-13**] 05:10AM BLOOD PT-17.4* PTT-47.8* INR(PT)-1.6*
[**2135-9-13**] 05:10AM BLOOD Glucose-86 UreaN-10 Creat-0.6 Na-131*
K-3.6 Cl-100 HCO3-24 AnGap-11
[**2135-9-13**] 05:10AM BLOOD ALT-16 AST-72* LD(LDH)-130 AlkPhos-219*
TotBili-6.0*
[**2135-9-13**] 05:10AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.7
[**2135-9-11**] 03:41AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2135-9-12**] 05:05AM BLOOD HIV Ab-NEGATIVE
[**2135-9-11**] 03:41AM BLOOD HCV Ab-NEGATIVE
.
[**2135-9-10**] Abd US:
1. Echogenic, nodular liver compatible with cirrhosis.
2. Minimal ascites with splenomegaly likely reflects an element
of portal
hypertension.
3. Mildly distended gallbladder with trace pericholecystic
fluid, but no
evidence of acute cholecystitis.
.
[**2135-9-10**] EGD: Varices at the lower third of the esophagus and
middle third of the esophagus. Congestion, erythema and mosaic
appearance in the antrum, stomach body and fundus compatible
with gastropathy
(ligation, ligation). Otherwise normal EGD to second part of the
duodenum
.
[**2135-9-11**] EKG: Sinus rhythm. Borderline prolonged QTc interval is
non-specific but clinical correlation is suggested. Since the
previous tracing of [**2135-9-10**] sinus tachycardia is absent and QTc
interval appears borderline prolonged.
Brief Hospital Course:
Pt is a 49 y.o. homeless male with h/o alcohol abuse admitted
with hematemesis and melena
.
#) Hematemesis - The initial differential included
[**Doctor First Name 329**]-[**Doctor Last Name **], variceal bleed, gastritis, PUD vs portal
hypertensive gastropathy. Pt was seen by GI, and underwent EGD
showing varices at the lower third of the esophagus and middle
third of the esophagus congestion, erythema and mosaic
appearance in the antrum, stomach body and fundus compatible
with gastropathy. The pt was given 2 units pRBC and placed on IV
octreotide gtt, IV PPI gtt. The pt was given cipro x 3 days
after EGD for SBP ppx. He was transferred to the floor on
[**2135-9-11**] with a stable HCT which remained at 28.7 on discharge.
He was discharged on Nadolol and Pantoprazole.
.
#) EtOH abuse - The patients last drink was 24hrs prior to
discharge. The patient denied prior episodes of seizures or
withdrawl. Pt was placed on CIWA scale and given thiamine and
folate. His CIWA remained <10 during the hospitalization and was
discontinued on the floor. He was counselled about avoiding EtOH
use in the future given his new diagnosis of alcoholic cirrhosis
which is not yet biopsy proven. Social work was also consulted
for EtOH counselling.
.
#) Liver Disease - The pt has a long history of ETOH abuse, on
admission elevated AST/ALT ratio, MELD of 16 and a discriminant
ratio of 30. All this is consistent with EtOH induced liver
pathology as was his abd US. He has no known h/o vericeal
bleeding, ascites, SBP, or encephalopathy. The patients LFTs
trended down and at discharge TBili was 6.0. His Hep B, HepC
and HIV serologies were negative this admission. He was given
his first HepB immunization prior to discharge. He will follow
up with liver clinic [**10-6**] but prior to this, was given an appt
for an EGD on [**9-27**] and encouraged to keep all his follow up
appointments.
Medications on Admission:
None
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Upper GI Bleeding
2. Melena
3. Alcoholic Cirrhosis
Secondary Diagnosis:
1. Alcohol abuse
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted after vomiting blood. You were in the ICU
briefly where you were closely monitored. You were given blood
transfusions. You also had an endoscopy that showed that you
had varices (or large veins) that caused your bleeding. These
varices were banded to stop your bleeding. You were then
transferred to the medical floor. Your blood counts were
monitored closely and continued to be stable. We also closely
monitored you for alcohol withdrawal which you did not have. You
will need to follow up with gastroenterology and get another
endoscopy to look at the varices.
.
Your varices are caused by liver damage which alcohol has caused
over time. You should not drink any alcohol any more. Doing so
is a great risk to your health and will continue to damage your
liver.
.
You have been prescribed several medications while in the
hospital. You are being provided with a list of these
medications and prescriptions for them. Please take these
medications as prescribed.
Please keep all your medical appointments.
If you have any of the following symptoms, please call your
doctor or go to the nearest ER: fever > 101, chest pain,
shortness of breath, abdominal pain, bright red blood per
rectum, black stools, red stools, vomiting blood, confusion, or
any other concerning symptoms.
Followup Instructions:
Please follow up your primary care doctor, Dr. [**Last Name (STitle) 3357**]. To make
an appointment, please call [**Telephone/Fax (1) 4606**]. Alternatively, you
might consider following up with a primary care provider at
[**Name9 (PRE) 86**] Healthcare for the Homeless. Their number is ([**Telephone/Fax (1) 79836**].
.
You will need to have a follow-up endoscopy on Tuesday [**9-27**] at
10am. Please arrive to [**Hospital Ward Name 1950**] 3. You will need a ride home at
1pm. Do not eat anything after midnight the night before your
procedure. Please call [**Telephone/Fax (1) 9557**] if you need to reschedule.
.
Please follow up at the liver clinic on Thursday [**10-6**] at 3:20 pm
with Dr. [**Last Name (STitle) 696**]. The clinic is located in the [**Hospital Ward Name **] bldg [**Location (un) **], suite E on the [**Hospital Ward Name **]. Please call [**Telephone/Fax (1) 24157**] if
you need to reschedule.
Completed by:[**2135-9-16**]
|
[
"2875"
] |
Admission Date: [**2138-5-27**] Discharge Date: [**2138-5-30**]
Date of Birth: [**2071-5-6**] Sex: F
Service: NEUROLOGY
Allergies:
Egg / Pineapple / Aspirin
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 yo F with hx AVM, seizure disorder, headaches, right-sided
numbness, "AMS", glaucoma, cataracts, transferred from ALF with
altered behavior, and developed seizure activity upon arrival to
ED.
This AM she was sitting on couch at ALF and was unable to follow
commands or talk. She was reported to have a headache earlier
this AM and was last seen in USOH two hours prior. En route by
EMS she BP was 190/100 P 109 and she was moving spontaneously
but nonverbal. Upon arrival here she started having extensor
posturing of arms, lip smacking, and limb shaking,
intermittently
over 10-15 minutes. She received a total of 4 mg lorazepam with
resolution of symptoms. She was later intubated for airway
protection.
She is followed at [**Hospital1 2177**] for seizures and takes phenytoin, keppra,
and zonisamide at home. [**Name6 (MD) **] her NP, [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 10686**], she does not
believe she has had recent seizures and notes most recently her
phenytoin level was elevated prompting decrease in dose, but no
other known recent med changes.
ROS unobtainable
Past Medical History:
-AVM s/p onyx embolization in [**2134**] and cyberknife radiation in
[**2135**]
-epilepsy
-borderline DM
-"AMS"
-glaucoma/cataracts
-headaches
-R-sided numbness
-s/p vocal cord polyp removals
-hypercholesterolemia
Social History:
Lives in ALF. further details unknown. NP is [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 10686**]
[**Telephone/Fax (1) 61866**]. PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1661**] [**Telephone/Fax (1) 11463**]. Lives at [**Location 8389**]
ALF. Daughter is [**Name2 (NI) 109618**] [**Telephone/Fax (1) 109619**].
Family History:
Two daughters - one with SLE and the other with stomach cancer
diagnosed at age 36. Father died at age 50 of stomach cancer.
Sister with breast cancer at age 51. Brother with [**Name2 (NI) 109620**] HTN.
Physical Exam:
Exam on admission:
VS; T 100.1 P 116 BP 160/75 RR 18 98% on NRB (seen shortly after
receving 4 mg lorazepam)
Gen; eyes closed, NAD, NRB in place
HEENT; NC/AT
Neck; no rigidity
Pulm; CTA b/l
CV; tachy, regular rate, no murmurs
Abd; soft, nt, nd
Extr; no edema
Neuro;
MS; Eyes closed, unarousable to noxious stimuli.
CN; PERRL 2mm-->1.5mm, does not track or blink to threat. weak
corneals b/l. face appears symmetric but obscured by NRB.
Motor; normal bulk and tone. no spontaneous movement or
withdrawl to noxious stimuli
Sensory; no grimace to noxious throughout
Reflexes; toes mute
Pertinent Results:
[**2138-5-27**] 11:10AM BLOOD WBC-6.0 RBC-4.26 Hgb-13.3 Hct-40.0 MCV-94
MCH-31.2 MCHC-33.2 RDW-13.2 Plt Ct-282
[**2138-5-27**] 09:05PM BLOOD Glucose-114* UreaN-8 Creat-0.6 Na-142
K-3.4 Cl-110* HCO3-21* AnGap-14
[**2138-5-27**] 11:30AM BLOOD cTropnT-<0.01
[**2138-5-28**] 01:49AM BLOOD Albumin-3.9 Calcium-8.4 Phos-1.6* Mg-1.5*
[**2138-5-29**] 07:00AM BLOOD Phenyto-13.2
CT head:
1. Large likely treated AVM in the left posterior parafalcine
location with extensive vasogenic edema on the left resulting in
6 mm of subfalcine
herniation and slight effacement and possible impending downward
transtentorial herniation.
2. No intracranial hemorrhage.
MRI head:
Gradient images demonstrate artifacts in the left posterior
parietal region from prior Onyx embolization of arteriovenous
malformation. Diffusion sequences demonstrate bright signal in
the splenium of corpus callosum and a small area involving the
medial aspect of the calcarine cortex. These are probably recent
ischemic events from post-treatment changes. Extensive and
asymmetric white matter vasogenic edema is shown, left larger
than the right, likely reflecting post-radiation changes.
Post-contrast images demonstrate abnormal enhancement
surrounding at the Onyx material at the site of treated AVM.
There is a shift of midline structures to the right by 10 mm.
Incidental note is made of cavum septum pellucidum and a cyst
within the septum pellucidum. Minor mucosal thickening is seen
in the ethmoid air cells. Bilateral mild mucosal thickening is
seen in the mastoid air cells.
Brief Hospital Course:
Patient is a 67 year old RHW with history of R parieto-occipital
AVM (no rupture but presented with seizures) s/p onyx
embolization in [**2134**] followed by radiation therapy in [**2135**] with
residual R sided weakness. She was undergoing AED modifications
including lowering of zonisamide recently given that she did not
have any seizures since [**2135**]. She normally gets all her medical
care at [**Hospital1 2177**] but her insurance recently changed and her care was
being tranferred to [**Hospital1 18**].
On [**5-27**], she was found to have a seizure that generalized
(normal seizure semiology is complex partial with R sided
twitching). She was brought to the [**Hospital1 18**] ED and intubated for
airway protection. She underwent head CT which showed artifacts
and large area of left hemispheric edema with a smaller area of
right hemispheric edema. Given the lack of her prior MRI brain
and conventional angiograms reports from [**Hospital6 **],
initially there were concerns that the large left hemispheric
edema and small area of right hemispheric edema were new
changes. Unfortunately, it took more than 24 hours to obtain
records from [**Hospital1 2177**] and clarify that she does not have
contraindications to undergo MRI of brain.
MRI/A/V was finally obtained which showed artifacts from onyx
embolization and vasogenic edema consistent with findings in the
past and likely post-radiation change.
MRI brain reports and images from [**2136**] were eventually obtained
from [**Hospital6 **] showing that the large left cerebral
hemispheric edema and smaller area of right cerebral hemispheric
edema were in fact chronic changes. Dr. [**Last Name (STitle) 36611**], her
neurointerventionalist from [**Hospital1 2177**], stated that the above areas of
edema were due to radiation necrosis from Cyber Knife
radiotherapy.
Patient was monitored on EEG which showed no continued seizure
activities.
She returned to near baseline and remained stable. She was
evaluated by physical and occupational therapists who
recommended short rehabilitation stay but the patient and family
refused rehabilitation stay. Given that she is near baseline
and she lives in [**Hospital3 **] facility with supervision, she
is discharged back to her [**Hospital3 **] facility with
recommendations to follow-up with her medical care providers
including Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the neurologist who oversaw her care
during this admission.
Medications on Admission:
-ca and vit d
-fulticasone 50 mcg nasal daily
-keppra 1500 mg [**Hospital1 **]
-lisinopril 10 mg daily
-loratadine 10 mg daily
-mvt
-omeprazole 20 mg daily
-pht 200 qAM, 100 qhs
-zocor 40
-vit d
-xalatan 0.005% both eyes qhs
-zonisamide 100 mg daily
-tylenol prn
-capzasin cream
-hydrocortisone cream
Discharge Medications:
1. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. zonisamide 100 mg Capsule Sig: Two (2) Capsule PO at bedtime.
Disp:*60 Capsule(s)* Refills:*2*
5. levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
7. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml
PO at bedtime.
8. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
9. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for fever or pain.
10. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
12. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
13. Outpatient Occupational Therapy
Evaluation and treatment
14. Outpatient Physical Therapy
evaluation and treatment
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Seizures
hx of R parieto-occipital AVM s/p Onyx embolization and
radiation therapy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neuro deficits: Mildly confused about place and time. Small
right superior quadranopsia. Mild R sided weakness including
pronation of R hand and RLE weakness.
Discharge Instructions:
You were brought to the hospital after having a breakthrough
seizure (generalized). You were intubated then initially
admitted to the intensive care unit. You underwent EEG
monitoring which showed that you were not have continued
seizures and given the report of recent lowering of your
anti-seizure medications, your medications were titrated back up
to Keppra 1500mg twice daily, Zonisamide 200mg at bedtime and
Dilantin 100mg three times daily.
Because this was your first time at [**Hospital1 827**], your abnormal head CT scan was very concerning.
You underwent MRI/A/V of head which showed no acute process and
records from [**Hospital6 **] was obtained corroborating
that the abnormality has been seen and evaluated in the past.
You were successfully extubated and transferred to the neurology
floor where you remained stable with near normal exam except for
mild R sided weakness and possible superior quadranopsia.
You are discharged back to your [**Hospital3 **] facility.
Please take meds as prescribed and follow-up with your
healthcare providers.
Followup Instructions:
Your insurance has changed and your medical care is transferred
to [**Hospital1 18**]. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], the
neurologist who oversaw your care during this admission.
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2138-7-30**] 1:30
Your nurse practitioner, [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 14106**] is aware of your
admission, findings and discharge. She will be arranging your
medical care follow-up that is currently being transferred to
[**Hospital1 18**] given the insurance coverage change.
Completed by:[**2138-5-30**]
|
[
"2720"
] |
Admission Date: [**2147-5-19**] Discharge Date: [**2147-7-3**]
Date of Birth: [**2093-1-28**] Sex: M
Service: SURGERY
Allergies:
Penicillins / Coumadin / Latex / Adhesive Tape
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Esophageal Cancer
Major Surgical or Invasive Procedure:
[**2147-5-19**] Minimally invasive esophagectomy complicated by
anastamotic leak
[**2147-6-27**] EGD with balloon dilation of pylorus and botox injection
History of Present Illness:
This is a 54 yoM who was diagnosed in [**2147-1-12**] with Stage
IIa esophageal cancer. He underwent chemotherapy and radiation
with good response and was scheduled for elective laparoscopic
esohagectomy.
Past Medical History:
1) cardiomyopathy s/p pacemaker and defibrillator, mitral valve
repair
2) Chronic Atrial Fibrillation
3) nonfunctioning left kidney (BaseLine Cr 1.3)
4) GERD
Surgery:
5) ORIF right wrist
Social History:
The patient currently lives in [**Location (un) 3844**] in the city of [**Location (un) 81594**]. The patient has been on disability since [**2140**] due to
his cardiac problems.
Tobacco: 30 to 35 pack year history of smoking.
Alcohol: Prior significant alcohol intake.
Family History:
Noncontributory
Physical Exam:
Admission Physical
AAO x 3, NAD
RR Afib, rate controlled, mitral regurgitation
B/L rales at apices, Right base is crackles with decreased
breath sounds
soft, appropriately tender, mildly distended, wounds CDI
+ 1 edema B/L
Discharge Physical Exam
AOx3, NAD, comfortable
Irregular rhythm, normal rate, +MR
Lungs are clear
Left JP wound site with mild occasional drainage
J-tube site intact, abdomen protuberant but soft
Pertinent Results:
[**2147-5-20**] 02:34PM BLOOD Hgb-11.7* calcHCT-35
[**2147-5-19**] 12:08PM BLOOD Glucose-148* Lactate-1.4 Na-140 K-5.6*
Cl-103
[**2147-5-20**] 02:34PM BLOOD Glucose-122* Lactate-2.6* Na-138 K-4.4
Cl-108
[**2147-6-12**] 02:27AM BLOOD Digoxin-0.7*
[**2147-6-13**] 05:20AM BLOOD Digoxin-0.8*
[**2147-6-26**] 08:00PM BLOOD Digoxin-1.0
[**2147-6-11**] 01:35AM BLOOD TSH-3.0
[**2147-5-31**] 02:43AM BLOOD Triglyc-230*
[**2147-6-1**] 02:18AM BLOOD Triglyc-259*
[**2147-6-1**] 02:18AM BLOOD calTIBC-160* Ferritn-1138* TRF-123*
[**2147-5-19**] 05:24PM BLOOD Calcium-8.3* Phos-4.1 Mg-1.6
[**2147-5-20**] 01:14AM BLOOD Calcium-8.4 Phos-4.6* Mg-2.2
[**2147-5-21**] 12:09AM BLOOD Calcium-8.9 Phos-3.0# Mg-1.6
[**2147-5-22**] 01:30AM BLOOD Calcium-8.7 Phos-1.8* Mg-1.9
[**2147-6-28**] 05:38AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9
[**2147-6-29**] 05:57AM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
[**2147-6-30**] 06:00AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.0
[**2147-7-1**] 08:05AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
[**2147-5-20**] 01:14AM BLOOD CK(CPK)-691* Amylase-40
[**2147-5-24**] 08:39AM BLOOD ALT-18 AST-37 LD(LDH)-348* AlkPhos-76
TotBili-4.2*
[**2147-6-5**] 01:24AM BLOOD ALT-27 AST-51* LD(LDH)-175 AlkPhos-438*
TotBili-0.9
[**2147-5-19**] 05:24PM BLOOD Glucose-125* UreaN-16 Creat-1.1 Na-142
K-4.6 Cl-106 HCO3-27 AnGap-14
[**2147-5-20**] 01:14AM BLOOD Glucose-120* UreaN-17 Creat-1.2 Na-142
K-4.8 Cl-107 HCO3-26 AnGap-14
[**2147-5-21**] 12:09AM BLOOD Glucose-131* UreaN-26* Creat-1.7* Na-142
K-4.5 Cl-106 HCO3-26 AnGap-15
[**2147-5-22**] 01:30AM BLOOD Glucose-119* UreaN-22* Creat-1.1 Na-143
K-3.6 Cl-109* HCO3-25 AnGap-13
[**2147-5-23**] 03:10AM BLOOD Glucose-99 UreaN-19 Creat-1.1 Na-147*
K-3.9 Cl-111* HCO3-28 AnGap-12
[**2147-5-23**] 01:20PM BLOOD Glucose-98 UreaN-19 Creat-1.1 Na-150*
K-3.9 Cl-110* HCO3-29 AnGap-15
[**2147-6-28**] 05:38AM BLOOD Glucose-104 UreaN-29* Creat-0.9 Na-139
K-3.5 Cl-108 HCO3-23 AnGap-12
[**2147-6-29**] 05:57AM BLOOD Glucose-123* UreaN-30* Creat-0.8 Na-139
K-3.7 Cl-109* HCO3-23 AnGap-11
[**2147-6-30**] 06:00AM BLOOD Glucose-111* UreaN-29* Creat-0.8 Na-140
K-3.4 Cl-107 HCO3-23 AnGap-13
[**2147-7-1**] 08:05AM BLOOD Glucose-130* UreaN-26* Creat-0.8 Na-137
K-3.7 Cl-107 HCO3-22 AnGap-12
[**2147-5-19**] 05:24PM BLOOD PT-13.0 PTT-23.8 INR(PT)-1.1
[**2147-5-20**] 01:14AM BLOOD PT-13.7* PTT-30.0 INR(PT)-1.2*
[**2147-5-21**] 12:09AM BLOOD Plt Ct-145*
[**2147-5-22**] 01:30AM BLOOD Plt Ct-119*
[**2147-6-12**] 02:27AM BLOOD PT-14.0* PTT-34.1 INR(PT)-1.2*
[**2147-6-19**] 07:09AM BLOOD Plt Ct-269
[**2147-6-27**] 07:00AM BLOOD Plt Ct-420#
[**2147-6-28**] 05:38AM BLOOD Plt Ct-350
[**2147-5-19**] 05:24PM BLOOD WBC-11.8*# RBC-3.87* Hgb-13.2* Hct-37.9*
MCV-98 MCH-34.0* MCHC-34.7 RDW-14.4 Plt Ct-219
[**2147-5-20**] 01:14AM BLOOD WBC-9.6 RBC-3.74* Hgb-12.2* Hct-36.9*
MCV-99* MCH-32.6* MCHC-33.1 RDW-14.7 Plt Ct-201
[**2147-5-21**] 12:09AM BLOOD WBC-8.2 RBC-2.92* Hgb-10.0* Hct-29.4*
MCV-101* MCH-34.2* MCHC-33.9 RDW-14.5 Plt Ct-145*
[**2147-6-14**] 06:20AM BLOOD WBC-5.2 RBC-2.76* Hgb-8.8* Hct-26.4*
MCV-96 MCH-31.9 MCHC-33.3 RDW-14.8 Plt Ct-270
[**2147-6-19**] 07:09AM BLOOD WBC-5.2 RBC-2.92* Hgb-9.6* Hct-28.0*
MCV-96 MCH-32.8* MCHC-34.1 RDW-14.7 Plt Ct-269
[**2147-6-27**] 07:00AM BLOOD WBC-5.1 RBC-3.02* Hgb-9.2* Hct-27.8*
MCV-92 MCH-30.4 MCHC-33.0 RDW-14.5 Plt Ct-420#
[**2147-6-28**] 05:38AM BLOOD WBC-4.8 RBC-3.47* Hgb-10.7* Hct-31.4*
MCV-91 MCH-30.7 MCHC-33.9 RDW-15.0 Plt Ct-350
[**2147-5-20**] 07:04AM URINE Hours-RANDOM UreaN-149 Creat-279 Na-11
K-98 Calcium-1.3 Phos-96.8 Mg-3.0
[**2147-5-20**] 04:11PM URINE Hours-RANDOM Creat-346 Na-11
[**2147-5-20**] 07:22PM URINE Osmolal-487
[**2147-6-4**] 09:13PM URINE CastHy-28*
[**2147-5-24**] 08:39AM URINE RBC-[**3-16**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-<1
[**2147-6-1**] 12:45PM URINE RBC-5* WBC-2 Bacteri-FEW Yeast-NONE Epi-0
[**2147-6-4**] 09:13PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
[**2147-5-24**] 08:39AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG
[**2147-6-4**] 09:13PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
[**2147-5-29**] 04:02AM ASCITES WBC-[**Numeric Identifier **]* RBC-7000* Polys-66*
Lymphs-2* Monos-10* Macroph-22*
[**2147-6-12**] 01:10PM ASCITES WBC-825* RBC-[**2113**]* Polys-11* Lymphs-56*
Monos-26* Eos-2* Basos-1* Mesothe-4*
[**2147-5-29**] 4:02 am PERITONEAL FLUID
**FINAL REPORT [**2147-6-4**]**
GRAM STAIN (Final [**2147-5-29**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **]. [**Doctor Last Name **] ON [**2147-5-29**] AT 0725.
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
FLUID CULTURE (Final [**2147-6-2**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
WORK UP PER DR. [**Last Name (STitle) **] [**4-/3288**] [**2147-5-30**].
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted. gram stain reviewed:.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS AND
CLUSTERS were observed ON [**2147-6-1**].
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. MODERATE
GROWTH.
VIRIDANS STREPTOCOCCI. HEAVY GROWTH.
PRESUMPTIVE STREPTOCOCCUS BOVIS. MODERATE GROWTH.
ENTEROCOCCUS SP.. MODERATE GROWTH.
ESCHERICHIA COLI. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ENTEROCOCCUS SP.
| | ESCHERICHIA
COLI
| | |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S <=1 S
LEVOFLOXACIN---------- 0.25 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- 8 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2147-6-4**]):
BACTEROIDES FRAGILIS GROUP. RARE GROWTH. BETA
LACTAMASE POSITIVE.
[**2147-6-12**] 10:50 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2147-6-14**]**
MRSA SCREEN (Final [**2147-6-14**]): No MRSA isolated.
[**Hospital1 69**]
[**Location (un) 86**], [**Telephone/Fax (1) 15701**]
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 81595**],[**Known firstname **] A [**2093-1-28**] 54 Male [**Numeric Identifier 81596**]
[**Numeric Identifier 81597**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/mtd
SPECIMEN SUBMITTED: Esophagectomy.
Procedure date Tissue received Report Date Diagnosed
by
[**2147-5-19**] [**2147-5-19**] [**2147-5-24**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dwc??????
Previous biopsies: [**Numeric Identifier 81598**] Slides referred for
consultation.
DIAGNOSIS:
Distal esophagus and proximal stomach, esophagogastrectomy:
- High grade glandular dysplasia present in a background of
Barrett's esophagus.
- No residual adenocarcinoma identified.
- No malignancy identified in seventeen paraesophageal
lymph nodes (0/17).
Note:
High grade glandular dysplasia is present in a background of
Barrett's esophagus (slide F). Some adjacent glands and ducts
show atypia consistent with treatment effect. Pathologic staging
of this specimen following neoadjuvant therapy is ypT0N0MX.
Proximal and distal surgical margins of resection are negative
for dysplasia.
Clinical: Adenocarcinoma, esophagus.
Gross:
The specimen is received fresh labeled with the patient's name,
"[**Known lastname 33474**], [**Known firstname 3613**] A", the medical record number and additionally
labeled "esophagectomy". It consists of an esophagogastrectomy
specimen that measures 20.5 x 8.5 x 2.2 cm in overall dimension.
The esophagus measures 13.5 cm in length and 1.3 cm in average
diameter. The gastric portion of the specimen measures 4.0 x 3.5
x 1.0 cm. Additionally, there is a triangle of stomach stapled
to the proximal esophageal margin measuring 7.0 x 5.5 x 0.8 cm.
Paraesophageal soft tissue is present measuring 11.5 x 4.0 x 1.0
cm. The omentum measures 13.0 x 6.0 x 1.2 cm. A palpable mass
is not present. The true distal stapled margin is inked [**Location (un) 2452**]
and the periesophageal soft tissue is inked black. The esophagus
and stomach are opened to reveal unremarkable tan mucosa. The
gastroesophageal junction is blocked out in two parts: a
proximal block and a distal block. The proximal and distal ends
of each block are inked blue and yellow, respectively. The
blocks are serially sectioned to reveal no residual tumor, there
the submucosa is diffusely fibrotic. The paraesophageal soft
tissue and omentum are dissected to reveal no grossly apparent
lymph nodes.
Final Report
INDICATION: 54-year-old man with rising T belly.
COMPARISON: No previous exam for comparison.
FINDINGS: The liver is diffusely echogenic consistent with fatty
infiltration. No focal liver lesion is identified. There is no
biliary
dilatation and the common duct measures 0.4 cm. The portal vein
is patent
with hepatopetal flow. A scant trace of ascites is seen in the
perihepatic
space. There are no gallstones and the gallbladder is not
distended. No
gallbladder wall thickening is seen. The pancrease is obscured
from view by
overlying bowel. The spleen is unremarkable and measures 10.7
cm. No ascites
is seen in the lower quadrants.
IMPRESSION:
1. No gallstones, no biliary dilatation, and no sign of
cholecystitis.
2. Echogenic liver consistent with fatty infiltration. Other
forms of liver
disease and more advanced liver disease including significant
hepatic
fibrosis/cirrhosis cannot be excluded on this study.
3. Scant trace of ascites in the perihepatic space. No ascites
seen in the
lower quadrants.
The study and the report were reviewed by the staff radiologist.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 20982**], RDMS
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: [**Doctor First Name **] [**2147-5-25**] 7:02 PM
Final Report
STUDY: Percutaneous jejunostomy tube placement using ultrasound
and
fluoroscopic guidance.
INDICATION: Patient has previous laparoscopic feeding
jejunostomy tube placed
approximately four months previous. The tube has been removed,
yet needs to
be replaced given need for tube feeding since nutritional
requirements are not
met. Esophageal cancer.
RADIOLOGISTS: Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] performed the
procedure. Dr.
[**Last Name (STitle) **], the attending radiologist, was present and
participating throughout.
FINDINGS/PROCEDURE: Informed consent was obtained after the
risks, benefits,
and alternatives to the procedure were explained. A preprocedure
timeout was
performed using three patient identifiers. The patient was
placed supine on
the angiographic table and the abdomen was prepped and draped in
standard
sterile fashion. Fluoroscopy was used to identify the surgically
placed
staples indicating the site of jejunal loop tacking to the
anterior peritoneal
surface. Ultrasound and micropuncture set was utilized to gain
access to this
loop of jejunum. Conray contrast material confirmed entry into
the jejunal
loop. A guidewire followed by Kumpe catheter was used to secure
placement
into the jejunal loop. An Amplatz wire secured this site and
provides
stiffness for dilation of the tract. A 12 French Wills-[**Doctor Last Name 12433**]
jejunostomy
tube was secured in the jejunal loop and the guidewire was
removed. The
feeding tube was sutured to the skin. The patient tolerated the
procedure
well. There were no post-procedural complications.
ANESTHESIA: The patient was continually monitored by
radiological nursing
staff and 100 mcg fentanyl was administered for patient comfort.
Total
intraservice time was 40 minutes. 20 cc buffered lidocaine was
administered
for local anesthesia.
IMPRESSION: Successful ultrasound and fluoroscopic-guided
placement of
12 french jejunostomy tube. Tube is ready for use.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Doctor Last Name 4391**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
Approved: [**Doctor First Name **] [**2147-6-8**] 10:46 AM
Final Report
HISTORY: Rising creatinine, absent left kidney.
FINDINGS: The right kidney is normal in size, contour, and
echogenicity. The
right kidney measures 13.1 cm, with no hydronephrosis or
nephrolithiasis. The
left kidney is absent, as seen on prior PET/CT from [**12-19**]. The
urinary
bladder is within normal limits. Moderate ascites is noted.
IMPRESSION:
1. Normal appearance of the right kidney.
2. Nonvisualization of the left kidney, as noted on prior PET/CT
from [**12-19**].
3. Moderate ascites.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 81599**]
DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**]
Approved: TUE [**2147-6-6**] 12:07 PM
HISTORY: 54-year-old man status post esophagectomy with
persistent ileus,
please inject p.o. contrast through J-tube, question anastomotic
leak, ileus.
TECHNIQUE: 5-mm contiguous axial images from the thoracic inlet
through the
lesser trochanters without IV and with Gastrografin which was
injected via the
J-tube were obtained. Coronal and sagittal reconstructions were
included in
this study. Correlation is made to a prior abdominal ultrasound
dated [**2147-5-25**] as well as a prior PET scan dated [**2147-1-10**].
FINDINGS:
CT THORAX WITHOUT IV CONTRAST:
There are small bilateral pleural effusions with associated
compressive
atelectasis of the posterior lower lobes. Ground-glass opacities
are seen in
the right greater than left lungs. Central airways are patent.
The patient is status post esophagectomy with gastric
pull-through. Oral
contrast is admixed with gastric pull-through fluid. No frank
dehiscence of
the anastomotic sutures. No evidence of mediastinal
lymphadenopathy. Mild
atherosclerotic disease is seen in the thoracic aorta and
coronary arteries.
No evidence of pericardial effusion.
There is a single-lead left chest wall cardiac pacemaker with
its tip in the
right ventricle. Tip of the right PICC line is in the SVC.
Visualized
portion of the thyroid gland is unremarkable. A surgical drain
tracks along
the left aspect of the neck into the mediastinum to the level of
the distal
trachea.
CT ABDOMEN WITHOUT IV CONTRAST:
There is a moderate amount of ascites, predominantly located in
the
perihepatic region, bilateral pericolic gutters and tracking
along the small
bowel mesentery in the pelvis.
The lack of IV contrast limits the evaluation of the solid
parenchymal organs.
Liver, gallbladder, pancreas, spleen, adrenal glands, and right
kidney appear
normal. There is a rounded soft tissue density (29 [**Doctor Last Name **]) lesion in
the left
renal fossa which contains a peripheral calcification. This
lesion measures
1.8 cm x 1.5 cm and may represent a left kidney remnant.
Surgical staples are seen in the upper abdomen from the
patient's recent
esophagectomy and gastric pull-through. A J-tube is visualized.
Oral
contrast passes through the nondistended small bowel and colon
to the level of
the rectum. No evidence of bowel obstruction or ileus. No
evidence of
pneumatosis. No focal fluid collections or free air.
Moderate atherosclerotic disease is seen in the abdominal aorta
which is
normal in course and caliber. No evidence of retroperitoneal or
mesenteric
lymphadenopathy.
CT PELVIS WITHOUT IV CONTRAST:
The bladder is partially distended and contains air, likely from
prior
catheterization. Prostate gland contains calcifications. Seminal
vesicles are
unremarkable. No evidence of pelvic or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No suspicious osteolytic or osteoblastic
lesions. Mild
multilevel degenerative changes are seen in the thoracic and
lumbar spine.
IMPRESSION:
1. No evidence of ileus or bowel obstruction.
2. No frank dehiscence of the gastric pull-through anastomosis.
If there is
a clinical suspicion for anastomotic leak, a fluoroscopic study
is recommended
with water-soluble contrast. This study was performed with
Gastrografin
injection into the J-tube per the referring team's request.
3. Small bilateral pleural effusions.
4. Moderate amount of ascites.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 306**] [**Last Name (NamePattern1) 6891**]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: MON [**2147-6-12**] 12:41 AM
HISTORY: 54-year-old male status post esophagectomy, with
distended abdomen,
found to have ascites.
No prior studies available for comparison.
FINDINGS: After discussion of the risks and benefits of the
procedure,
written informed consent was obtained. A preprocedure timeout
was performed
using multiple different patient identifiers.
Preliminary son[**Name (NI) 493**] images of the abdomen demonstrate a
moderate amount of
ascites, with the largest pocket within the right lower
quadrant, which was
chosen for percutaneous access. The right lower quadrant was
then prepped and
draped in a standard sterile fashion. 1% lidocaine was used for
local
anesthesia. A 5 French [**Last Name (un) 11097**] catheter was then advanced into the
abdomen, and
approximately 1.5 liters of tan-colored ascites was drained,
with samples sent
to the laboratory as requested.
The patient tolerated the procedure well, without immediate
post-procedural
complications. Dr. [**Last Name (STitle) **], the attending radiologist, was
present and
supervising throughout the procedure.
IMPRESSION: Uncomplicated ultrasound-guided diagnostic and
therapeutic
paracentesis, yielding 1.5 liters of tan-colored ascites.
Samples were sent
to the laboratory as requested.
ESOPHAGRAM DATED [**2147-6-21**]
HISTORY: A 54-year-old male with a history of laparoscopic
esophagectomy with
prolonged course of intolerance to p.o. and question anastomotic
leak in neck.
COMPARISON: CT dated [**2147-6-11**].
FINDINGS: Conray and thin barium were administered to the
patient orally.
Fluoroscopic images of the esophagogastric anastomosis were
obtained. The
barium passes through the upper esophagus into the intrathoracic
stomach
freely with no evidence of constrast extravasation, obstruction
or stricture.
A surgical drain is noted overlying the mediastinum in addition
to pacemaker
leads.
IMPRESSION:
No extravasation of contrast at the level of the intrathoracic
esophagogastric
anastamosis.
Date: Tuesday, [**2147-6-27**] Endoscopist(s): [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **],
MD
[**First Name (Titles) **] [**Last Name (Titles) 81600**], MD (fellow)
Patient: [**Known firstname 3613**] [**Known lastname 33474**]
Ref.Phys.: [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **], MD
Assisting Nurse(s)/
Other Personnel: [**First Name9 (NamePattern2) 3548**] [**Doctor Last Name **], Anesth
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 81601**], RN
[**Doctor Last Name 40535**] [**Last Name (un) **]
Birth Date: [**2093-1-28**] (54 years) Instrument: GIF 180
ID#: [**Numeric Identifier 81597**]
Medications: Monitored anesthesia care
Indications: 54 y/o gentleman with history of esophageal cancer,
s/p esophagectomy with gastroesophageal anastomosis, with
persistent drainage from the JP drain in the neck
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered MAC
anesthesia. The patient was placed in the left lateral decubitus
position and an endoscope was introduced through the mouth and
advanced under direct visualization until the third part of the
duodenum was reached. Careful visualization of the upper GI
tract was performed. The procedure was not difficult. The
patient tolerated the procedure well. There were no
complications.
Findings: Esophagus:
Other Esophago-gastric anastomosis visualized. Minimal air used
to insufflate the esophagus and stomach.
Stomach:
Contents: Bilious fluid was seen in the stomach body. The fluid
was removed with suction. The gastric folds in the region of the
antrum appeared erythematous and edematous. Mild resistance was
encountered in passing the scope past the pylorus in the
duodenum. Balloon dilation of the pylorus was performed. A 10mm
balloon was introduced for dilation and the diameter was
progressively increased to 15 mm successfully. Subsequently, 5
ml (100 Units) of Botox was injected in and around the pylorus.
Duodenum: Normal duodenum.
Impression: Esophago-gastric anastomosis visualized.
Minimal air used to insufflate the esophagus and stomach.
Bilious fluid was seen in the stomach body. The fluid was
removed with suction.
The gastric folds in the region of the antrum appeared
erythematous and edematous.
Mild resistance was encountered in passing the scope past the
pylorus in the duodenum.
Balloon dilation of the pylorus was performed. A 10mm balloon
was introduced for dilation and the diameter was progressively
increased to 15 mm successfully.
Subsequently, 5 ml (100 Units) of Botox was injected in and
around the pylorus.
Recommendations: NPO
Follow for response/complications
Follow-up with Dr. [**Last Name (STitle) **]
Additional notes: The procedure was performed by Dr. [**Last Name (STitle) **] and
the ERCP fellow. The patient's reconciled home medication list
is appended to this report.
Brief Hospital Course:
Patient was admitted postoperatively, in stable condiditon, to
the SICU. On POD 0, overnight, he went into atrial fibrillation
with rapid ventricular rate which was controlled with diltiazem
drip. His urine output was low and unresponsive to significant
fluid bolus. He was begun on vasopressin, low dose drip, which
imptoved his renal perfusion and his urine output increased. By
POD 2 he became more agitated and he was cared for on a CIWA
scale as he had a significant alcohol history. He required a
large amount of oxygen to keep his saturation up. Otherwise he
was doing well. On POD 3 he was diuresed with lasix which he
responded to well. This was continued on POD 4 as well, with
good response when he was restarted on lovenox and given
aggressive lasix diuresis. On POD 7 his chest tube was
discontinued and a clonidine patch and lopressor were added. TPN
was started on POD 8 and he had an ECHO which was unremarkable.
On POD 9 lopressor was increased and on POD 10 he was
persistantly tachycardic so a diltiazem drip was started. Given
large JP output and ? fevers he was started on
flagyl/zosyn/vanc/fluc. On [**6-1**] he was started on levaquin for
presumptive pneumonia. On [**6-2**] he underwent a J tube in IR and
his diltiazem drip was changed to J-tube medications.
On [**6-6**] he underwent a renal usg for increased creatinine which
was essentialy normal, though he remained distended. He was
discontinued off levo/flagyl on [**6-8**]. His creatinine improved
significantly by [**6-8**] with hydration. On [**6-10**] EP was consulted
and he was started on digoxin for refractory atrial
fibrillation. His atrial fibrillation responded well however
given his distension he underwent a CT torso which showed a
significant amount of ascited. This was tapped and he responded
well. On [**6-15**] he was started on tubefeeds slowly. For the next 2
weeks he had fluctuating levels of nausea and vomiting, which
were attributed to ? pyloric stenosis. His tubefeeds were held
and then restarted multiple times.
Given continued output from his JP drain each time he had a
small amount of retching, it was assumed that he had a leak in
his esophageal anastamosis, despite a drain study in radiology
that had indicated otherwise. He was noted to have continued
bouts of small amounts of emesis vs. regurgitation which
sometimes would have increased output in his L neck JP drain.
On [**6-25**] roughly 600cc was emptied from a JP drain and he
underwent EGD for presumptive pyloric stenosis. In this EGD his
pyloris was dilated and injected with botox and his symptoms
improved signficantly. Prior to discharge all of his medications
were switched to J tube with good effect. His JP was
progressively pulled back and ultimately d/c'ed on [**7-1**]. He was
tolerating his tubefeeds well with minimal regurgitation and no
drainage from his neck. Presumably his anastamotic leak was
self-contained. He will be discharged on a soft solid diet with
explicit warning about certain signs of collection / fevers. He
was also discharged on full tubefeeds.
Medications on Admission:
Toprol 50'', Lasix 40', K 20', Ativan 1prn, Protonix 40'',
Hydroxyzine 50'', Lovenox 120'
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe [**Month/Year (2) **]: Ninety (90) mg Subcutaneous
DAILY (Daily).
Disp:*qs x1month * Refills:*2*
2. Lorazepam 0.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Furosemide 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. All medications per J tube, strictly nothing by mouth
6. Digoxin 250 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily):
per J tube.
Disp:*30 Tablet(s)* Refills:*2*
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
8. Codeine-Guaifenesin 10-100 mg/5 mL Syrup [**Last Name (STitle) **]: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
Disp:*200 ML(s)* Refills:*0*
9. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*60 Tablet(s)* Refills:*2*
10. Colace 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) cc PO twice a day.
Disp:*400 cc* Refills:*2*
11. Replete/Fiber Liquid [**Last Name (STitle) **]: Seventy Five (75) cc PO
hourly: Replete with fiber Full strength;
Goal rate:75 ml/hr
Flush w/ 50 ml water q6h.
Disp:*qsig x 2 weeks * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
community health and hospice
Discharge Diagnosis:
Esophageal carcinoma
Atrial fibrillation
Poor nutrition
Acute renal failure
Respiratory Insufficiency
Pyloric Stenosis
Anastomotic leak
Discharge Condition:
Stable, soft solids diet, tubefeeds at goal, afebrile,
occasional small amounts of expectoration 25-50cc daily
(positional)
Discharge Instructions:
You are being discharged home in stable condition. You may eat a
soft solid diet. It is very important to follow up your
medication regimen very strictly and continue your tubefeeds at
their current rate (goal). As we have discussed in your hospital
stay, it is ok to have small episodes of regurgitation but
should you have any significant bouts of emesis or significant
abdominal pain, please call Dr.[**Name (NI) 1482**] office or return to
the emergency room.
If you have any of the other following problems or concerns,
please call your doctor or return to the emergency room.
*Fever > 101.2
*Chest pain, shortness of breath
*Heart palpitations
*Abdominal pain, retching, vomiting
*Significant amounts of diarrhea
Followup Instructions:
Please call Dr.[**Name (NI) 1482**] office to follow up within 2 weeks
of discharge. ([**Telephone/Fax (1) 1483**]
Completed by:[**2147-7-3**]
|
[
"5849",
"2760",
"42731",
"3051",
"4280",
"53081",
"V5861"
] |
Admission Date: [**2134-6-7**] Discharge Date: [**2134-6-12**]
Date of Birth: [**2064-6-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Shortness of breath, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69 year old man with COPD (on 2L NC at home; FEV1 1.12 at
baseline), central hypoventilation, sleep disordered breathing
on home BiPAP, obesity, CAD s/p MI and LAD stent, h/o recurrent
Vfib/Vtach s/p AICD placement, presents from pulmonary clinic
with dyspnea and hypoxia. He reports that since a
hospitalization in [**State 108**] in late [**Month (only) 547**] for COPD exacerbation,
although improved, his breating has never subjectively felt back
to his previous baseline although his oxygen sats were at his
baseline low 90s% on 2-3L NC. Over the past few weeks however,
he has noted worsening LE edema and increasing DOE so that even
walking across the room from the bathroom made him feel SOB. He
reports discomfort in B/L LEs with the edema, but not marked
pain nor asymmetry. He reports he drove from [**State 108**] to Mass.
in 10 hour stretches approximately 2 weeks ago. He reported his
worsening LE edema and SOB to his cardiologist who increased his
lasix dose from 40mg PO daily to 80mg PO daily for the 4 days
prior to his admission. He reports he has been making "good"
urine to this and his LE edema has improved, however his SOB has
not. He denies increased sputum production nor fevers/chills.
so held on seeking medical attention until this previously
scheduled appointment. At pulmonary clinic, he was noted to be
hypoxic to 82% on 2-3L NC. A CT chest was performed which
showed bilateral ground glass opacities. Following imaging and
in the setting of his worsened hypoxia, he was referred to the
medical floor for direct admission.
.
With respect to his late [**Month (only) 547**] admission for hypoxia. He
reports he developed worsening hypoxia at home and presented to
a local hospital in [**State 108**]. He endorses worsening in his
sputum production at that time. He was treated for COPD
exacerbation with 10 day course of levofloxacin and 30 day slow
taper of prednisone. Although he reports improvement from that
hospitalization, he never returned to baseline and over the past
2 weeks has further decompensated as outlined above.
.
Upon direct admission to the floor, initial O2 sats were noted
to be in the 70s, he was placed on additional supplemental O2
(unclear exact amount via NC) and initial ABG revealed
7.28/75/72. He was then placed on bipap after which repeat gas
was 7.28/76/51. From there he was changed to cpap although ABG
on cpap was not obtained. He received 100mg IV lasix x1 to
which he put out 450ccs urine. Upon transfer to the ICU, he was
on 4L NC with O2 sats high 80s to low 90s. Repeat ABG at that
time was 7.30/77/57. He has made an additional 220 ccs urine
for a total of 670cc out since lasix dosing.
.
ROS: No changes in vision, no headache. No
numbness/tingling/weakness. No chest pain/palpitations. No
abdominal pain, no frank blood in stool (but endorses guaiac
positive at recent PCP [**Name Initial (PRE) **]), no dark tarry stools. No
dysuria/hematuria. No rashes. +joint pain specifically low
back.
Past Medical History:
1. COPD (on 2L nc at home, last PFTs [**7-/2133**]: FVC 1.82 (44%
predicted), FEV1 1.12 (39% predicted), FEV1/FVC 61 (90%
predicted)); DLCO 34% predicted.
2. Complex sleep disordered breathing on home BiPAP.
3. Obesity, kyphosis, and restrictive pulmonary dysfunction.
4. CAD s/p anteroseptal MI in [**2125**], s/p prox LAD stenting.
5. History of recurrent Vfib/Vtach and cardiac arrest, s/p AICD.
6. Hypercholesterolemia.
7. History of bladder cancer.
8. Diabetes mellitus.
9. Status post multiple laminectomies for disc disease.
10. CRI; baseline creatinine unclear ? 1.4-1.6
11. Anemia
Social History:
Lives with wife. Spends winter and early spring in [**State 108**],
summers in [**State 350**]. Quit tobacco in [**2124**], smoked 2ppd x
30years prior to that. No EtOH since [**2124**] prior to which he
reports "heavy" drinking although does not elaborate. Denies
other illicits. Previously worked in construction as welder.
Family History:
non-contributory
Physical Exam:
T 96.9 BP 104/57 HR 87 RR 30 O2sat 95% on 4L NC
GEN: Speaking in full sentences however appears mildly
tachypneic
HEENT: PERRL, EOMI, no conjuctival injection, anicteric, OP
clear although dry from recent cpap mask, neck supple, no
carotid bruits, unable to assess jvd given body habitus
CV: RRR, distant heart sounds however no m/r/g appreciated
PULM: Bibasilar rales [**12-24**] way up, no wheezes nor rhonchi
ABD: obese, soft, NT, ND, + BS
EXT: warm, dry, palpable DP/PT pulses b/l, 2+ pitting edema to
mid shins b/l
NEURO: alert & oriented x3, CN II-XII grossly intact, strength
intact throughout grossly. No sensory deficits to light touch
appreciated. Mild asterixis.
PSYCH: appropriate affect
Pertinent Results:
[**2134-6-7**] CT chest: Newly occurred diffuse, inhomogeneous, and
slightly apical predominant pattern of parenchymal opacities
that suggests either RB-ILD or DIP. Early NSIP is less likely
given the distribution of the changes.
.
[**2134-6-7**] TTE: The left atrium and right atrium are normal in
cavity size. The estimated right atrial pressure is 0-5 mmHg.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and global systolic function (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets are moderately thickened. There is mild
aortic valve stenosis (area 1.2-1.9cm2). Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild aortic valve stenosis. Pulmonary artery systolic
hypertension (50 mmHg).
.
[**2134-6-9**] Bubble study: Right to left intracardiac shunting is
present at rest. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. Tricuspid regurgitation is present but cannot
be quantified.
Compared with the prior study (images reviewed) of [**2134-6-7**],
right to left intra-cardiac shunting is present at rest. If
clinically indicated, a TEE may clarify the degree of
intracardiac shunting and to clarify PFO versus ASD.
Brief Hospital Course:
69yo M with h/o COPD (2-3L home O2 requirement), CAD, CHF, v.
fib/v. tach arrest s/p AICD presents with subacute worsening of
dyspnea and hypoxemia and hypercarbia.
.
# Hypoxemia/Hypercarbia: Multifactorial in the setting of known
COPD with mixed obstructive/restrictive pattern on PFTs. He was
not, however, markedly bronchospastic on exam and denies
increased sputum production to suggest overt COPD exacerbation.
Also without focal infiltrate, leukocytosis and fever to suggest
underlying lobar pneumonia although atypical infection was
possible, but less likely. Further review of ground glass
opacities on chest CT suggested that this was actually the
result of poor inspiratory effort more than fluid buildup or
atypical pneumonia. His BNP was 838 (although may be somewhat
lower than expected given obesity) and thus not overwhelming for
CHF. On TTE he had pulmonary htn (50 mmHg) when compared to
prior which may also be contributing.
In terms of risk for PE, he had long drives from [**State 108**] and
thus perhaps a significant risk, but a lung scan was done and
suggested low probability for PE. Additionally TTE without
decline in EF (actually better than previously) to suggest acute
ischemic event causing drop in EF; CEs negative x2 and EKG
without ischemic changes.
.
Additionally, it appears that he had a right-to-left shunt seen
on TTE, which likely contributed to hypoxia; additionally with
increased right heart pressure, left ventricular function may
have worsened and contributed to pulmonary hypertension. This
would help to explain his right heart failure symptoms like
increasing peripheral edema while his hypoxia was really most
response to steroids. He was started on 125mg IV solumedrol
followed by 80mg q8h for one day, 60 mg q6h for one day, and
then a conversion to PO prednisone with a taper described in the
outpatient medication list below. Azithromycin for four days was
given for bronchitis and effects on inflammation. Supplemental
oxygen and home BiPAP was continued.
.
# COPD/central hypoventilation: Patient was hypercarbic however
by history had no increase in cough nor sputum production and on
exam is not bronchospastic. We gave albuterol/atrovent nebs, his
home advair, and steroids as described above.
.
# Metabolic alkalosis: Was started on diamox nearly a year ago
per old OMR pulmonary note twice weekly. Appears compensatory
in the setting of CO2 retention however worsened in the setting
of contraction with diuresis. Diamox was held but was restarted
for his outpatient regimen as detailed below.
.
# CAD: H/o CAD s/p LAD stent in [**2125**]. CEs negative and EKG
without new ischemic changes. Had multiple VF/VT events and in
fact his wife informs us that he was the topic of an academic
medical article; of note, this was in the same room of the same
MICU that he was admitted to this time, which he and his wife
took to be a good sign. Less suspiciously, we continued aspirin,
statin, and beta blocker.
.
# CHF: Repeat chemistries show hypernatremia and climbing
bicarb (contraction alkalosis). Given BNP of 838 and echo with
evidence of LVH, however with improved LVEF from prior, suspect
CHF not contributing markedly to the above picture despite
ground glass opacities on CT chest. He put out nearly 700ccs to
100mg IV lasix. He got diamox x1 but this was then held as
above. BB and [**Last Name (un) **] were continued.
.
# CRI: In review of labs, appears baseline creatinine runs
1.4-1.6 however we have few measurement points since [**2125**]
admission. He has been stable at 1.6 thus far. We continued his
[**Last Name (un) **] and monitored closely. At discharge his creatinine was 1.3.
.
# Diabetes mellitus: We used an insulin SS for much of the
admission pending possible further imaging modalities in the
setting of CRI, but then switched to his oral medications and an
insulin sliding scale. His glucose was poorly controlled prior
to the switch, and after the switch his glucose was improved;
serum glucose was 87 on the morning of discharge after being
elevated in all prior labs.
.
# Anemia: Hct 34 on this admission (no priors since [**2126**] and
prior to that [**2125**] at which time he was hospitalized for
prolonged period). Elevated MCV and RDW. Guaiac positive
stools however without gross blood nor black stools. His Hct did
not drop precipitously. This merits GI followup. Heparin gtt was
stopped and pneumoboots were used for PPX.
.
# Hyperlipidemia: Continued atorvastatin 40mg PO daily.
.
#FEN: DM, cardiac diet. Replete lytes PRN
.
#ACCESS: PIV
.
#PPx:
- pneumoboots
- continued omeprazole as on as outpatient
- bowel meds
.
#CODE: FULL
.
#COMMUNICATION: patient and wife [**Name (NI) **] [**Name (NI) 1683**] [**Telephone/Fax (1) 32629**]
.
#DISPO: Home
Medications on Admission:
Acetazolamide 125mg PO qTuesday and Thursday
Advair Diskus 500-50mcg 1 puff [**Hospital1 **]
Allopurinol 100mg PO daily
ASA 81mg PO daily
Benzonatate 100mg q6h prn
Calcium 500mg PO daily
Centrum silver MVI
Clobetasol 0.05% apply to skin [**Hospital1 **]
Coreg 25mg PO bid
Cozaar 50mg PO bid
Erythromycin ointment to affected areas as needed for skin
irritation from CPAP
Glyburide-metformin 5-500mg; 1.5 tabs PO bid
K-Dur 10mEq [**Hospital1 **]
Lasix 80mg daily, recently increased from 40mg daily
Lipitor 40mg PO daily
Magnesium oxide 400mg once daily
Meloxicam 15mg PO daily
NTG 0.4mg SL prn
Oxygen 2-3L
Prilosec 40mg PO daily
Uniphyl 600mg SR daily
Vitamin E
Xopenex neb q4h prn
Discharge Disposition:
Home
Discharge Diagnosis:
COPD
Diabetes
Right-to-left intracardiac shunt
Hypertension
Chronic renal insufficiency
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for shortness of breath and lack of oxygen in
your blood. There are several things that might have contributed
to this, but things that did contribute were: 1)a flare of your
COPD and 2)heart failure, complicated by the shunt in your heart
that causes blood without oxygen to mix with blood that has
oxygen.
.
Additionally, probably mostly because we used high-dose steroids
to help treat you, you had very high sugar levels while you were
here. While you are still on steroids, you will need to watch
your sugar levels closely. We are starting you on insulin, and
you should stop taking the diabetes pills you take for the time
being. If you are consistently having sugar levels about 250 or
you are having low blood sugars (below 70) please call your
doctor as soon as possible to consider redosing your insulin. If
your sugar levels are below 60, you should drink a glass of
juice. You will probably need less insulin as you take lower
doses of steroids. You should write down each sugar level and
bring them to your PCP's office. You will need to see your PCP
early next week, and regularly after that for continued
manegment.
.
Follow the prescription for your steroid taper closely. You'll
be changing doses after two days, and then every five days after
that.
If you develop worsened shortness of breath, fever, chest pain,
palpitations, lightheadedness, or other concerning symptoms,
call your PCP or go to the emergency room.
Followup Instructions:
You should call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 5424**] on
monday morning to schedule an appointment early next week.
Dr[**Name (NI) 4025**] office is trying to find you a time within the
next 1-2 weeks to see Dr [**Last Name (STitle) 575**]. If you do not hear from Dr [**Name (NI) 20186**] office, you should call to make an appointment at
the first available time; call ([**Telephone/Fax (1) 513**].
.
Already-made appointments:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] & DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2134-6-18**] 9:20
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2134-8-30**]
8:30
|
[
"5849",
"4280",
"32723",
"4168",
"41401",
"V4582",
"412",
"2724"
] |
Admission Date: [**2147-1-27**] Discharge Date: [**2147-1-31**]
Date of Birth: [**2077-12-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Central Venous Line x2
Arterial Line
History of Present Illness:
This is a 69M with CAD, CHF, PVD, aplastic anemia (last
transfusion [**1-25**]), and DM2, who presented to the ED after his
family called EMS for agonal breathing. He was intubated in the
field and brought to the ED. As he is intubated and sedated,
history is obtained from the online medical record and family.
In the ED, he was fighting the vent; he had poor peripheral
access, so a groin line was placed. While placing the groin
line, no femoral pulse was present and the rhythm on the bedside
monitor was wide complex. Epinephrine was given via ETT and once
venous access was obtained, CaCl2, bicarb, and insulin were
administered. He never received chest compressions, as
spontaneous circulation returned quickly (<45 seconds, according
to ED resident). He received kayexalate via OG tube. He is
receiving 2 units of PRBCs for Hct of 21. Vital signs at the
time of transfer were afebrile, pulse 120s, SBP 130s-140s,
vented with good O2 saturation.
ROS: Unable to obtain
Past Medical History:
# Diabetes Mellitus type 2
# Hypertension
# Chronic Kidney Disease, Cr 1.6-1.9
# Coronary Artery Disease s/p balloon angioplasty in [**2133**] &
NSTEMI in [**9-/2146**]
# scar-mediated VT, s/p failed ablation
# aplastic anemia/MDS, Hct 25-28 & transfusion dependent (most
recent was [**1-25**] for Hct of 22.1); platelets usually 70-130k;
WBC usually 3.0-4.0k.
# Peripheral Vascular Disease s/p R fem-[**Doctor Last Name **] bypass in [**Month (only) 216**],
[**2138**]
# s/p right Carotid Endarterectomy in [**2135-1-26**]; left carotid
artery completely occluded but asymptomatic
# s/p right 5th toe amputation in [**2137-6-25**]
Social History:
He is retired. He worked as a maintenance worker at [**Hospital1 2177**] for 25
yrs. He is widowed but has a son and daughter-in-law in town who
he stays in close touch with. He lives by himself in poor
financial circumstances. He has smoked one and a half packs of
cigarettes/day for at least 50 years. He denies alcohol or other
drugs.
Family History:
His mother and sister have diabetes mellitus type two. Many
members of his family have hyptertension.
Physical Exam:
On Presentation:
Vitals: T:92.6 BP:133/83 HR:65 Vent: AC 600x14(24), 5 PEEP, 40%
FiO2 O2Sat: 99%
GEN: thin elderly male intubated, nonresponsive, after receiving
versed in the ED
HEENT: EOMI, PERRL 4-2mm and brisk, sclera anicteric, no
epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses doppler on R, 1+
on Left, where there is a large hematoma
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: + gag, + corneals, but no withdrawal to pain/noxious
stimuli
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
No petechiae
Pertinent Results:
IMAGING:
CT A/P: Prelim read:
Limited noncontrast evaluation. Bilateral moderate pleural
effusions and
bibasilar consolidations likely representing aspiration in the
setting of
recent cardiac/respiratory arrest. Mild free abdominal fluid and
anasarca.
Large gallstone. No definite evidence for acute intra-abdominal
process.
HEAD CT:
No evidence of hemorrhage. Multifocal areas of cortical and
subcortical hypodensity represent chronic infarct, though
further evaluation with MRI may be pursued to evaluate for acute
or subacute components.
ECHo:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 10-20mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
No masses or thrombi are seen in the left ventricle. Overall
left ventricular systolic function is severely depressed (LVEF=
20 %) with akinesis of the inferior, infero-lateral, distal
LV/apical segments. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
ADMISSION LABS:
-[**2147-1-27**] BLOOD WBC-3.2* RBC-1.83* Hgb-6.8* Hct-21.0* MCV-116*
MCH-37.1* MCHC-32.1 RDW-20.9* Plt Ct-28*#
-[**2147-1-27**] BLOOD PT-28.8* PTT-90.5* INR(PT)-2.9*
-[**2147-1-28**] BLOOD FDP->1280*
-[**2147-1-28**] BLOOD Glucose-235* UreaN-120* Creat-4.7* Na-142 K-5.7*
Cl-107 HCO3-10* AnGap-31*
-[**2147-1-28**] BLOOD ALT-1592* AST-1808* LD(LDH)-2890* CK(CPK)-9394*
AlkPhos-147* TotBili-4.3* DirBili-2.6* IndBili-1.7
-[**2147-1-28**] BLOOD CK-MB-60* MB Indx-0.6 cTropnT-1.14*
-[**2147-1-28**] BLOOD Albumin-3.6 Calcium-10.2 Phos-10.6*# Mg-3.5*
-[**2147-1-28**] BLOOD Hapto-<20*
-[**2147-1-28**] BLOOD D-Dimer-8754*
-[**2147-1-28**] BLOOD Cortsol-158.6*
-[**2147-1-27**] BLOOD [**Year/Month/Day **]-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
-[**2147-1-27**] BLOOD pO2-502* pCO2-23* pH-7.05* calTCO2-7* Base
XS--23
-[**2147-1-27**] BLOOD Glucose-GREATER TH Lactate-12.5* Na-134* K-6.3*
Cl-106 calHCO3-9*
Brief Hospital Course:
69M with multiple medical problems including DM2, CAD, CHF,
aplastic anemia, CKD, who presented to the ICU s/p respiratory
and cardiac arrests with hyperkalemia, acute on chronic renal
failure, and DIC. The exact nature of these events is unclear,
but he has had worsening renal function over the past week,
leading to electrolyte disturbances and possibly an
arrhythmogenic cardiac arrest with spontaneous return of
circulation prior to the arrival of EMS. On admission, patient
was intubated, unresponsive, in acute renal failure, liver
failure and had cardiac damage as evidenced by elevated cardiac
biomarkers. He was aggressively fluid recussitated, started on
broad spectrum antibiotics for presumed sepsis, transfused RBC's
and started on pressors for blood pressure support. Heme/onc
was consulted and patient was determined to be in DIC. Renal
was consulted and it was determined that renal replacement
therapy was not indicated.
Patient was maintained on vent, antibiotics and pressors but
continued to deteriorate with worsening renal function, no
improvement in respiratory status, and decreasing blood pressure
to systolics of 30 in spite of pressor support. The decision
was made by his family to make patient comfort measures only.
He was started on a morphine drip for comfort, extubated and all
non-comfort medications were discontinued. He expired on [**2147-1-31**]
at 12:10pm.
Medications on Admission:
Folic Acid 2 mg daily
Clopidogrel 75 mg daily
Aspirin 325 mg daily
pravastatin 10 mg daily
Isosorbide Dinitrate 60mg tid
Hydralazine 25 mg tid
Metoprolol Tartrate 75mg [**Hospital1 **]
furosemide 20mg daily
Neoral 50mg QAM and 25 mg QPM -- HELD for elevated Cr since
[**1-25**]
Procrit everyother week, started [**1-25**]
novolin 70/30 insulin, unknown dose
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
none
Discharge Condition:
Expired.
Discharge Instructions:
none
Followup Instructions:
none
|
[
"0389",
"51881",
"78552",
"5849",
"2767",
"5859",
"2875",
"4280",
"99592",
"40390",
"25000",
"41401",
"412",
"V4582"
] |
Admission Date: [**2169-4-1**] Discharge Date: [**2169-4-5**]
Date of Birth: [**2110-3-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Concern epidural abscess, back pain, diabetic ketoacidosis
Major Surgical or Invasive Procedure:
Intubation, extubation, central line placement, hemodialysis
History of Present Illness:
59 yo man with a h/o epidural abscess in the [**2150**], ESRD on HD
(started last week), HTN, lomgstanding type 1 diabetic,
dyslipidemia who initially presented to an OSH with worsening
back pain. He was transferred to [**Hospital1 18**] for neurosurgical
evaluation. Pt reported that he was at the end of his HD session
when he began to experience a back spasm that involved his
entire back up to his neck. He has been having these for the
last few months, but that this was the worst one that he's had
to date. When he gets this at home, he usually doesn't take
anything and they go away on their own. He has been frustrated
with his care recently and requested to be brought to [**Hospital1 18**] for
evaluation.
Past Medical History:
H/O epidural abscess in the [**2150**]
ESRD on HD- began week prior to admission
Heart failure (unknown whether diastolic or systolic)
DM type 1, initially diagnosed in his 30s
HTN
Dyslipidemia
GERD
COPD
Social History:
History of tobacco (cigars) for approximately 30 yrs, quit 1 yr
ago. No EtOH, no IVDU. Lives with wife in [**Name (NI) 2498**].
Family History:
No history diabetes, HTN or malignancy.
Physical Exam:
Vitals: T:97.9 BP:120/56 P:67 R: 18 O2:98% 1L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, HD line clean and dry
without tenderness
Lungs: crackles RLL otherwise clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 intact, [**6-20**] upper and lower ext strength.
Diminished sensation in lower ext bilaterally. Gait not
assessed.
Pertinent Results:
LABORATORY DATA
[**2169-4-1**] 07:50PM WBC-13.6* RBC-3.78* HGB-11.2* HCT-31.7*
MCV-84 MCH-29.7 MCHC-35.5* RDW-14.4; NEUTS-86.1* LYMPHS-9.2*
MONOS-4.0 EOS-0.4 BASOS-0.4
[**2169-4-3**] 12:45PM BLOOD WBC-20.6* RBC-2.88* Hgb-8.7* Hct-24.3*
MCV-84 MCH-30.1 MCHC-35.8* RDW-15.1 Plt Ct-182, Neuts-88.8*
Lymphs-6.6* Monos-3.0 Eos-1.5 Baso-0.2
[**2169-4-4**] 09:05AM BLOOD WBC-10.0# RBC-2.90* Hgb-8.6* Hct-24.4*
MCV-84 MCH-29.8 MCHC-35.5* RDW-15.3 Plt Ct-159
[**2169-4-1**] 07:50PM GLUCOSE-319* UREA N-21* CREAT-3.0* SODIUM-140
POTASSIUM-4.3 CHLORIDE-95* TOTAL CO2-30 ANION GAP-19
[**2169-4-4**] 09:05AM BLOOD Glucose-185* UreaN-75* Creat-6.8* Na-136
K-4.1 Cl-94* HCO3-30 AnGap-16
[**2169-4-1**] 07:50PM CALCIUM-9.2 PHOSPHATE-2.1* MAGNESIUM-1.8
[**2169-4-1**] 07:55PM LACTATE-3.0*
[**2169-4-1**] 07:50PM PT-14.4* PTT-24.6 INR(PT)-1.3*
[**2169-4-1**] 07:50PM SED RATE-45*
[**2169-4-2**] 04:41PM BLOOD %HbA1c-8.7*
[**2169-4-2**] 07:31PM BLOOD Lactate-1.4
[**2169-4-3**] 12:45PM BLOOD calTIBC-228* Ferritn-665* TRF-175*\
CARDIAC ENZYMES
[**2169-4-2**] 12:19PM BLOOD CK-MB-18* MB Indx-6.3* cTropnT-0.34*
[**2169-4-3**] 05:03AM BLOOD CK-MB-17* MB Indx-3.5 cTropnT-1.69*
[**2169-4-3**] 12:45PM BLOOD CK-MB-11* MB Indx-2.0 cTropnT-1.38*
[**2169-4-4**] 09:05AM BLOOD CK-MB-8 cTropnT-1.46*
IMAGING
CHEST (PORTABLE AP) Study Date of [**2169-4-1**] 10:36 PM
No evidence of acute cardiopulmonary process.
Brief Hospital Course:
59M with type 1 diabetes, ESRD recently started on HD, h/o
epidural abscess transferred for neurosurgical evaluation and
found to be in DKA.
# Diabetic Ketoacidosis: On [**4-2**] found to have DKA with AG 30
and patient had missed his long acting insulin dose prior to
admission. No source of infection was found to have prompted
his DKA. Additionally, on admission there was no evidence of
cardiac ischemia that may have prompted it. Thus, the episode
was attribued to a missed insulin dose. In the ICU he was given
fluids and placed on an insulin gtt. Once his gap closed he was
transitioned to subcutaneous insulin.
# Diabetes. Patient states he is type 1 and has been on insulin
although was on oral agents before. He has been very difficult
to control since [**2168-11-16**] with numbers running in the
300-400s and frequent hospital visits, HgbA1c here 8.7%. Suspect
there has been a component of uremia making patient resistant to
insulin. Hopefully, with more stable HD his blood glucose will
be easier to control. After he was transitioned off the insulin
drip, he was continued on his home dosing of Glargine 25 units
QHS and a Humalog sliding scale. He was discharged with this
regimen and had good glycemic control but will need continued
titration as an outpatient for further improvement. Upon
discharge, patient and wife expressed that they will call the
[**Hospital **] Clinic for further management.
# Elevated Troponins. Concerning for an NSTEMI, but uncertain
if clearly met criteria. He did have an elevated Troponin, CK,
and CK-MB but no EKG changes and was asymptomatic. Could be
demand ischemia in setting of DKA and severe stress. He was
continued on ASA 81mg daily. His Atorvastatin was increased to
80mg daily. Additionally, he was started on low dose Metoprolol
12.5 mg [**Hospital1 **]. He was on Labetolol prior to admission, but his
blood pressure was well controlled without this medication.
Likely he will need less blood pressure meds given hemodialysis.
Upon discharge, patient was instructed to discuss his new
medications with his primary care physician.
# Leukocytosis. This is possibly due to acute demarginalization
in setting of DKA. Blood cultures and urine cultures were
negative or no growth to date upon discharge. CXR without
evidence of an acute process. Throughout hospitalization
remained pain free and afebrile without any localizing sypmtoms
of infection.
# Back pain. History of epidural abscess in the [**2150**]. Upon
admission, he was seen by Neurosurgery who suggested an
infectious work-up but no need for imaging of his spine given
lack of localizing symptoms. Back pain resolved in ED and did
not recur during hospitalization. This was likely secondary to
muscle spasm in the setting of his hemodialysis.
# End Stage Renal Disease. Presumed to be secondary to diabetes
and HTN. He was followed by Renal while inpatient and was
dialyzed. He has a Quentin catheter in his right chest and a
maturing fistula in his right forearm. He was also continued on
calcium acetate and discharged with continued dialysis as an
outpatient.
# Chronic Obstructive Pulmonary Disease. Patient states he is
on Advair at home. While inpatient he was placed on standing
Ipratropium and PRN Albuterol. He was discharged on his prior
medications.
# Anemia. This was presumed to be secondary to ESRD. His iron
studies were checked an most consistent with anemia of chronic
disease.
# Altered mental status. This briefly occurred while in the
ICU, prompting intubation for airway protection. He was
successfully extubated and had no further symptoms of confusion.
This may have been related to pain medication or uremia given
his ESRF.
Patient requested to be a FULL CODE while inpatient.
Medications on Admission:
Atorvastatin 10 daily
Aspirin 81 daily
Albuterol-Ipratropium 2 puffs IH q6
Humalog 14 Units SC TIDAC
Levemir 25-27 Units SQ qPM
Phoslo 1334mg PO TIDPC
Iron 325mg PO TID
Nephrocaps 1 cap daily
Labetolol 100mg [**Hospital1 **]
Lisinopril 10mg daily
Ibuprofen 600mg q6h PRN
Omeprazole 20mg daily
Discharge Medications:
1. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months: This medication is increased given concern
for damage to your heart.
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day) for 1 months: This may be continued by your regular
doctor, please discuss.
Disp:*30 Tablet(s)* Refills:*0*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Levemir 100 unit/mL Solution Sig: 25-27 units Subcutaneous at
bedtime: Levemir 25-27 Units SQ qPM .
9. Humalog 100 unit/mL Solution Sig: Fourteen (14) units
Subcutaneous TIDAC : Please check your blood sugar 3-4 times
daily.
10. LINE CARE
Heparin Flush (5000 Units/mL) 4000-[**Numeric Identifier 2249**] UNIT DWELL PRN line
flush
Dialysis Catheter (Tunneled 2-Lumen): DIALYSIS NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen.
Discharge Disposition:
Home With Service
Facility:
VNA of S.Southeastern Mass
Discharge Diagnosis:
Primary: Diabetic Ketoacidosis
Secondary: Concern for myocardial ischemia, leukocytosis, back
pain, end stage renal disease, anemia, COPD
Discharge Condition:
Hemodynamically stable and afebrile, with no further back pain.
Discharge Instructions:
You were admitted with back pain and shaking chills. You were
found to have poorly controlled blood sugar prompting admission
to the ICU. You were treated with fluids. Once improved, you
were admitted to the floor and then discharged home. One of
your blood tests indicated you may have had some damage to your
heart during your illness. All your blood tests and urine test
did not reveal in infectious cause of your illness.
Keep all outpatient appointments.
Take all medications as prescribed.
Your Labetolol and Lisinopril have been discontinued.
Seek medical advice if you notice fevers, chills, difficulty
breathing, abdominal pain or any other symptom which is
concerning to you.
Followup Instructions:
Please keep all outpatient appointments. You need to schedule
an appointment with your primary care, Dr. [**First Name (STitle) 429**] to be seen
next week. Please call him the day after discharge and schedule
a follow-up appointment with him.
|
[
"40391",
"4280",
"496",
"2724",
"53081",
"V5867"
] |
Admission Date: [**2174-2-28**] Discharge Date: [**2174-3-7**]
Date of Birth: [**2105-8-28**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
[**2174-3-3**] right internal carotid stent placement
History of Present Illness:
68 female with a distant history of seizure disorder (on
dilantin) who recently underwent a right [**Month/Day/Year **] [**2174-2-22**] at [**Hospital1 **] for questionable TIAs with left sided weakness. She
was discharged from hospital on [**2174-2-23**] and was doing well
untill the evening of [**2174-2-27**]. That evening she had a syncopal
episode in the bathroom. In route to the hospital she had a 3
minute long seizure which resolved spontaenously. She had an
additional seizure in the ED with dense left hemiparesis. She
received ativan and dilantin for the seizures and was
transferred to [**Hospital1 18**] for further evaluation. On CTA of neck, she
was found to have focal moderate-to-severe narrowing of the
distal right CCA and CT/MRI head did not demonstrate any obvious
evidence of stroke.
Past Medical History:
Seizure d/o (only had 2 grand mal seizures when 35 y/o; on
dilantin)
Right ICA stenosis
Hypertension
Rheumatoid Arthritis
Migraines
Degenerative disc disease
PAST SURGICAL HISTORY: R [**Hospital1 **] [**2174-2-21**]
L knee arthroscopic surgery x 2
Plate and screws in R ankle
Social History:
Lives with her husband, retired nurse, does not smoke, drink
ETOH, no IVDU.
Family History:
father and brother who have both had strokes and father had [**Name2 (NI) **]
(? side) and brother had b/l [**Name2 (NI) **]
Physical Exam:
T: 98.4 HR: 83 BP: 134/50 RR: 14 Spo2: 97%
Gen: alert and oriented x 3
Neuro: CN II-XII, no focal deficits
Cardiac: RRR, no mrg, + S1, S2
Lungs: CTA bilaterally, no resp distess
Abd: soft, NT. ND
Wound: right groin cdi, no hematoma or bleed
Pedal pulses palpable
Pertinent Results:
[**2174-3-6**] 08:40AM BLOOD WBC-12.4* RBC-3.24* Hgb-10.4* Hct-31.2*
MCV-96 MCH-32.0 MCHC-33.2 RDW-13.5 Plt Ct-428
[**2174-3-5**] 03:51AM BLOOD WBC-12.5* RBC-3.10* Hgb-10.0* Hct-29.3*
MCV-95 MCH-32.3* MCHC-34.1 RDW-13.5 Plt Ct-411
[**2174-3-4**] 03:45PM BLOOD Hct-26.9*
[**2174-3-4**] 10:56AM BLOOD Hct-25.0*
[**2174-3-4**] 04:15AM BLOOD WBC-12.0* RBC-2.73* Hgb-9.1* Hct-25.9*
MCV-95 MCH-33.3* MCHC-35.2* RDW-13.3 Plt Ct-355
[**2174-3-6**] 08:40AM BLOOD Plt Ct-428
[**2174-3-5**] 03:51AM BLOOD Glucose-132* UreaN-5* Creat-0.5 Na-140
K-4.3 Cl-102 HCO3-31 AnGap-11
[**2174-3-4**] 03:45PM BLOOD Na-136 K-4.1 Cl-103
[**2174-3-4**] 04:15AM BLOOD Glucose-140* UreaN-5* Creat-0.5 Na-140
K-3.5 Cl-102 HCO3-31 AnGap-11
[**2174-3-4**] 04:15AM BLOOD CK(CPK)-32
[**2174-3-3**] 11:00PM BLOOD CK(CPK)-23*
[**2174-3-3**] 08:30AM BLOOD CK(CPK)-20*
[**2174-3-7**] 09:30AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.8
[**2174-3-5**] 03:51AM BLOOD Calcium-9.2 Phos-4.6* Mg-1.9
[**2174-3-1**] 02:30AM BLOOD Phenyto-7.4*
[**2174-2-28**] 09:23AM BLOOD Phenyto-9.3*
[**2174-2-27**] 11:00PM BLOOD Phenyto-11.3
[**2174-2-28**]
Chest xray
FINDINGS: As compared to the previous radiograph, there is
improved
ventilation of both lungs. A minimal area of atelectasis at the
right lung
base has improved. The size of the cardiac silhouette is
borderline, but
there is no pulmonary edema. No pleural effusions. No
pneumothorax. No
evidence of pneumonia.
Brief Hospital Course:
On [**2174-2-28**] the patient was transferred from [**Hospital3 4107**] for
seizures after recent [**Hospital3 **] . She was alert and oriented x3 on
exam. On heparin and Nicardipine drip. A-line placed on
admission and the patient was deemed ICU level. An MRI was
ordered and Dilantin level was checked. [**Hospital3 **] surgery was
consulted for ICA stenosis and possible intervention. The
patient was placed on seizure precautions. Blood pressure
managed on labetalol and nicardipine drip. Speech and swallow
evaluation initiated. Remained in the SICU for blood pressure
management and seizure precautions.
[**Date range (1) 80017**]
Monitored in ICU. Continued on heparin drip. Patient passed
swallow evaluation. Carotid duplex was obtained which showed
significant stenosis of right CCA and proximal ICA. Continued on
aspirin and started on statin medication. Neurological deficits
resolving. The decision was made for the patient to undergo
stent/angioplasty of previous [**Date range (1) **]. The patient was also enrolled
in the Sapphire trial.
[**2174-3-3**]
Underwent right carotid stent without complications. Bedrest
overnight. NPO. Plavix for 30 days. Frequent neurological checks
in [**Month/Day/Year **] step down. Required additional oral blood pressure
agents for management of hypertension. Neuro continued to follow
and recommended weaning dilantin and treating the patient with
Keppra.
[**Date range (1) 56565**]
Stable and transferred to step down unit. Continued on blood
pressure agents and dilantin was continued to be weaned. Started
on Ancef for right upper extremity thrombophlebitis.
Neurologically continues to do well.
[**2174-3-7**]
Stable and cleared for home. Will follow up with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) **] as an outpatient. She was discharged on a
course of keflex for R upper arm thrombophebitis on DC.
Medications on Admission:
abatacept [ORENCIA] ? dose/freq
hydrochlorothiazide - 12.5 mg Capsule daily
methotrexate sodium [Methotrexate (Anti-Rheumatic)] ?dose
phenytoin sodium extended [Dilantin Extended] - 300 mg daily
prednisone ? dose
propranolol - 120 mg Capsule,Extended Release [**Hospital1 **]
ramipril - 10 mg Capsule [**Hospital1 **]
aspirin - 81 mg Tablet daily
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day): Call PCP for refills [**Name9 (PRE) **],[**Doctor Last Name **]
Phone: [**Telephone/Fax (1) 31188**]
Fax: [**Telephone/Fax (1) 34848**]
.
Disp:*180 Tablet(s)* Refills:*2*
3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Call PCP for refills
Phone: [**Telephone/Fax (1) 31188**]
Fax: [**Telephone/Fax (1) 34848**]
.
Disp:*60 Tablet(s)* Refills:*2*
4. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): 30 days poststent.
Disp:*30 Tablet(s)* Refills:*0*
6. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for thrombophlebitis.
7. Keflex 500 mg Capsule Sig: One (1) Capsule PO twice a day for
10 days.
Disp:*20 Capsule(s)* Refills:*0*
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
11. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily): 5 days only then stop.
Disp:*5 Capsule(s)* Refills:*0*
12. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily): call pcp for refills.
Disp:*30 Capsule(s)* Refills:*2*
13. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
15. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
16. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
call pcp for refills.
Disp:*60 Tablet(s)* Refills:*2*
17. ramipril 5 mg Capsule Sig: Two (2) Capsule PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
[**2174-3-3**]
1. Ultrasound-guided puncture of left common femoral vein.
2. Ultrasound-guided puncture of right common femoral
artery.
3. Selective catheterization of the right carotid artery.
4. Selective arteriogram of the right carotid artery.
5. Primary stenting of the right carotid artery.
6. Perclose closure of right common femoral arteriotomy.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? You should not have an MRI scan within the first 4 weeks after
carotid stenting
?????? Call and schedule an appointment to be seen in [**1-28**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
[**Date Range 1106**] office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2174-3-31**] 9:00
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2174-3-31**]
8:30
You should follow up with our Neurology team in [**11-28**] months.
Please call ([**Telephone/Fax (1) 7394**] to make a follow up appointment
with Dr. [**Last Name (STitle) **]
Completed by:[**2174-3-7**]
|
[
"4019",
"2720"
] |
Admission Date: [**2122-4-1**] Discharge Date: [**2122-4-5**]
Date of Birth: [**2063-3-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Rocephin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
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 > posterior descending artery)
[**2122-4-1**]
History of Present Illness:
58 year old male with positive stress test, underwent cardiac
catherization that revealed coronary artery disease and was
referred for cardiac surgery
Past Medical History:
Diabetes mellitus
Hypertension
Elevated cholesterol
CVA
Pericarditis s/p pericardiocentesis
Hypothyroid
Hiatal hernia
Social History:
Natural gas leak consultant
Lives alone
Denies tobacco
Rare alcohol
Family History:
Noncontributory
Physical Exam:
General NAD
Skin Rubor
HEENT unremarkable
Neck supple full ROM
Chest anterior/lateral CTA
Heart RRR
Abdomen soft, NT, ND +BS
Extremeties warm well perfused no edema
Varicosities none
Neuro grossly intact
Pertinent Results:
[**2122-4-5**] 06:55AM BLOOD
WBC-10.2 RBC-3.26* Hgb-9.6* Hct-27.8* MCV-85 MCH-29.4 MCHC-34.5
RDW-13.5 Plt Ct-301
[**2122-4-1**] 02:40PM BLOOD
PT-14.7* PTT-34.3 INR(PT)-1.3*
[**2122-4-4**] 07:30AM BLOOD Glucose-159* UreaN-23* Creat-1.2 Na-138
K-4.7 Cl-103 HCO3-20* AnGap-20
[**2122-4-4**] 01:44PM
URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
URINE Blood-SM Nitrite-NEG Protein-30 Glucose-300 Ketone-10
Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
URINE RBC-4* WBC-7* Bacteri-FEW Yeast-NONE Epi-<1
CHEST (PA & LAT) [**2122-4-4**] 5:05 PM
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with
REASON FOR THIS EXAMINATION:
r/o inf, eff
CMG unchanged, increased retrocardiac opacity concerning for
worsening atelectasis, early infiltrate. Also small left pleural
effusion.
Brief Hospital Course:
On [**4-1**] was brought to the operating room and underwent coronary
artery bypass graft surgery. See operative report for further
details. He was transferred to the intensive care unit for
further hemodynamic monitoring. In the first 24 hours he was
weaned from sedation, awoke neurologically intact, and was
extubated without difficulty. He was started on beta blockers
and was gently diuresed. On POD 1 he was transferred to the
floor. Physical therapy worked with him for strength and
mobility. He continued to progress, his chest tubes, foley. amd
pacing wires were DC'd without incidence.
Pt did have lowgrade temp 99. On Dc WBC is decreased, ua
negative, cxr atelectasis
Pt [**Name (NI) 1788**] home in stable condition
Medications on Admission:
Lipitor 40 daily
lotrel 5-40 daily
Zetia 10 daily
HCTZ 25 daily
Plavix 75 daily
Synthroid 112 daily
Toprol XL 50 daily
Protonix 40 daily
ASA 81 [**1-25**] x/week
Lantus 50 units in am, 30-40units in pm
Humalog sliding scale
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. 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*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
12. Lantus 50 units in am, 30-40units in pm
Humalog sliding scale
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease s/p CABG
post op atrial fibrillation
Diabetes Mellitus
Hypertension
Hiatal Hernia
Hypothyroid
Pericarditis s/p pericardiocentesis
Elevated cholesterol
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 6700**] in 1 week ([**Telephone/Fax (1) 6699**]) please call for
appointment
Dr [**Last Name (STitle) **] in [**1-25**] weeks
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
Completed by:[**2122-4-5**]
|
[
"41401",
"9971",
"5180",
"42731",
"25000",
"4019",
"2720",
"2449"
] |
Admission Date: [**2170-4-4**] Discharge Date: [**2170-4-23**]
Date of Birth: [**2124-9-29**] Sex: M
Service: Thoracic Surgery
CHIEF COMPLAINT: Tracheal stenosis.
HISTORY OF PRESENT ILLNESS: The patient is a 45-year-old
male with a history of chronic obstructive pulmonary disease
and obstructive sleep apnea who underwent uvulopalatotectomy
in [**2165**]. This was complicated by hemorrhage and a
tracheostomy for a period of two weeks.
Subsequently, he has had multiple dilatations for the
tracheal stenosis. He is now here for tracheal
reconstruction.
PAST MEDICAL HISTORY:
1. Obstructive sleep apnea, status post uvulopalatotectomy.
2. Tracheostomy for two weeks in [**2165**].
3. Chronic obstructive pulmonary disease.
4. Hypertension.
5. Atrial fibrillation. The patient has failed several
direct cardioversions.
6. Alcohol abuse.
7. History of cardiac catheterization in [**2169-6-28**]
with an ejection fraction of 69% and clean coronaries.
8. Kidney stones.
9. Umbilical hernia.
10. Gastroesophageal reflux disease.
MEDICATIONS ON ADMISSION: Flovent, Atrovent, albuterol,
guaifenesin 500 mg p.o. q.d., prednisone 60 mg p.o. q.d.,
Protonix 40 mg p.o. q.d., diltiazem 120 mg p.o. b.i.d.,
Zestril 10 mg p.o. q.d., amiodarone 200 mg p.o. q.d.,
Lopressor 25 mg p.o. b.i.d., digoxin 0.25 mg p.o. q.d.,
Colace 100 mg p.o. b.i.d., Klonopin 0.5 mg p.o. t.i.d.
p.r.n., trazodone 50 mg p.o. q.h.s. p.r.n., Lipitor 10 mg
p.o. q.d., Coumadin (which has been held).
ALLERGIES: PENICILLIN.
HOSPITAL COURSE: The patient underwent a rigid bronchoscopy
and direct laryngoscopy, tracheal resection and
reconstruction on [**2170-4-4**]. His intraoperative course was
uneventful. He was admitted to the Intensive Care Unit
postoperatively in an intubated condition. He remained
intubated overnight and was in a stable condition.
He was extubated on postoperative day one. He remained in
atrial fibrillation at this time. He was started on a
diltiazem drip for the atrial fibrillation with a rate
of 150s. He underwent a bronchoscopy which showed mild
anastomotic edema and was therefore continued on diuresis.
He remained in the Intensive Care Unit for the next few days
slowly improving with aggressive respiratory treatment. His
Coumadin was restarted on postoperative day three. He was
continued on antibiotics of vancomycin and Flagyl which had
been started in the initial postoperative period.
On postoperative day six, he complained of some left lower
extremity pain. He underwent a lower extremity noninvasive
study which revealed a left lower extremity deep venous
thrombosis. At this point, he was started on Lovenox as he
was not yet therapeutic on his Coumadin.
On [**2170-4-10**], he underwent another bronchoscopy which
again revealed mucosal edema at the anastomotic site. In the
next few days in the Intensive Care Unit were essentially
uneventful as he slowly improved, and his respiratory
function was slowly improving.
He was deemed ready for transfer to the regular floor on
postoperative day eight. He was stable on the floor over the
next few days. His Coumadin was continued until it reached a
therapeutic level, and at that point the Lovenox was stopped.
He continued to have left leg pain secondary to the deep
venous thrombosis and was treated with a morphine
patient-controlled analgesia. He had aggressive respiratory
toilet as well at this point. His clinical condition slowly
improved, and he started ambulating, and his respiratory
function improved as well.
On postoperative day 16 ([**2170-4-20**]), he went back to the
operating room for a bronchoscopy. At that time, his airways
were clean, and there was no mucosal edema. He was now ready
for discharge home on Coumadin.
MEDICATIONS ON DISCHARGE:
1. Diltiazem 120 mg p.o. b.i.d.
2. Lisinopril 10 mg p.o. q.d.
3. Amiodarone 20 mg p.o. q.d.
4. Digoxin 0.25 mg p.o. q.d.
5. Colace 100 mg p.o. b.i.d.
6. Vitamin A 25,000 units q.d.
7. Zinc 220 mg p.o. q.d.
8. Atrovent inhaler 2 puffs q.i.d.
9. Flovent 110 mcg 2 puffs b.i.d.
10. Lopressor 25 mg p.o. b.i.d.
11. Protonix 40 mg p.o. q.d.
12. Vitamin C 500 mg p.o. q.d.
13. Percocet one to two tablets p.o. q.4-6h. p.r.n.
14. Lipitor 10 mg p.o. q.d.
15. Coumadin 5 mg p.o. q.d. (INR is to be checked twice
every week by primary care physician and then subsequently
per primary care physician's recommendations).
DISCHARGE FOLLOWUP: Follow up with Dr. [**Last Name (STitle) 952**] in clinic in
one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2170-4-21**] 22:14
T: [**2170-4-24**] 20:01
JOB#: [**Job Number 35005**]
|
[
"496",
"42731",
"53081",
"4019"
] |
Admission Date: [**2116-11-27**] Discharge Date: [**2116-11-30**]
Date of Birth: [**2067-7-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
Nausea, Vomiting, Diarrhea, Dehydration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Name13 (STitle) 10213**] is a 49 year old female with a history of alcohol
abuse, hypertension, pancreatitis and bulimia who presented from
[**Hospital 1680**] Hospital with dizziness and lightheadedness. She has
been admitted at [**Hospital 1680**] Hospital for alcohol detox and for the
past week has had nausea, vomiting, diarrhea and anorexia. She
says that she has been unable to tolerate po intake for the past
week and has had decreased appetite, also complaining of a
burning abdominal pain after she vomits that moves up into her
throat. She has been having [**4-19**] bowel movements per day, and
sometimes the diarrhea will wake her up at night but she has
been drinking coffee, water and gingerale during this time. She
denies any fever/chills, dysuria, hematuria, urinary
frequency/urgency. She is currently two weeks out from her last
drink. She says that this nausea/vomiting/diarrhea is
significantly different than her prior episodes of bulimia, now
she is nauseous with even the thought of food. At [**Hospital1 1680**] she
had been recieving her usual medications of lisinopril and
atenolol daily, along with tigan for nausea. Today the event
that prompted the staff at [**Hospital1 1680**] to send to the ER was that she
fell becuase she was lightheaded and then vomited on a staff
member.
.
In the ED inital vitals were 98, 80, 90/51, 78/56 sitting up,
16, 100% on RA. She triggered on arrival to the ER for
hypotension. Her initial exam was notable for evidence of
dehydration, bedside ultrasound showed an IVC that collapsed
with respiration. Labs were notable for a Cr of 2.3 (unknown
baseline), Ca of 11.1, white count of 13.6 with 79% neutrophils,
no bands and urinalysis with small leuk, few bacteria and 4
WBC's. EKG was NSR at 79bpm, with TWI in III. Chest x-ray with
no infiltrates. She was given 5L NS and her blood pressures
remained in the 90's systolic, zofran for nausea and calcium
gluconate for question of over beta blockade. VS on transfer:
92/48, 86, 21, 96% on RA.
.
On arrival to the ICU her initial VS were: 97.5, 86, 107/60, 10,
99% on RA. She currently says that she feels much better, but
that her abdomen is sore from the vomiting but otherwise feels
well.
Past Medical History:
Alcohol Abuse
Hypertension
Pancreatitis
Bulimia
Social History:
- Tobacco: denies
- Alcohol: history of abuse, currently in a detox program at
[**Hospital1 1680**]
- Illicits: denies
Currently homeless and living out of her car
Family History:
History of hypertension on her father's side, mother was an
alcoholic
Physical Exam:
On admission:
Vitals: 98, 80, 90/51, 78/56 sitting up, 16, 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Prior to discharge:
98.3 138/88 82 16 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission Labs:
===============
[**2116-11-27**] 07:38PM BLOOD WBC-13.6* RBC-4.36 Hgb-13.1 Hct-38.7
MCV-89 MCH-30.0 MCHC-33.8 RDW-13.5 Plt Ct-405
[**2116-11-27**] 07:38PM BLOOD Neuts-78.8* Lymphs-14.3* Monos-4.9
Eos-1.5 Baso-0.6
[**2116-11-27**] 07:38PM BLOOD Glucose-126* UreaN-36* Creat-2.3* Na-135
K-3.9 Cl-99 HCO3-20* AnGap-20
[**2116-11-27**] 07:38PM BLOOD ALT-33 AST-30 AlkPhos-82 TotBili-0.7
[**2116-11-27**] 07:38PM BLOOD Albumin-5.0 Calcium-11.1* Phos-5.3*
Mg-1.5*
[**2116-11-27**] 07:38PM BLOOD Osmolal-291
[**2116-11-27**] 07:38PM BLOOD TSH-1.9
[**2116-11-27**] 07:38PM BLOOD Cortsol-22.3*
[**2116-11-27**] 07:38PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Discharge Labs:
===============
[**2116-11-30**] 07:00AM BLOOD WBC-4.7 RBC-3.51* Hgb-10.5* Hct-31.0*
MCV-89 MCH-30.0 MCHC-33.9 RDW-13.2 Plt Ct-281
[**2116-11-30**] 07:00AM BLOOD Glucose-100 UreaN-8 Creat-0.7 Na-142
K-3.5 Cl-109* HCO3-26 AnGap-11
.
Other studies:
===============
Chest X-ray: no focal infiltrates
.
EKG: NSR @ 79 with TWI in III
.
Studies Pending at time of discharge:
=====================================
Stool cultures
Brief Hospital Course:
Primary Reason for Hospitalization:
=====================================
Ms. [**Name13 (STitle) 10213**] is a 49 y/o F with a h/o alcohol abuse who presents
from detox with one week of nausea/vomiting/diarrhea resulting
in dehydration and symptomatic hypotension.
.
ACTIVE ISSUES:
===============
#) Viral gastroenteritis: P viral gastroenteritis, especially
since she has been living in a group/healthcare setting for the
past two months although no known sick contacts. She was
aggressively hydrated on admission to the MICU. Stool studies
were sent. She was tolerating a regular diet prior to discharge.
Vomiting had totally resolved however still some watery diarrhea
present at time of discharge which was symptomatically
controlled with loperamide
- cdiff was negative but other stool cultures still pending at
discharge
- patient can continue symptomatic control of diarrhea with
loperamide. If no resolution of diarrhea within 3-5 days patient
should see PCP for further workup.
.
#) Hypotension: Resolved. Likely was hypovolemic from vomiting
and diarrhea in combination with her regular anti-hypertensives.
Blood pressures are now improved s/p IVF resuscitation. She
received a total of 6L NS in the ED and 2 L LR in the MICU. Her
home antihypertensives were initially held but are now resumed.
.
#) Acute Renal Failure: Likely was hypovolemic from vomiting and
diarrhea in combination with her regular anti-hypertensives.
After volume rescussitation in the MICU her renal function
improved to baseline. Her lisinopril was initially held but now
resumed.
.
#) History of Alcohol Abuse: is now two weeks out from her last
drink, so is out of the window for withdrawal. Our Social
Workers gave patient information for help with housing and
resources
- Patient going back to the Arbours for further substance abuse
treatment.
.
CHRONIC ISSUES:
===============
#) Hypertension:
- Resumed home lisinopril and atenolol
.
#) Depression:
- continue home medications of sertraline, trazodone and
seroquel.
.
#) H/O withdrawal seizures:
- Continue home keppra and gabapentin
.
TRANSITIONAL ISSUES:
=====================
Code: DNR/I (confirmed with patient)
Studies Pending at time of discharge: Stool cultures
Patient should have PCP appointment scheduled for after she
leaves the detox facility
Medications on Admission:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. quetiapine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day.
5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
6. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Discharge Medications:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. quetiapine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. sertraline 100 mg Tablet Sig: Two (2) Tablet PO once a day.
5. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
6. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
7. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 1680**] - [**Hospital **] Hospital - [**Location (un) **]
Discharge Diagnosis:
Primary:
- Hypovolemic Shock
- Acute Renal Failure
- Viral Gastroenteritis
Secondary:
- Hypertension
- Depression
- Seizure Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Last Name (Titles) **], it was a pleasure taking care of you here at [**Hospital1 18**].
You were admitted to the hospital because of vomiting and
diarrhea. This had caused you to become severely dehydrated. As
a result of this you had low blood pressure and kidney injury.
You were given large amounts of IV fluids and fortunately your
kidneys fully returned to [**Location 213**] function. Most likely your
vomiting and diarrhea was caused by a viral illness. You should
be very careful about washing your hands for the next 5 days
because these kinds of illnesses are very contagious.
The following addition was made to your medications:
START Loperamide (Immodium) 2mg four times daily as needed for
diarrhea
You should continue taking all of your medications as you were
previously.
Make sure you stay well hydrated for the next several days.
Followup Instructions:
Name: PANERIO-[**Last Name (LF) 10214**],[**First Name3 (LF) **] L
Location: [**Hospital **] [**Hospital **] HEALTH CENTER
Address: [**Location (un) 10215**], [**Hospital1 **],[**Numeric Identifier 9647**]
Phone: [**Telephone/Fax (1) 10216**]
*It is recommended that you see your PCP [**Name Initial (PRE) 176**] 2 weeks. Please
call Dr. [**Last Name (un) 10217**] to schedule an appointment.
|
[
"5849",
"4019",
"311"
] |
Admission Date: [**2138-9-10**] Discharge Date: [**2138-9-25**]
Service: C-MED
HISTORY OF PRESENT ILLNESS: Dr. [**Known lastname **] is a [**Age over 90 **]-year-old
gentleman with a history of coronary artery disease, aortic
insufficiency, atrial fibrillation, asthma, and chronic renal
insufficiency, who was transferred to [**Hospital1 190**] from [**Hospital3 **] following an
episode of respiratory distress.
Four days prior to admission the patient had fallen at home
and was taken to [**Hospital1 **] where hip films
indicated no fracture. He was discharged to [**Hospital3 1761**] short-term unit where he received Tylenol
No. 3 as well as Ambien. On the morning of admission, the
patient became confused, anxious, and dyspneic with a
respiratory rate in the 40s, and oxygen saturation dropping
to 70% on 2 liters; this improved to 95% on a 40% face mask.
The patient was also noted to have recently developed zoster
in the right fifth cranial nerve, ophthalmic division
distribution.
The patient was taken to the Emergency Department at [**Hospital1 **], again, on [**9-10**], which is the date of
admission, where his vital signs were stable; however, his
mental status was still altered. Electrocardiogram indicated
atrial flutter at a rate of 110. He was given Lopressor,
nitroglycerin paste, Levaquin, Lasix, acyclovir, and
Captopril in the Emergency Department with better rate
control. The patient also had lower extremity noninvasive
Doppler studies which were negative. According to the
patient's son, the patient has been agitated and not himself
since admission to the [**Hospital3 **] four days prior
to admission. The patient also has baseline changes of
[**Last Name (un) 6055**]-[**Doctor Last Name **] respiration; however, his baseline mental
status is extremely lucid per the patient's family.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post non-Q-wave
myocardial infarction in [**2116**]; catheterization in [**2124**] with
percutaneous transluminal coronary angioplasty of the left
anterior descending artery; catheterization in [**2130**] with left
main stenting, and multiple cardiac catheterizations in [**2131**]
including a left anterior descending rotablation and stent.
2. Asthma/chronic obstructive pulmonary disease with
restrictive pulmonary function tests and on home oxygen.
3. Pericarditis in [**2135**].
4. Chronic renal insufficiency with a baseline creatinine
of 1.8.
5. Congestive heart failure, 35% ejection fraction.
6. Atrial fibrillation, chronic.
7. Aortic insufficiency.
8. Temporal arteritis.
9. Ascending aortic dilatation, 6.2 cm in [**2133**].
10. Zoster, first noted on [**2138-9-2**], started Valtrex
on [**2138-9-4**].
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Acyclovir 600 mg p.o. five times
per day times five days, Coumadin 3 mg p.o. q.h.s.,
Lopressor 12.5 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d.,
folate 1 mg p.o. q.d., aspirin 325 mg p.o. q.d.,
Isordil 30 mg p.o. t.i.d., captopril 25 mg p.o. t.i.d.,
co-enzyme Q 100 mg p.o. q.d., vitamin E 400 mg p.o. q.d.,
vitamin C 500 mg p.o. q.d., Tylenol No. 3 p.r.n.,
vitamin B6 100 mg p.o. q.d., vitamin B12 1000 mg p.o. q.d.,
Ambien p.r.n., Milk of Magnesia p.r.n.
SOCIAL HISTORY: The patient is a retired ophthalmologist
from [**State 350**] Eye & Ear Infirmary. He denies smoking or
alcohol use.
FAMILY HISTORY: Family history was noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: The patient was a
somnolent and arousable elderly gentleman, slightly agitated,
in no acute distress. He was afebrile with a heart rate
of 72, respiratory rate of 24, blood pressure of 170/58,
oxygen saturation 95% on 2.5 liters. HEENT examination
indicated zoster in a cranial nerve V division 1 distribution
on the right. The pupils were equal, round, and reactive to
light. Extraocular muscles were intact. The oral mucosa was
dry. The patient had a right subconjunctival hemorrhage.
The neck was supple with no jugular venous distention. The
chest indicated reduced breath sounds at the bases. No
wheezes, rhonchi or rales. Cardiovascular examination
indicated a regular rhythm, normal S1 and S2. A [**1-4**]
decrescendo diastolic murmur at the right upper sternal
border and a soft systolic murmur at the apex. The abdomen
was soft, with mild diffuse tenderness, without guarding or
rebound. It was not distended. There were normal abdominal
bowel sounds, and no hepatosplenomegaly. The extremity
examination indicated peripheral pulses that were 2+. No
clubbing, cyanosis or edema. On neurologic examination, the
patient was somnolent but arousable, oriented to person,
month, and year only. He had a positive oculocephalic gag
and corneal reflexes, was moving all four extremities.
Reflexes were 1+ and symmetric. Toes were upgoing
bilaterally.
LABORATORY VALUES ON PRESENTATION: Initial laboratory
studies indicated a creatine kinase of 90, MB negative,
troponin of 0.3. Chem-7 with sodium of 140, potassium 5.3,
chloride 110, bicarbonate 28, BUN 72, creatinine 2.1, glucose
of 131. White blood cell count 10.8, hematocrit 36.5,
platelets 175. PT 23.4, PTT 34.8, INR of 3.6. An initial
arterial blood gas indicated a pH of 7.35, PCO2 of 52, and
PO2 of 77.
RADIOLOGY/IMAGING: Chest x-ray indicated stable mediastinal
widening and aortic root dilatation with a tracheal shift to
the right which was old. There were small bilateral pleural
effusions that were unchanged.
Lower extremity noninvasive Doppler studies were negative as
was a urinalysis.
Electrocardiogram #1 indicated atrial flutter at a rate
of 111 with 2:1 conduction, left axis deviation, left
ventricular hypertrophy, Q waves in leads III and aVF, ST
depressions in V4 through V6, and a T wave inversion in I and
aVL.
Electrocardiogram #2 indicated a rate of 72, continued atrial
flutter with persistent electrocardiogram changes.
HOSPITAL COURSE BY SYSTEM: The patient was admitted to the
C-MED Service for rule out of myocardial infarction as well
as for management of altered mental status.
1. CARDIOVASCULAR: The patient was ruled out for myocardial
infarction. He remained in atrial flutter with heparin for
anticoagulation. He was occasionally tachycardic to the low
100s which was treated successfully times two with
intravenous Lopressor.
An echocardiogram indicated mild left ventricular
hypertrophy, moderately decreased left ventricular function,
2+ aortic regurgitation, and 1+ mitral regurgitation, 4+
tricuspid regurgitation, as well as severe cor pulmonale and
severe pulmonary hypertension.
The patient's rate remained stable in the 70s to 80s, in
atrial flutter throughout the remainder of his hospital stay
until the last few hours prior to the patient's expiration.
2. INFECTIOUS DISEASE: An Infectious Disease consultation
was obtained on the first day of hospitalization. Per
Infectious Disease recommendations, the patient had a lumbar
puncture which indicated 45 white blood cells in tube #1, 28
white blood cells in tube #4, and elevated protein at 67,
normal opening pressure, and normal glucose. A VVV PCR from
the patient's cerebrospinal fluid was sent for analysis and
was still pending at the time of the patient's demise;
however, ultimately, the VVV PCR was read as negative.
The patient was started on intravenous acyclovir and
maintained on this throughout his hospital course. An MRI of
the head indicated moderate atrophy, small vessel disease.
No evidence of meningoencephalitis. No hematoma or mass
effect.
3. PULMONARY: The patient continued to exhibit
[**Last Name (un) 6055**]-[**Doctor Last Name **] respiration throughout his hospital course.
Serial blood gases indicated PCO2 in the 70s to 80s; however,
this did not always correlate with the patient's mental
status. Two times over the course of the hospitalization,
the patient was sent to the Medical Intensive Care Unit in
order to receive BiPAP treatment overnight. Each time the
patient was returned to the floor with some improvement in
mental status as well as in PCO2; however, again, the patient
would revert to a waxing and [**Doctor Last Name 688**] mental status with
elevated PCO2. He was also given a course of intravenous
steroids which was later tapered to p.o. steroids, as well as
tried on an aminophyllin drip; however, neither seemed to
effect the patient's pulmonary status. The patient was also
started on levofloxacin and Flagyl to treat possible
aspiration pneumonia; although, a sputum culture ended up
being negative, and the Infectious Disease consultation did
not think the patient had a pneumonia, and these antibiotics
were subsequently discontinued.
4. OPHTHALMOLOGY: The patient was seen by the Ophthalmology
consultation service and was determined not to have zoster
ophthalmicus. Ophthalmology continued to follow him during
his hospital course. He was also started on prophylactic
antibiotic eyedrops.
5. NEUROLOGY: The patient had a head CT on the date of
admission which was negative for mass lesion or bleed.
Neurologically was consulted secondary to the patient's
waxing and [**Doctor Last Name 688**] mental status. A metabolic workup was
initiated which was negative with the exception of an
elevated PCO2, which again did not seem to correlate with the
patient's mental status. Initially, it was thought that the
patient's altered mental status might be secondary to Tylenol
No. 3 and Ambien which he had received at [**Hospital3 1761**]; however, during his course at [**Hospital1 **] the patient received no benzodiazepines or other
sedating medication, and his mental status continued to wax
and wane.
6. DISPOSITION: On hospital day 16, following extended
discussions with the patient's family and his attending
Dr. [**Known lastname **], it was determined that given the patient's likely
poor outcome he should be do not intubate as well as do not
resuscitate.
On hospital day 16, the patient was noted to develop
hypotension with a systolic blood pressure in the 60s as well
as bradycardia. He was continued on nasal CPAP; however, two
hours prior to the initial finding of hypotension and
bradycardia, the patient expired at 1 o'clock in the morning
of [**2138-9-25**]. The patient's family was contact[**Name (NI) **] and
came into the hospital. They declined a postmortem
examination.
DISCHARGE DIAGNOSES:
1. Zoster.
2. Viral encephalitis.
3. Restrictive lung disease.
4. Coronary artery disease.
5. Renal insufficiency.
6. Congestive heart failure.
7. Atrial fibrillation/flutter.
8. Aortic dilatation.
CONDITION AT DISCHARGE: Expired.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**]
Dictated By:[**Last Name (NamePattern1) 194**]
MEDQUIST36
D: [**2138-10-1**] 00:17
T: [**2138-10-2**] 07:46
JOB#: [**Job Number 100909**]
(cclist)
|
[
"4280",
"5070",
"42731"
] |
Service: NEONATOLOGY Date: [**2122-8-18**]
Date of Birth: [**2122-8-16**] Sex: M
Attending: [**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
HISTORY OF THE PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 43984**] [**Known lastname **]
delivered at 38 and 2/7ths week gestation, weighing 3080
grams, and was admitted to the Intensive Care Unit Nursery
from labor and delivery for evaluation of sepsis and
monitoring of transition.
Mother is a 29-year-old gravida 1, para 0, now 1 mother with
an uncomplicated pregnancy. Prenatal screens included blood
type O positive, antibiotic screen negative, RPR nonreactive,
rubella immune, hepatitis B surface antigen negative and
group B strep negative. The mother presented in spontaneous
labor. Maternal temperature during labor was 104 degrees.
Membranes were artificially ruptured around four hours prior
vacuum-assisted vaginal delivery. The infant emerged floppy,
pale, without spontaneous respiratory effort; dried, suction
stimulated, and given positive pressure ventilation for 30 to
60 seconds with good response. He remained hypotonic and
pale. Apgar scores 3 and 7 at 1 and 5 minutes respectively.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: 3080 grams (50th to 75th percentile). Length:
51.5 cm (90th percentile). Head circumference: 34.5 cm
(75th to 90th percentile). The infant, on admission, was
pale, listless, with minimal activity. Anterior fontanelle
was soft, flat, overriding sutures, caput, red reflex
bilaterally, palate intact. Lungs were clear to auscultation
and equal. Regular rate and rhythm. There was +2/6 systolic
ejection murmur at the lower left sternal border, 2+ femoral
pulses. Abdomen was soft, positive bowel sounds, no
hepatosplenomegaly, no masses. GENITALIA: Normal phallus,
testes descended bilaterally. RECTAL: Patent anus, stable
hips. No sacral anomalies. Peripheral perfusion delayed.
HOSPITAL COURSE: (by system)
REPIRATORY: Initially, was grunting and tachypneic,
requiring some free-flow oxygen for a short time. Arterial blood
gas showed a pH of 7.29, PACO2 37, PAO2 256, base
deficit-7. The respiratory symptoms resolved fairly quickly and
has been in room air since with comfortable work of
breathing, respiratory rates in the 30s to 50s.
CARDIOVASCULAR: Required normal saline bolus for perfusion
and hypotension on admission with resolution of the symptoms
after bolus. Has a soft murmur at the left upper sternal
border, present at the time of transfer. Recent blood
pressure 63/41, with a mean of 49.
FLUIDS, ELECTROLYTES, AND NUTRITION: Initially, received IV
fluid of D10W until respiratory symptoms resolved. On day of
birth, started ad lib breast feeding and at the time of
transfer, ad lib breast feeding well. Voiding and stooling
appropriately. GI: Bilirubin drawn at 48 hours of age on
[**8-18**] showed a total of 12.9, direct 0.3. Follow up bilirubin
is planned for [**8-19**].
HEMATOLOGY: Hematocrit on admission was 45.7. Follow up
hematocrit on [**8-18**] revealed 43.8. The patient has not
required any blood products.
INFECTIOUS DISEASE: CBC on admission revealed the following:
White count 8.3, with 31 polys, 8 bands, 232,000 platelets.
Blood culture was drawn and Ampicillin and Gentamicin was
started for sepsis risk factors. A lumbar puncture was done
on day of life #1 to rule out meningitis. There were six
white blood cells with a protein of 98, glucose of 46,
culture is pending. A follow up CBC done on [**8-18**] showed a
white count of 10.7 with 56 polys, no bands, 170,000
platelets. Plan is to treat the infant for seven days for
presumed sepsis. Gentamicin levels today: Trough 1.2, peak
7.6.
NEUROLOGICAL: Examination is age appropriate.
SENSORY: Needs hearing screening performed prior to
discharge.
CONDITION ON DISCHARGE: Stable term infant ad lib breast
feeding well with jaundice.
DISCHARGE DISPOSITION: Transfer to newborn nursery.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43985**], [**Hospital1 43986**] in [**Location 43987**], MA. Telephone #:
[**Telephone/Fax (1) 43988**]. Fax #: [**Telephone/Fax (1) 40467**].
CARE RECOMMENDATIONS: Feedings: Ad lib breast feeding.
MEDICATIONS:
1. Ampicillin 460 mg IV q.12 hours for a total of sevendays.
2. Gentamicin 12 mg IV q.24 hours for a total of seven days.
STATE NEWBORN SCREEN: Screen is to be drawn tomorrow on
[**2122-8-19**].
IMMUNIZATIONS RECEIVED: Recieved hepatitis B immunization on
[**2122-8-18**].
FOLLOW-UP APPOINTMENT: Scheduled recommended follow up with
pediatrician per in-house [**Location (un) 2274**] pediatrician.
DISCHARGE DIAGNOSES:
1. AGA term male.
2. Hypotension resolved.
3. Transitional respiratory distress resolved.
4. Presumed sepsis.
5. Neonatal jaundice.
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 36096**]
MEDQUIST36
D: [**2122-8-18**] 12:19
T: [**2122-8-18**] 12:31
JOB#: [**Job Number 43989**]
|
[
"0389",
"V053"
] |
Admission Date: [**2191-1-5**] Discharge Date: [**2191-5-27**]
Date of Birth: [**2191-1-5**] Sex: M
Service: NEONATAL
HISTORY: This is a 705 gram 24-5/7 week twin gestation male
born to a 28 year old gravida 1, para 0, now 1 female.
PRENATAL SCREENS: A positive, antibody negative, RPR
nonreactive, rubella immune, hepatitis B surface antigen
negative, Group beta Streptococcus negative.
IVF pregnancy with di-amniotic, di-chorionic twins. The
pregnancy was complicated by vaginal bleeding at six weeks
and was treated with bed rest. Diagnosed with cervical
shortening on [**2191-12-16**], and treated with magnesium
sulfate, then treated with terbutaline p.o. Contractures
recurred, therefore she was transferred from [**Hospital **] Hospital
to [**Hospital1 69**] on [**2191-12-25**].
Abdominal pain secondary to constipation treated with
aggressive bowel regimen. Subsequently she had recurrence of
contractions and restarted on magnesium sulfate.
Betamethasone complete on [**2190-12-31**].
On the evening of [**1-5**], noted to have advanced dilation
with breech/vertex presentation, therefore magnesium sulfate
was discontinued and proceeded to cesarean section. This
twin was vertex. Rupture of membranes at delivery. Infant
required bag mask ventilation and intubation in Delivery
Room. Apgars were 5 at one minute and 7 at five minutes.
PHYSICAL EXAMINATION: On admission, weight 705 grams (40th
percentile); length 33.5 centimeters (approximately 50th
percentile); head circumference 23.25 centimeters (30th
percentile). Anterior fontanel soft, flat, bruised scalp and
face, fused eyes, orally intubated, good aeration on
ventilator after receiving Survanta. Grade II/VI murmur left
sternal border. Good pulses. Soft abdomen. Three vessel
cord. No hepatosplenomegaly. Decreased tone and activity.
Normal male genitalia. Testes not palpable. No hip click.
Patent anus; no sacral dimple. Bruising on feet. Sensitive
skin with redness at site of lead placement.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: [**Known lastname **] remained orally intubated on maximum
ventilatory settings of high frequency oscillating ventilator
with a mean airway pressure of 12, delta-P of 22. He
received three doses of Surfactin. He extubated to CPAP on
day of life number nine and was re-intubated on day of life
number 15. He remained orally intubated until day of life
number 63 and was extubated to CPAP. He weaned to nasal
cannula on day of life number 71 and remained on nasal
cannula and weaned to low flow nasal cannula until he was
able to be weaned to room air on [**2191-5-9**], which was day
of life number 24.
Caffeine citrate was started on day of life number eight and
he received that until day of life number 83. Caffeine was
discontinued on [**2191-3-7**], and his last apnea and
bradycardia was on [**2191-4-23**]. Diuretic therapy of
Diuril was started on day of life number 32 and he continues
on Diuril currently on 35 mg per kilogram per day p.o. The
plan is to wean the Diuril dose or to allow [**Known lastname **] to outgrow
the dose over the next two to three months. If Pulmonary
follow-up would be useful, Dr [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**], [**Hospital3 1810**]
Pulmonology is available to see patients such as [**Known lastname **].
2. CARDIOVASCULAR: [**Known lastname **] received one course of
Indomethacin on [**1-6**] and [**1-7**], for presumed
patent ductus arteriosus. He has not received an
echocardiogram this hospitalization. [**Known lastname **] required
Dopamine for hypotension from day of life zero to day of life
two with a maximum dose of 15 micrograms per kilogram per
minute. Otherwise, he has remained hemodynamically stable
this hospitalization; no murmur, with mean blood pressures 50
to 60 and heart rate 120 to 160.
3. FLUIDS, ELECTROLYTES AND NUTRITION: [**Known lastname **] was initially
nothing by mouth and received parenteral nutrition through a
central venous catheter with total fluids of 150 to 160 cc.
per kilogram per day. He was started on trophic feedings of
10 cc. per kilogram per day on day of life eight and advanced
to full volume feedings by day of life number 17. He
advanced to maximum caloric density of 32 calories per ounce
with ProMod by day of life number 29. He is currently on
Enfamil 28 calories per ounce with four calories per ounce of
concentration and four calories per ounce of corn oil,
receiving a minimum of 120 cc. per kilogram per day [**Initials (NamePattern4) **]
[**Known lastname **] tolerated this feeding advancement and caloric density
advancement without difficulty. During the terminal portion of
his hospitalization, [**Known lastname **] had some difficulty maintaining
adequate po intake. This lead to discussions with his mother
and father about the possible need for [**Name (NI) 9945**] placement. Over
the week prior to discharge however, [**Known lastname **] has markedly
improved his intake and is making his minimum volumes. He will
need close attention to his growth velocity and nutritional
intake.
He was also started on sodium chloride and potassium chloride
supplements on day of life number 23. Sodium chloride was
discontinued on day of life number 63. He continues on
potassium chloride supplements of 3 mEq per kilogram per day.
The most recent electrolytes on [**5-25**] were sodium of 137,
potassium 4.1, chloride 100, bicarbonate of 26, BUN of 9,
creatinine of 0.1.
The most recent weight is 4.095 kilograms, head circumference
37 centimeters, length 53 centimeters.
4. GASTROINTESTINAL: [**Known lastname **] received phototherapy from day
of life one to day of life 17. Maximum bilirubin level of
6.0/0.4. The most recent bilirubin level on day of life
number 29 was a total bilirubin of 1.5 with a direct of 0.4.
[**Known lastname **] was started on Reglan and Zantac on [**2191-4-29**],
for gastroesophageal reflux.
Due to increased vomiting, an upper gastrointestinal was
performed on [**5-10**], which revealed no obstruction and mild
gastroesophageal reflux. At that time, the medications were
changed to Reglan and Prilosec, and he continues on those
medications currently.
5. HEMATOLOGY: Blood type A positive. [**Known lastname **] received nine
packed red blood cell transfusions this hospitalization. The
most recent hematocrit on [**5-17**] was 30.2%, reticulocyte
count of 7%.
6. INFECTIOUS DISEASE: [**Known lastname **] was initially started on
Ampicillin and gentamicin which was changed to Ampicillin and
cefotaxime for positive Klebsiella pneumoniae in his
cerebrospinal fluid culture on [**2191-1-13**]. [**Known lastname **]
received a total of 21 days of Ampicillin and Cefotaxime.
Blood cultures were negative at that time.
[**Known lastname **] received a ten day course of Gentamicin and
Ceftazidime for positive Pseudomonas aeruginosa from an
endotracheal sputum culture. He received that ten day course
of antibiotics from day of life 55 to day of life 64. Blood
cultures were negative at that time.
7. NEUROLOGY: Head ultrasound on day of life two revealed
no interventricular hemorrhage, although head ultrasound on
day of life six revealed bilateral interventricular
hemorrhage with ventriculomegaly. Neurology from the
[**Hospital3 1810**] was consulted and it was recommended that
[**Known lastname **] receive daily therapeutic lumbar punctures from
[**2191-1-20**] until [**2191-2-7**]. Head ultrasound on
day of life number eight also revealed ventriculomegaly with
a clot in the cisterna magna.
Serial head ultrasounds after the therapeutic lumbar
punctures revealed decrease in ventriculomegaly. The most
recent head ultrasound on [**2191-4-28**], showed stable
ventriculomegaly with ventricles measuring 6 millimeters and
6.7 millimeter ventricular horns bilaterally.
[**Known lastname **] is to receive follow-up with Neurology, Dr. [**Last Name (STitle) **]
approximately six weeks after discharge and he will receive
follow-up at the Neonatal Neurology Program at the [**Hospital3 18242**].
8. HEARING: Hearing screening was performed with automatic
auditory brain stem responses. The infant passed both ears.
9. OPHTHALMOLOGY: Eyes were examined most recently on [**2191-5-25**], revealing retinopathy of prematurity, Stage I, Zone
3, regressing, not active. Recommended follow-up examination
should be scheduled one month from that examination.
10. PSYCHOSOCIAL: Parents are very involved with [**Known lastname **]
care. His sibling's name is [**Name (NI) **]. [**Hospital1 190**] Social Work was involved with the family. The
contact social worker can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Former 24-4/7 week twin gestation
now stable in room air.
DISCHARGE DISPOSITION: Home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 47116**] [**Name (STitle) 3394**], phone number
[**0-0-**], [**Hospital 1121**] Pediatrics, [**Street Address(2) 47117**],
[**Location (un) 4047**], [**Numeric Identifier 47118**].
CARE RECOMMENDATIONS:
1. Feedings at discharge: Enfamil 28 calories per ounces
with four calories per ounce concentration and four calories
per ounce of corn oil; minimum 120 cc. per kilogram per day
p.o.
2. Medications: Ferrous sulfate 25 mg per ml
every q. day p.o.; diuril 76 mg p.o. q. 12 hours; Omeprazole
3.8 mg p.o. q. day; Metoclopramide 0.4 mg p.o. q. eight
hours; potassium chloride supplements 3 mEq p.o. q. six
hours; prune juice 5 cc., p.o. q. day; corn oil 4 calories
per ounce.
3. Car seat position screening was performed and the infant
passed.
4. State Newborn Screens were sent on [**2191-1-8**],
which revealed a low T4. Repeat newborn screens sent on
[**2191-1-20**], and [**2191-2-26**], were within normal
range.
5. Immunizations:
Hepatitis B vaccine given on [**2191-3-6**], and [**2191-5-7**].
DTAP [**2191-3-6**], and [**2191-5-6**].
HIB on [**2191-3-7**], and [**2191-5-5**].
IPV [**2191-3-6**], and [**2191-5-9**].
Prevnar [**2191-3-6**] and [**2191-5-5**].
He also received Synagis vaccine on [**2191-4-15**].
6. Immunizations recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants
that meet any of the three criteria: 1) Born at less than 32
weeks; 2) born between 32 and 35 weeks with plans for day
care during RSV season, with a smoker in the household, or
with preschool siblings or 3) with chronic lung disease.
Influenza immunization should be considered annually in the
Fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, the family and
other care givers should be considered for immunization
against influenza to protect the infant.
DISCHARGE INSTRUCTIONS:
1. Follow-up appointment with Dr. [**Last Name (STitle) 3394**] on Tuesday, [**2191-5-31**].
2. Follow-up with Dr. [**Last Name (STitle) **] at the Neonatal Neurology
Program approximately six weeks after discharge.
3. Infant follow-up program at three months.
4. Ophthalmology one month after most recent eye
examination.
5. Visiting Nurses Association early intervention program.
DISCHARGE DIAGNOSES:
1. Prematurity: Former 24-4/7 week twin gestation.
2. Respiratory distress syndrome.
3. Bilateral interventricular hemorrhage with
ventriculomegaly.
4. Klebsiella meningitis.
5. Pseudomonas pneumonia.
6. Presumed patent ductus arteriosus.
7. Status post hypotension.
8. Anemia of prematurity.
9. Apnea of prematurity.
10. Gastroesophageal reflux disease.
11. Retinopathy of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 47119**]
MEDQUIST36
D: [**2191-5-27**] 17:11
T: [**2191-5-27**] 19:46
JOB#: [**Job Number 47120**]
|
[
"7742"
] |
Admission Date: [**2192-6-12**] Discharge Date: [**2192-6-22**]
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5167**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo F with history of seizure disorder, recently
discharged from epilepsy service [**6-8**] after hospital course with
STEMI, RLL PNA, and NCSE. At that time her keppra was increased
from 750 mg [**Hospital1 **] to 1500 mg [**Hospital1 **] and depakote was added (initially
200 mg IV q8h then changed to sprinkles 250/375). She took
several days to awaken and track and start eating, but was not
thought to have recovered to her baseline at time of discharge.
She was noted to not speak or follow commands but tracks and
swallows at time of discharge to [**Hospital1 599**] [**Location (un) 55**] [**2192-6-8**].
During her last hospitalization she was initially CMO but after
discussion with her family she was changed to DNR/DNI.
She returned with recurrent seizures. [**Name6 (MD) **] [**Name8 (MD) **] RN at her
nursing home (who was not there at time of event) she was told
the patient was seizing for 30 minutes up to one hour starting
around 6:45 AM. She did not receive her AM medications. While
en route to [**Hospital1 18**] she had two more GTCs lasting 2-3 minutes each
and received 2 mg lorazepam.
Past Medical History:
seizure disorder, diagnosed in [**8-23**] of unclear etiology. Has
episodes of speech arrest with gaze deviation, occasional GTCs,
and recently NCSE. Initially treated with benzo/dilantin load
which led to respiratory depression and intubation. Started on
keppra in [**10-25**], and depakote recently added in setting of NCSE.
-Dementia NOS
-Hypertension
-Coronary artery disease
-Mild LV [**Date Range 7216**] dysfunction
-Mitral regurgitation
-Rheumatoid arthritis
-COPD/asthma on inh steroid/[**Last Name (un) **] (Advair) and PRN nebs
-Hypertension
-Coronary artery disease
-Mild LV [**Last Name (un) 7216**] dysfunction
-Mitral regurgitation ([**12-18**]+)
-Mild pulmonary artery systolic hypertension
-Rheumatoid arthritis
-h/o hospitalization for PNA [**4-24**], [**5-26**]
Social History:
Immigrant from [**Country 38213**]; lived at home with son. At baseline, the
family says that she talks, eats purees, and walks with a
walker. Over the last few months, however, she has no longer
been able to go to the bathroom on her own. No [**Country **],
smoking, or ETOH use
Family History:
No family history of seizures.
Physical Exam:
VS; T 101 (rectal) P 106 BP 122/63 RR 30 90% on 4L NC, now 100%
on NRB
Gen; lying in bed, eyes closed
CV; distant S1,S2, no murmurs
Pulm; coarse breath sounds b/l
Abd; soft, nt, nd
Extr; no edema
Neuro; Eyes closed, unarousable to noxious stimuli.
Exodeviation
of right eye in primary gaze, R pupil 5mm, L pupil 3mm, both
minimally reactive. Weak corneal on right, normal on left.
Face
appears symmetric but obscured by NRB. Flaccid tone, diffuse
atrophy. withdrawl to noxious in LUE and minimal withdrawl in
RUE. triple flexion in legs. upgoing toes b/l.
Pertinent Results:
[**2192-6-12**] 08:20AM BLOOD WBC-11.9*# RBC-3.95* Hgb-11.9* Hct-36.0
MCV-91 MCH-30.0 MCHC-32.9 RDW-14.3 Plt Ct-263
[**2192-6-12**] 08:20AM BLOOD Neuts-81* Bands-0 Lymphs-13* Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2192-6-13**] 03:00AM BLOOD PT-12.3 PTT-27.3 INR(PT)-1.0
[**2192-6-12**] 08:20AM BLOOD Glucose-94 UreaN-16 Creat-0.5 Na-140
K-4.6 Cl-98 HCO3-35* AnGap-12
[**2192-6-12**] 08:20AM BLOOD ALT-9 AST-21 AlkPhos-71 TotBili-0.6
[**2192-6-12**] 08:20AM BLOOD cTropnT-0.03*
[**2192-6-12**] 08:20AM BLOOD Albumin-3.2* Calcium-8.7 Phos-2.8 Mg-1.9
[**2192-6-12**] 08:20AM BLOOD Digoxin-0.6*
[**2192-6-12**] 08:20AM BLOOD Valproa-20*
HEAD CT
IMPRESSION: Suboptimal due to patient motion without acute
intracranial
process seen.
EEG [**2192-6-12**]
This is an abnormal video EEG due to the presence of
nearly continuous periodic lateralized epileptiform discharges
(PLEDs)
at about 1 Hz frequency over the left hemisphere which represent
highly
epileptogenic cortex in this region. The PLEDs improved in the
night
after 22:00 and became reduced in amplitude, less well formed,
more
broad-based, and less periodic, as well as more focally
localized to the
left temporal leads. There were no corresponding clinical
changes on
video with the PLEDs. Also seen were left hemisphere and left
anterior
temporal interictal discharges indicating focal epileptogenic
cortex.
The background was slow representing a moderate encephalopathy.
There
were no clear electrographic seizures.
Brief Hospital Course:
[**Age over 90 **] yo F with history of seizure disorder, recently discharged
from the [**Hospital1 18**] epilepsy service [**6-8**] after hospital course with
STEMI, RLL PNA, and NCSE. She returned after prolonged
generalized tonic clonic seizure at nursing home followed by two
more seizures in route. She had not received her morning seizure
medications.
Depakote level was subtherapeutic on presentation. She was
loaded with Depakote and her home dose was continued. She was
also continued on Keppra 1500 mg [**Hospital1 **]. She was found to be
febrile with leukocytosis and a dirty UA, which may have
triggered this event for which she was treated with ceftriaxone.
CXR showed mild worsening of previously present R lower lobe
infiltrate concerning for aspiration PNA. She had already
completed a course of broad spectrum antibiotics for this on her
last admission. She was continued on ceftriaxone only.
During the week prior to her demise, Ms. [**Known lastname 79941**] unfortunately
remained in a state of diminished responsiveness continuous left
sided PLEDs on EEG. The family refused an NG tube with the
understanding that she may wake up following her prolonged
seizure and begin to eat again. There were several days without
any form of nutrition other than continuous IV fluids. She
continued to receive treatment for her infection as above.
Intermittently, she would spike a new WBC and this would improve
with the expansion of IV antibiotics. The family of the patient
refused to transition her to CMO status, and therefore we
continued to treat her with multiple AEDs and titrate levels,
etc. She eventually began to develop daily episodes of tachypnea
with occasional oxygen desaturations down to the 80s, which
would improve with repositioning and increasing FiO2. It
ultimately got to a point where the patient was on a 100% NRB
oxygen on the floor.
On [**2192-6-22**], the patient's family, our senior EEG
attending and representatives from the division of palliative
care met to discuss how to increase her level of comfort in this
end of life situation. The family agreed to adding on PRN
morphine/ativan to help improve her respiratory
distress/tachypnea. At approximately 2200hrs on that evening,
she passed peacefully. The patient had just been visited by her
family just one hour prior. The family was notified by phone and
they refused an autopsy by phone. All the necessary paper work
was completed at the time.
Medications on Admission:
-aspirin 325 mg daily
-fluticasone-salmeterol 250/50 inh [**Hospital1 **]
-ipratropium bromide 1 inh q6h prn wheeze
-depakote sprinkles 250/375
-keppra 1500 mg [**Hospital1 **]
-digoxin 125 mcg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Cerebrovascular disease, intractable seizures
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2192-6-26**]
|
[
"5990",
"5180",
"4019",
"4240",
"41401",
"412"
] |
Admission Date: [**2105-4-13**] Discharge Date: [**2105-4-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Bradycardia, dyspnea
Major Surgical or Invasive Procedure:
Pacemaker insertion
History of Present Illness:
86 y/o M with PMHx of dilated cardiomyopathy (EF of 20-25%),
mitral regurgitation s/p MVR with bioprosthetic valve,
paroxysmal AF, atrial tachycardia, CAD s/p remote inferior MI
who presents with SOB, dizziness, and bradycardia to the 30's.
He had recent medication increases to his metoprolol, digoxin,
and lasix doses. Patient has had a few weeks of shortness of
breath, acutely worse over the last couple of days. He
presented to physical therapy today, was found to have a HR in
the 40s and BP in the 90-100s. His PCP advised him to present
to the ED.
.
In the ED his initial vitals were: 97.6, 35, 14, 135/51, 99% on
3L . He was able to ambulate from chair to bed, mentated well,
and had stable blood pressures. He was found to have HR in
20-30s. Did not receive any atropine. Patient was given 1
liter of IVF. He had no crackles, edema, or hypoxia on exam.
Patient was admitted to CCU for further management.
.
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.
S/he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, palpitations, syncope or
presyncope.
Past Medical History:
- CRI - baseline cre 1.8 since [**12-27**], etiology unknown per pt.
- CAD - s/p inferior/post MI [**2092**], LHC [**11-26**] no flow limiting
disease.
- dilated cardiomyopathy (EF 30-35% [**8-27**])
- h/o MR - s/p MVR ([**12-27**] 33mm bioprosthetic)
- h/o embolic CVA (loss of peripheral vision in left eye) felt
[**12-23**]
afib [**2092**].
- paroxysmal atrial fibrillation/flutter - s/p DCCV [**4-27**], trial
of amiodarone.
- hyperlipidemia
- h/o trigeminal neuralgia s/p trigeminal ablation procedure
- h/o ?esophageal mass (13 x 8 mm) - [**2-25**] EGD showed gastritis,
duodenitis, but no mass.
- OA
- s/p rotator cuff repair
- s/p orchiectomy for a benign left testicular mass '[**74**]
- h/o diverticula on colonoscopy (no bleeds)
.
- denies h/o DM, PE/DVT, malignancy
Social History:
lives with wife and daughter, independent of adls, former
probation officer. denies tobacco/ivdu. 5 glasses wine/week. no
regular exercise over past 2-3 months [**12-23**] increased fatigue/DOE.
Family History:
Denies renal disease.
.
No premature CAD. Brother and mother died of MI in their 70's.
Physical Exam:
VS: 96.9, 118/52, 34, 17, 96% RA
GENERAL: WDWN male in NAD. AAO x3
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
JVP to earlobe
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Bradycardic, 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. Crackles bibasilarly.
Upper respiratory end expiratory wheeze.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 2+ edema to mid shins bilaterally.
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:
CBC
[**2105-4-18**] 08:50AM BLOOD WBC-6.5 RBC-3.69* Hgb-11.5* Hct-36.0*
MCV-97 MCH-31.1 MCHC-31.9 RDW-14.9 Plt Ct-137*
[**2105-4-17**] 08:10AM BLOOD WBC-6.8 RBC-3.65* Hgb-11.6* Hct-35.9*
MCV-98 MCH-31.8 MCHC-32.3 RDW-15.2 Plt Ct-125*
[**2105-4-16**] 05:58AM BLOOD WBC-6.8 RBC-3.76* Hgb-11.5* Hct-36.3*
MCV-97 MCH-30.5 MCHC-31.5 RDW-14.7 Plt Ct-130*
[**2105-4-15**] 04:56AM BLOOD WBC-5.9 RBC-3.64* Hgb-11.2* Hct-35.1*
MCV-97 MCH-30.8 MCHC-31.8 RDW-14.7 Plt Ct-117*
[**2105-4-14**] 04:33AM BLOOD WBC-5.1 RBC-3.36* Hgb-10.6* Hct-33.0*
MCV-98 MCH-31.4 MCHC-32.0 RDW-14.8 Plt Ct-108*
[**2105-4-13**] 06:30PM BLOOD WBC-5.3 RBC-3.42* Hgb-10.8* Hct-33.8*
MCV-99* MCH-31.6 MCHC-32.0 RDW-15.0 Plt Ct-101*
Coags
[**2105-4-19**] 08:00AM BLOOD PT-18.3* PTT-28.7 INR(PT)-1.7*
[**2105-4-18**] 08:50AM BLOOD PT-17.5* PTT-29.0 INR(PT)-1.6*
[**2105-4-17**] 08:10AM BLOOD PT-17.2* PTT-80.2* INR(PT)-1.5*
[**2105-4-16**] 05:58AM BLOOD PT-17.6* PTT-68.7* INR(PT)-1.6*
[**2105-4-15**] 04:56AM BLOOD PT-19.6* PTT-90.8* INR(PT)-1.8*
[**2105-4-14**] 04:34PM BLOOD PT-19.7* PTT-64.1* INR(PT)-1.8*
[**2105-4-13**] 06:30PM BLOOD PT-19.8* PTT-28.2 INR(PT)-1.8*
Chemistry
[**2105-4-18**] 08:50AM BLOOD Glucose-101* UreaN-40* Creat-1.7* Na-140
K-4.8 Cl-104 HCO3-27 AnGap-14
[**2105-4-17**] 08:10AM BLOOD Glucose-117* UreaN-34* Creat-1.6* Na-138
K-4.1 Cl-101 HCO3-29 AnGap-12
[**2105-4-16**] 05:58AM BLOOD Glucose-120* UreaN-34* Creat-1.5* Na-142
K-4.3 Cl-104 HCO3-29 AnGap-13
[**2105-4-15**] 08:11AM BLOOD Glucose-104* UreaN-38* Creat-1.6* Na-142
K-4.5 Cl-104 HCO3-29 AnGap-14
[**2105-4-15**] 04:56AM BLOOD Glucose-128* UreaN-40* Creat-1.9* Na-146*
K-5.6* Cl-108 HCO3-25 AnGap-19
[**2105-4-14**] 04:33AM BLOOD Glucose-101* UreaN-42* Creat-2.0* Na-146*
K-4.4 Cl-110* HCO3-29 AnGap-11
[**2105-4-13**] 06:30PM BLOOD Glucose-104* UreaN-47* Creat-2.4* Na-143
K-5.0 Cl-109* HCO3-25 AnGap-14
[**2105-4-18**] 08:50AM BLOOD Calcium-8.9 Phos-2.7 Mg-2.5
[**2105-4-17**] 08:10AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.3
[**2105-4-16**] 05:58AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.3
[**2105-4-15**] 08:11AM BLOOD Albumin-3.9 Calcium-8.9 Phos-2.8 Mg-2.4
[**2105-4-15**] 04:56AM BLOOD Calcium-10.4* Phos-3.6 Mg-3.0*
[**2105-4-14**] 04:33AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.5
[**2105-4-13**] 06:30PM BLOOD Calcium-8.4 Phos-3.5 Mg-2.5
Cardiac Enzymes
[**2105-4-14**] 03:29PM BLOOD CK(CPK)-78
[**2105-4-14**] 04:33AM BLOOD CK(CPK)-133
[**2105-4-14**] 03:29PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2105-4-14**] 04:33AM BLOOD CK-MB-6 cTropnT-0.10*
[**2105-4-13**] 06:30PM BLOOD cTropnT-0.09*
TSH
[**2105-4-14**] 04:33AM BLOOD TSH-4.0
Brief Hospital Course:
86M with PMHx of dilated cardiomyopathy (EF of 20-25%), mitral
regurgitation s/p MVR with bioprosthetic valve, paroxysmal AF,
atrial tachycardia, CAD s/p remote inferior MI who presents with
SOB, dizziness, and bradycardic atrial fibrillation and acute on
chronic systolic heart failure
.
# ATRIAL FIBRILLATION: Presented with atrial fibrillation with
bradycardia most likely due to accumulation of AV nodal blocking
agents (Metoprolol and Digoxin) in the setting of acute on
chronic renal failure. These medicines were held on admission,
and the pt was then noted to have paroxysmal, narrow complex
atrial tachycardias to the 110's. Beta blockade was restarted,
however these paroxysms continued. Beta blockade was uptitrated
and pt went for pacemaker placement. Warfarin was held on
admission and patient was maintained on heparin drip. Warfarin
was restarted following pacemaker placement. His INR was 1.7 on
discharge. He was instructed to have his INR rechecked in two
days in order to further manage his warfarin dosing.
# ACUTE ON CHRONIC SYSTOLIC HEART FAILURE: TTE from [**2101**] shows
moderate regional LV systolic dysfunction with akinesis of the
inferior wall, apex, and hypokinesis of the anterior wall. LVEF
of 30-35%. Clinically he was volume overloaded with JVP to
earlobe and pedal edema. The pt was diuresed with IV Lasix which
he responded very well to with dramatic improvement in his
physical exam. The pt was discharged on his original home
regimen of alternating 20 mg and 40 mg of furosemide daily. His
home regimen of lisinopril was held because of hypotension.
Patient will follow up with his cardiologist regarding when to
restart the ACE inhibitorl.
.
# CORONARIES: cath from [**2100**] shows no flow limiting coronary
artery disease. Patient was continued on ASA, metoprolol, and
atorvastatin
.
# CKD - baseline creatinine of 1.8. Patient was admitted with
creatinine of 2.4, which improved to 1.7 by discharge.
.
# Severe MR s/p bioprosthetic MVR: Pt was bridged with Heparin
gtt while Coumadin was initially held.
Medications on Admission:
Atorvastatin 20mg daily
Digoxin 125 mcg daily
Lasix 40mg and 20mg daily alternating
Lisinopril 2.5mg daily
Lorazepam 0.5mg qhs
Toprol 37.5mg daily
Warfarin as directed
Aspirin 81 mg daily
Discharge Medications:
1. Outpatient Lab Work
Please check INR on tuesday [**4-21**] and call results to Dr.
[**Last Name (STitle) **],[**First Name3 (LF) **] H. at [**Telephone/Fax (1) 4615**]
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK
([**Doctor First Name **],MO,WE,FR).
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(TU,TH,SA).
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Lasix 20 mg Tablet Sig: 1-2 Tablets PO once a day: Take 40mg
on Sunday, Tuesday, Thursday, and Saturday. Take 20mg on
Monday, Wednesday, Friday. .
8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 2 doses.
Disp:*2 Capsule(s)* Refills:*0*
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Bradycardia
Atrial Tachycardia
Dilated Cardiomyopathy
Paroxysmal Atrial Fibrillation
Coronary Artery Disease
Acute on Chronic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 95715**].
You were admitted to the hospital for low heart rate
(bradycardia). This was likely due to the digoxin you were
taking. You were seen by Dr. [**Last Name (STitle) **] and you had a pacemaker
implanted to keep your heart rate from being very low. You
tolerated the procedure well and your device was functioning
properly. An appointment was made for you to follow up in
pacemaker device clinic in one week.
Your coumadin level (INR) was slightly below where it should be
(1.7 on [**4-18**]). Please get your next level checked on
Tuesday. A prescription has been provided.
We made the following changes to your medication:
1. STOP TAKING DIGOXIN
2. START TAKING KEFLEX 500mg for one day
3. INCREASE METOPROLOL XL from 37.5mg daily to 50mg daily (take
2 25mg tablets)
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
1. PACEMAKER DEVICE CLINIC
Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2105-4-28**] 1:30
.
2. Dr. [**Last Name (STitle) **] (PRIMARY CARE PHYSICIAN)
Phone: [**Telephone/Fax (1) 4615**] Date/time:
Office will call you with an appt in 1 week.
.
3. CARDIOLOGIST:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time: [**5-22**] at 3:40pm.
Date/Time:[**2105-9-2**] 1:40
.
4. Physical Therapy:
Provider: [**First Name11 (Name Pattern1) 2620**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **], PT Phone:[**Telephone/Fax (1) 4832**]
Date/Time:[**2105-4-27**] 9:30
.
5. Anesthesiology:
Provider: [**Name10 (NameIs) 8673**] [**Last Name (NamePattern4) 8674**],
MD Phone:[**Telephone/Fax (1) 1652**]
Date/Time:[**2105-5-7**] 1:00
.
|
[
"42789",
"5849",
"41401",
"42731",
"4280",
"2724",
"40390",
"5859",
"412"
] |
Admission Date: [**2189-9-22**] Discharge Date: [**2189-9-28**]
Date of Birth: [**2136-2-23**] Sex: M
Service: SURGERY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Fall from standing
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53 yo male [**2136**]0 days ago presents with 2 days of abdominal
pain. CT revealed ruptured spleen w/ HCT 45-->39 and FSG 400's.
No N/V/CP/SOB
Past Medical History:
NIDDM
[**First Name9 (NamePattern2) 30065**] [**Location (un) **]
HTN
Social History:
lives at home
lawyer
Family History:
n/c
Physical Exam:
AOx3, NAD
RRR CTA bilat
SOFT, NT/ND, nabs, no external signs of trauma
Ext: WWP, No C/C/E
Pertinent Results:
[**2189-9-25**] 06:55AM BLOOD WBC-12.3* RBC-3.06* Hgb-9.0* Hct-27.0*
MCV-88 MCH-29.5 MCHC-33.5 RDW-13.3 Plt Ct-253
[**2189-9-25**] 12:30AM BLOOD Hct-27.0*
[**2189-9-24**] 12:01PM BLOOD Hct-29.2*
[**2189-9-23**] 09:57PM BLOOD Hct-28.7*
[**2189-9-23**] 10:55AM BLOOD WBC-15.0* RBC-3.68* Hgb-10.4* Hct-31.8*
MCV-87 MCH-28.4 MCHC-32.8 RDW-13.5 Plt Ct-231
[**2189-9-23**] 02:34AM BLOOD WBC-19.5* RBC-3.93* Hgb-11.3* Hct-34.0*
MCV-87 MCH-28.8 MCHC-33.2 RDW-13.7 Plt Ct-261
[**2189-9-22**] 08:40PM BLOOD WBC-15.3* RBC-3.98* Hgb-11.8*# Hct-34.7*#
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.5 Plt Ct-239
[**2189-9-22**] 09:45AM BLOOD WBC-22.2* RBC-5.12 Hgb-15.3 Hct-45.6
MCV-89 MCH-29.9 MCHC-33.6 RDW-13.4 Plt Ct-310
[**2189-9-23**] 10:55AM BLOOD Neuts-86.6* Lymphs-10.2* Monos-3.0
Eos-0.1 Baso-0.1
[**2189-9-22**] 08:40PM BLOOD Neuts-87.8* Lymphs-9.1* Monos-2.9 Eos-0.1
Baso-0.2
[**2189-9-22**] 09:45AM BLOOD Neuts-89.7* Bands-0 Lymphs-6.9* Monos-2.4
Eos-0.3 Baso-0.6
[**2189-9-25**] 06:55AM BLOOD Plt Ct-253
[**2189-9-25**] 06:55AM BLOOD PT-14.3* PTT-25.8 INR(PT)-1.4
[**2189-9-24**] 03:22AM BLOOD Plt Ct-258
[**2189-9-22**] 09:45AM BLOOD Plt Ct-310
[**2189-9-25**] 06:55AM BLOOD Glucose-130* UreaN-12 Creat-0.7 Na-136
K-4.0 Cl-101 HCO3-25 AnGap-14
[**2189-9-22**] 09:45AM BLOOD Glucose-442* UreaN-16 Creat-1.1 Na-136
K-5.0 Cl-93* HCO3-25 AnGap-23*
[**2189-9-25**] 06:55AM BLOOD Glucose-130* UreaN-12 Creat-0.7 Na-136
K-4.0 Cl-101 HCO3-25 AnGap-14
[**2189-9-22**] 06:47PM BLOOD ALT-15 AST-17 AlkPhos-80 Amylase-19
TotBili-0.6
[**2189-9-22**] 09:45AM BLOOD ALT-19 AST-20 AlkPhos-114 Amylase-27
TotBili-0.9
[**2189-9-22**] 06:47PM BLOOD Lipase-15
[**2189-9-22**] 09:45AM BLOOD Lipase-19
[**2189-9-25**] 06:55AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.9
[**2189-9-22**] 09:45AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.0
[**2189-9-23**] 02:34AM BLOOD HCG-<5
[**2189-9-23**] 02:34AM BLOOD CEA-1.1 AFP-<1.0
IMPRESSION:
1. Splenomegaly with splenic laceration/rupture. Blood is seen
tracking along the intra-abdominal fascia, including
perisplenic, perihepatic, and pericolonic gutters
2. 4.1 x 1.8 cm poorly defined soft tissue density mass in the
area of the splenic hilum, which appears to arise from the
pancreatic tail and is largely indistinguishable from the
surrounding blood. Repeat dedicated CTA is recommended for
complete evaluation.
3. Splenic vein thrombosis with additional thrombosis of several
prominent collaterals.
4. Splenic hemangioma.
5. Diverticulosis.
6. Low-density lesions within the liver are incompletely
characterized. These most likely represent simple cysts.
7. Bilateral renal cysts.
Brief Hospital Course:
Admitted to TSICU for serial hematocrit. After initial drop,
HCT stabilized at 27 for greater than 24 hours. Patient
transferred to general [**Hospital1 **] in stable condition. Noted
continuous improvement of LUQ pain and tenderness. Intermittent
fevers and mildly elevated WBC (19-->15-->13.9-->12.3) treated
empirically with vancomycin, ceftriaxone, and flagyl.
Infectious disease followed and recommended current therapy as
well as outpatient regimen of levaquin/flagyl x 7-10 days.
Patient was evaluated by the Gold Surgery team and deamed stable
for discharge with follow up in 1 week.
Medications on Admission:
Univasc
Metformin
Amaryl
Discharge Medications:
1. Resume home medications
2. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
3. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
4. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*45 Tablet(s)* Refills:*0*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Several peripheral segmental areas of portal venous occlusion
and thrombosis
2. Splenic rupture
3. Splenic hematoma
4. Vascular thrombosis
Discharge Condition:
Stable
Good
Discharge Instructions:
Avoid trauma to your abdomen and remain within 30 minutes of a
hospital at all times. Return to the emergency department for
continued fevers, worsening abdominal pain, chest pain,
difficulty breathing, nausea or vomiting or other significant
concerns.
Followup Instructions:
1. Gold Surgery, Dr. [**Last Name (STitle) 468**] in 1 week. [**Telephone/Fax (1) 6449**]
2. Trauma Clinic in 1 week ([**Telephone/Fax (1) 6449**]
|
[
"5180",
"25000",
"4019"
] |
Admission Date: [**2165-1-26**] Discharge Date: [**2165-1-27**]
Date of Birth: [**2123-1-27**] Sex: F
Service: MEDICINE
Allergies:
Codeine / E-Mycin / Motrin
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hematamesis/melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
41 yo female with h/o hypothyroidism and gastiric ulcer due to
motrin use in the [**Last Name (un) 18712**], presents to the ED with melena and
recent h/p hemetamesis. Patient reports that she returned from
the Carribbean on [**2165-1-14**] and felt well till [**2165-1-20**], when she
felt quezy, nauceaous, and had emesis times 2 (non-bloody and
bilious). Patient then felt quezy and had mild nausea Monday
through Wednesdy and also had very poor PO intake. Patient then
felt slightly better on Thursday and ate a rare steak on
Thursady night. SHortly there after, she noted hemetamesis (not
sure of the quantity of blood). Patient had [**1-25**] more episodes or
hematamesis. Patient noted on Friday that she had black stool
(multiple small black BMs). Hence, patient presents to the ED.
In the ED, patient's SBP 140, HR 90 and HCT 40. 2PIVs placed,
patient received iL NA and 40mg IV protonix and anzemet given.
Patient lavaged and it cleared after 700cc. Patient seen by GI
and plans made for MICU admission for EGD.
Past Medical History:
1. hypothyroidism
2. s/p appendectpmy
3. s/p tonillectomy
4. gastric ulcer in setting of motrin use
5. urterocele- s/p repair
6. gestational DM
Social History:
married, 2 children 5 and 11, no TOB, 1-2 beers per night, works
as a data analyst
Family History:
father with ulcers
mother- COPD, emphysema, depression
Physical Exam:
PE: 99.5 143/79 90 17 100% RA
NAD, A and O times 3
NCAT, EOMI, OP clear, MMM, no JVD
RRR no M
CTAB
+BS, soft, NT, ND, no HSM
no c/c/e
CN II-XII intact, strength 5/5 Bilat, nonfocal
Pertinent Results:
[**2165-1-26**] 10:56PM ALT(SGPT)-15 AST(SGOT)-48* ALK PHOS-85 TOT
BILI-1.3
[**2165-1-26**] 10:56PM ALBUMIN-3.5
[**2165-1-26**] 10:56PM WBC-7.2 RBC-3.16* HGB-11.6* HCT-32.2*
MCV-102* MCH-36.8* MCHC-36.1* RDW-12.5
[**2165-1-26**] 10:56PM PLT COUNT-83*
[**2165-1-26**] 04:51PM TOT BILI-1.2 DIR BILI-0.5* INDIR BIL-0.7
[**2165-1-26**] 04:51PM IRON-29*
[**2165-1-26**] 04:51PM calTIBC-282 HAPTOGLOB-101 FERRITIN-262*
TRF-217
[**2165-1-26**] 04:51PM AFP-11.0*
[**2165-1-26**] 04:51PM WBC-7.4 RBC-3.56* HGB-12.8 HCT-36.2 MCV-102*
MCH-35.8* MCHC-35.3* RDW-12.6
[**2165-1-26**] 04:51PM PLT SMR-LOW PLT COUNT-87*
[**2165-1-26**] 04:51PM PT-16.0* PTT-27.5 INR(PT)-1.5*
[**2165-1-26**] 04:51PM FDP-0-10
[**2165-1-26**] 04:51PM FIBRINOGE-248 D-DIMER-269
[**2165-1-26**] 04:51PM RET AUT-1.6
[**2165-1-26**] 02:30PM URINE HOURS-RANDOM
[**2165-1-26**] 02:30PM URINE UCG-NEGATIVE
[**2165-1-26**] 02:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2165-1-26**] 02:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-8.5*
LEUK-NEG
[**2165-1-26**] 02:30PM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2165-1-26**] 02:30PM URINE HYALINE-0-2
[**2165-1-26**] 02:13PM HGB-12.9 calcHCT-39
[**2165-1-26**] 10:37AM URINE HOURS-RANDOM
[**2165-1-26**]: RUQ US
The liver is somewhat coarse and increased in echogenicity
without focal mass. The gallbladder is normal without stones or
sludge. The common bile duct measures 3 mm. No free fluid is
seen in the right upper quadrant. The spleen is normal in size.
Pulse color Doppler imaging of the hepatic vasculature
demonstrates normal color flow with normal waveforms in the main
portal vein, left, anterior and posterior right portal veins,
splenic, and superior mesenteric veins. Normal color flow is
seen within the IVC and hepatic veins. Normal color flow and
waveforms are seen in the splenic artery. No varices are seen in
the splenic hilum.
IMPRESSION:
Increased echogenicity of the liver consistent with fatty
infiltration. Patent hepatic vasculature and splenic vein. No
evidence of splenic varices.
[**2164-1-27**] EGD:
EGD showed 1+ esophageal varices (non bleeding, no stigmata of
bleeding). Antrum had multiple erosions w/o bleeding. yellow
bile in stomach and duodenal bulb, which was normal.
Asses: Bleeding likely from erosive gastritis. Esophageal
varices indicate liver disease in all liklihood. Suggest abd CT
and US to characterize liver, hepatitis serologies, iron
studies,
AFP.
[**2165-1-26**] 10:37AM URINE UHOLD-HOLD
[**2165-1-26**] 10:10AM GLUCOSE-213* UREA N-11 CREAT-0.8 SODIUM-137
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17
[**2165-1-26**] 10:10AM ALT(SGPT)-22 AST(SGOT)-70* LD(LDH)-340* ALK
PHOS-111 TOT BILI-1.7*
[**2165-1-26**] 10:10AM ALBUMIN-4.3
[**2165-1-26**] 10:10AM NEUTS-76.5* LYMPHS-18.6 MONOS-3.4 EOS-1.0
BASOS-0.5
[**2165-1-26**] 10:10AM WBC-7.5 RBC-4.02* HGB-14.5 HCT-40.8 MCV-101*#
MCH-36.1* MCHC-35.6*# RDW-12.5
[**2165-1-26**] 10:10AM MACROCYT-1+
[**2165-1-26**] 10:10AM PLT COUNT-107*
[**2165-1-26**] 10:10AM PT-15.3* PTT-27.1 INR(PT)-1.4*
Brief Hospital Course:
1. Upper GIB: DDx included [**Doctor First Name 329**] [**Doctor Last Name **] tear, ulceration,
gastritis, AVM. EGD consistent with erosions and grade I
esophageal varices. Nature of varices not clear, but GI work up
of portal HTN started with RUQ US, which revealed a fatty liver
and normal flow on dopplers. Patient also noted to have
thrombovytopenia to 80s, elevated t. bili at 1.3 and mildly
elevated AST. DIC work-up negative and these lab abnormalities
felt likely secondary to mild liver disease vs low grade
hemolysis. COOMS test sent and pending at time of discharge.
Given stability of Plt CT and LFTs and patient's keen desire to
go home, as well as hemodynamic stability, patient dcd to home
with PCP follow up. Patient was advised to continue on [**Hospital1 **] PPI
and to avoid ETOH and offending foods. Patient also told that
she needs liver follow. At time of DC, Immunoglobulins, ASA,
hepatitis serologies and iron studies were pending and need to
be followed up by PCP.
In terms of her GI bleed, patient remained hemodynamically
stable and was maintained on [**Hospital1 **] IV Protonix. HCT stabilized to
32 (from 40). This drop felt likely secondary to IN hydration.
Patient initially NPO, but diet advanced after EGD. Patient
tolerated without event.
2. Hypothyroidism: Continued on home synthroid.
3. DM: Patient with h/o gestational DM. She was maintianed on
ISS and had fasting BS > 120. Patient's HBA1C sent and was
pending at time of discharge. This will need tp be followed up
by PCP. [**Name10 (NameIs) **] wa started on Metformin at 500mg QD and advised
of the side effects. will continue on ISS fo rnow and will
likely need outpatient follow up.
4. FEN: NPO initially and hten advanced.
5. PPx: [**Hospital1 **] IV PPI, pneumobots
6. Code: Full
7. Access: 2P IVs
8. Dispo: To floor once stable
9. Communication: Husband
Medications on Admission:
1. Synthroid 175mcg QD
2. MVI
3. Calcium
Discharge Medications:
1. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Upper Gi Bleed secondary to gastric erosions
Hyperglycemia
Elevated Liver Fuction Tests
Thrombocytopenia
Discharge Condition:
stable
Discharge Instructions:
Please take all medications as prscribed. Please report to your
primary care physician with nay nausea, vomiting, reflux
sensation in throat, fevers, chills, abdominal pain, diarrhea,
BRBPR, blood in your vomit.
Followup Instructions:
Please call your primary care physician [**Last Name (NamePattern4) **] [**2165-1-28**] and set up
follow up.
Your primary care physician needs to follow up on your
Hemoglobin A1C, imunoglobulins, hepatitis serologies, iron
studies.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2165-1-27**]
|
[
"2875",
"25000",
"2449"
] |
Admission Date: [**2201-4-17**] Discharge Date: [**2201-4-24**]
Date of Birth: [**2125-11-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
esophageal ca
Major Surgical or Invasive Procedure:
s/p laporascopic esophagectomy [**4-17**] for esophogeal Cancer.
Jejunostomy-tube replaced [**4-19**].
Past Medical History:
Hypertension, Hyperlipidemia, Colon CAncer, Arthritis, Coronary
artery disease
Social History:
lives alone in [**Location (un) 620**]
Family History:
n/a
Physical Exam:
NAD
RRR
CTA b/l
incision clean/dry/intact
Pertinent Results:
[**2201-4-17**] 04:33PM BLOOD WBC-8.5# RBC-3.33* Hgb-10.8* Hct-31.0*
MCV-93 MCH-32.4* MCHC-34.7 RDW-15.9* Plt Ct-158
[**2201-4-17**] 04:33PM BLOOD PT-12.5 PTT-24.7 INR(PT)-1.1
[**2201-4-17**] 04:33PM BLOOD Glucose-132* UreaN-24* Creat-1.7* Na-137
K-5.0 Cl-107 HCO3-21* AnGap-14
[**2201-4-17**] 08:46AM BLOOD Type-ART pO2-175* pCO2-49* pH-7.34*
calHCO3-28 Base XS-0 Intubat-INTUBATED
[**2201-4-17**] 08:46AM BLOOD Glucose-150* Lactate-1.0 Na-136 K-4.2
Cl-104
[**2201-4-17**] 08:46AM BLOOD Hgb-10.7* calcHCT-32
[**2201-4-17**] 08:46AM BLOOD freeCa-1.14
[**2201-4-21**] 11:30PM BLOOD WBC-5.0 RBC-2.71* Hgb-8.8* Hct-24.5*
MCV-90 MCH-32.5* MCHC-35.9* RDW-15.5 Plt Ct-141*
[**2201-4-21**] 11:30PM BLOOD Plt Ct-141*
[**2201-4-21**] 11:30PM BLOOD Glucose-101 UreaN-29* Creat-1.0 Na-140
K-3.7 Cl-105 HCO3-24 AnGap-15
[**2201-4-21**] 05:38AM BLOOD CK(CPK)-169
[**2201-4-21**] 11:30PM BLOOD Calcium-7.6* Phos-2.7 Mg-1.6
Brief Hospital Course:
Patient was admitted [**2201-4-17**] for elective minimally invasive
thoracoscopic and laparoscopic total esophagogastrectomy. He
tolerated procedure well please see operative note for detail.
After recovery in PACU he was transferred to [**Wardname 836**] for further
care. Initial postoperative CXR showed minimal Right apical ptx
and right subcutaneous emphysema.
On POD2 his chest tubes were placed to water seal and follwup
CXR showed tiny right apical pneumothorax and bibasilar linear
atelectasis and small amount of residual pneumoperitoneum.
On POD 3 he had asymtomatic bout of atrial fibrillation up to
160's which responded to medical managment with IV lopressor.
On POD6 his right chest tube was removed and followup CXR was
unremarkable compared to prior. He also received an radiologic
evaluation of his esophagus anastomosis and emptying which
revealed no evidence of anastomotic leak status post
esophagectomy and slightly slow transit into the small bowel.
On POD7 the remaining left side chest tube was removed along
with nasogastric tube. subsequent CXR revealed stable sml apical
ptx seen in prior studies otherwise unremarkable.
His hospital course was otherwise unremarkable and was cleared
for discharge home [**2201-4-24**] with appropiate followup with Dr.
[**Last Name (STitle) **].
Discharge Medications:
1. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*240 ML(s)* Refills:*0*
4. Docusate Sodium 150 mg/15 mL Liquid [**Last Name (STitle) **]: Fifteen (15) cc PO
BID (2 times a day).
5. Therapeutic Multivitamin Liquid [**Last Name (STitle) **]: Five (5) ML PO ONCE
(Once) for 1 doses.
Disp:*120 ML(s)* Refills:*0*
6. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. tubefeeding
ProBalance 75/hr for 24 hours continuous
See instruction sheet for rate for variable hour duration
7.5 cans ProBalance/day
9. tube feeding pump
Kangaroo Pump
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Homecare
Discharge Diagnosis:
s/p lap esophagectomy [**4-17**] for esophogeal CAncer.
Jejunostomy-tube replaced [**4-19**].
PMHx: Hypertension, Hyperlipidemia, Colon CAncer, Arthritis,
Coronary arterty disease
PSHx: Right hemicolectomy, Coronary artery bypass graft, Left
port and Jejunostomy tube placement [**1-8**]
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Doctor Last Name **]/ Thoracic Surgery office [**Telephone/Fax (1) 170**] for:
fevers, shortness of breath, chest pain, nausea, vomitting,
difficult swallowing, or constipation longer than 4 days.
Take medications as listed on discharge instructions.
Tubefeeding of ProBalance goal 75cc/hr for 24 hours. And as
scheduled provided in instructions for 20 hours, 16 hours, 12
hours duration.
Tube feeding support w/ [**Hospital 5065**] Healthcare-[**Telephone/Fax (1) 39931**].
VNA with Physician's HomeCare-[**Telephone/Fax (1) 39932**].VNA will assist you
w/ wound assessment and management, tubefeedings together w/
[**Hospital1 5065**].
YOu may shower when you get home. No tub baths or swimming for
3-4 weeks.
YOu may take clear-full liquids until follow appointment with
Dr. [**Last Name (STitle) 952**] in [**9-26**] days.
Followup Instructions:
Call Dr.[**Doctor Last Name **]/ Thoracic Surgery office [**Telephone/Fax (1) 170**] for an
appointment in [**9-26**] days.
Completed by:[**2201-4-29**]
|
[
"9971",
"42731",
"4019",
"2724",
"41401"
] |
Admission Date: [**2108-1-21**] Discharge Date: [**2108-2-4**]
Date of Birth: [**2046-11-6**] Sex: F
Service: NEUROLOGY
Allergies:
Opioids-Morphine & Related
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
* intubation
History of Present Illness:
PER ADMITTING RESIDENT:
This is a 61 yo female with h/o hypertension, CAD, s/p
stents, who developed shortness of breath and lightheadedness
and
headache over the past 3 days. She was being treated for
pneumonia and UTI by her primary care doctor [**First Name (Titles) 151**] [**Last Name (Titles) **] and
predisone which both started on [**2108-1-18**]. She developed severe
headaches subsequently which the family were due to the [**Date Range **].
The PCP changed the medication to Levaquin on [**2108-1-20**], but the
headache persisted. She presented to OSH ([**Hospital 84338**]) with shortness of breath and lightheadedness.
When she initally presented to the OSH ED, she was awake and
alert. However, code stroke was called when she suddenly
developed left sided facial droop and weakness in the right arm
and leg. She had a brief episode of eye blinking and shaking of
both arms. Head CT showed an acute subarachnoid hemorrhage
along
the convexity of the left parietal lobe and a suggestion of
intraparencymal subtle hemorrhagic area in the left parietal
lobe. Prioir to transfer she was received lopressor 5 mg IV,
fosphenytoin 1 g, and 2 mg Ativan. Chest X-ray showed changed
flattening the diaphragm and some mild blunting of the
costophrenic angles. EKG showed sinus tachycardia with poor
R-wave progression in the anterior leads which is consistnet
with
her previous MI. Upon arrival to [**Hospital1 18**], she was noted to be
agitated. She developed agonal breathing and was then
intubated.
CT/CTA was performed.
On neuro ROS, as above.
On general review of systems,her husband denies [**Name2 (NI) **] shehad
fever,
chills, neuasea, vomting, or other cymptoms.
Past Medical History:
- htn
- hyperlip
- COPD
- PVD s/p bilateral iliac
- s/p left renal stents
- CAD s/p STEMI [**7-18**] with stenting x 3.
Social History:
- She lives with her husband who is the primary care
giver. She was ambulating independently
prior to admission.
.
HABITS
- Tobacco history: 40 pack yr, quit 3 yrs ago
-ETOH: None
-Illicit drugs: None
Family History:
No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory
Physical Exam:
ON ADMISSION:
Physical Exam:
Vitals: T: 99.0 P:101 R: 22 BP: 138/86 SaO2: 100% on FiO2 40%
General: intubated and sedated
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: sedated, eyes closed, unable to follow commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2.5to 2mm and brisk. Funduscopic exam revealed no
papilledema, exudates, or hemorrhages.
III, IV, VI: unable to attest
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: unable
IX, X: + corneals bilaterallyl=
[**Doctor First Name 81**]: unable
XII: unable.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Moves all extremities to noxious stimuli
-Sensory: withdraws to painful stimuli
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response mute bilaterally.
-Coordination: unable
-Gait: unable
Pertinent Results:
Admission Labs:
.
WBC-32.0*# RBC-4.16* HGB-12.8 HCT-40.9 MCV-99* PLT-620
GLUCOSE-207* UREA N-18 CREAT-0.6 SODIUM-129* POTASSIUM-5.6*
CHLORIDE-99 TOTAL CO2-18* ANION GAP-18
CK-MB-NotDone cTropnT-<0.01
ALT(SGPT)-156* AST(SGOT)-202* CK(CPK)-76 ALK PHOS-49 TOT
BILI-0.2
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-LG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-MOD
.
[**2-3**] WBC 9.2, HCT 29.7, plts 958
ESR 75, lupus anticoagulant negative, hepatitis panel neg, HIV
Ab neg, ANCA neg, [**Doctor First Name **] neg, RF 12, beta-2 microglobulin 1.3, C3
166, C4 52
.
IMAGING
.
CTA ([**2108-1-21**]):
IMPRESSION: Unchanged small volume of focal subdural and
subarachnoid
hemorrhage with no underlying vascular malformation, cerebral
venous
thrombosis or aneurysm identified.
.
CXR ([**2108-1-21**]):
IMPRESSION:
1. ETT 5 cm from the carina.
2. No acute cardiopulmonary abnormality identified
CT head [**2108-1-26**]
FINDINGS: A non-contrast CT of the head was obtained. Again
noted is a small
amount of subdural hemorrhage layering along the
interhemispheric falx and
subarachnoid hemorrhage within the bilateral frontotemporal
sulci at the
cerebral convexities, mildly reduced in extent when compared to
the prior
study. There has been interval development of cortical and
subcortical
hypodensities within the bilateral posterior parietal lobes
extending
inferiorly into the occipital lobes, left greater than right.
There is no
evidence of intraparenchymal hemorrhage. No masses or shift of
midline
structures is identified. The ventricles are stable in size. The
basilar
cisterns are patent. The calvarium is intact. There is partial
opacification
of the left anterior ethmoidal air cells and mucosal thickening
within the
sphenoid sinuses.
IMPRESSION:
1. Interval development of cortical and subcortical
hypodensities within the
posterior parietal and occipital lobes. Differential diagnosis
includes PRES
versus bilateral infarctions, possibly secondary to venous sinus
thrombosis.
No definite CT evidence of venous sinus thrombosis is
identified. MRI and MRV
are recommended for further characterization.
2. Slight interval decrease in extent of subdural and
subarachnoid hemorrhage
within the bilateral frontotemporal regions at the cerebral
convexities.
MRI/V [**2108-1-27**]
1. Non-arterial distribution infarcts with large regions of
restricted
diffusion involving the left parietooccipital lobes, right
parietal lobe, and
additional scattered punctate foci within the right frontal
lobe. Stable
subarachnoid and subdural hemorrhage, as described above.
No evidence of arterial thrombosis, medium-to-large intracranial
vessel
vasospasm or vasculitis (though MRI/MRA may be insensitive), or
cerebral
venous thrombosis.
2. Mucosal thickening and fluid with near-complete opacification
of the left
maxillary sinus and partial opacification of the anterior left
ethmoid air
cells, not significantly changed in extent compared to CTA of
one day prior.
These findings were discussed at-length with Dr. [**Last Name (STitle) **] (Stroke
service), by
Dr. [**Last Name (STitle) **], on [**2108-1-27**] at 4:30 PM; by exclusion, this may
represent a severe
case of Call-[**Doctor Last Name 8271**] pathophysiology, proceding to infarction,
in a patient
with severe underlying vascular disease.
TTE [**2108-1-31**]
No atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF 70%). The aortic valve is not
well seen. No masses or vegetations are seen on the aortic
valve, but cannot be fully excluded due to suboptimal image
quality. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No
masses or vegetations are seen on the mitral valve, but cannot
be fully excluded due to suboptimal image quality. Mild to
moderate ([**1-14**]+) mitral regurgitation is seen. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. There is apparently
severe pulmonary artery systolic hypertension (however, due to
the technically suboptimal nature of this study, a falsely
elevated pulmonary artery systolic pressure measurement caused
by contamination of the tricuspid regurgitation signal by the
mitral regurgitation cannot be excluded with certainty). There
is no pericardial effusion.
TEE [**2108-2-2**]
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion.
IMPRESSION: PFO, ASD or intracardiac thrombus seen. Significant
thoracic aortic atherosclerosis.
CTA head/neck [**2108-2-2**]
Patent bilateral vertebral and carotid arteries. Mild narrowing
of the right
anterior carotid artery, new since prior CTA representing an
area of non-flow
limiting vasospasm
Discharge Labs:
136 | 99 | 6
-------------< 128
4.0 | 31 | 0.5
9.2
9.2 >------< 958
29.7
Brief Hospital Course:
Ms. [**Known lastname 4702**] is a 61 year-old woman with a past medical history
including hypertension, hyperlipidemia, CAD s/p STEMI, and PVD
s/p bilateral iliac stenting who initially presented to Caritas
with a three day history of headache, shortness of breath, and
lightheadedness. An emergent CT was performed when she developed
acute left facial droop, right hemiparesis, and apparent
convulsive movements; the imaging demonstrated a left parietal
subarachnoid hemorrhage and subdural hematoma in the falx
region. She was given ativan and fosphenytoin before transfer
to the [**Hospital1 18**] for further evaluation and care. She was admitted
to the stroke service from [**2108-1-21**] to [**2108-2-3**].
.
NEURO
Upon her arrival at the [**Hospital1 18**], a repeat CT was performed to
evaluate for any evolution of the lesions. The CT demonstrated
stability of the focal subdural and subarachnoid hemorrhage. CT
Angiography showed no underlying vascular malformation, cerebral
venous thrombosis or aneurysm identified. A repeat CT head
revealed bilateral parieto-occipital hypodensities, possibly
consistent with venous sinus thrombosis or PRES. However, no
evidence of thrombosis was seen on CTV. A TTE did not reveal a
cardioembolic source for her infarcts, however TEE was notable
for complex >4mm atheroma in the aortic arch. MRI with contrast
was performed which revealed no underlying malignancy, and
negative for venous sinus thrombosis. It was hypothesized her
presentation was most consistent with cerebral vasoconstriction
syndrome (Call [**Last Name (un) 8273**]). She was started on verapamil and
tolerating this [**Doctor Last Name 360**] well. A vasculitis panel was sent as
well, which was unrevealing and an LP showed 0 wbc, protein 30,
glucose 84. She was continued on her plavix and aspirin. In
response to her atheroma noted on TEE, it was decided to
increase the dose of her statin and continue her antiplatelet
agents rather than proceed with anticoagulation, primarily as it
was still thought unlikely that this was the cause of her
presentation.
.
Throughout the hospitalization, phenytoin was transitioned to
keppra for seizure prophylaxis. There were no further clinical
events noted and she has remained on 750 mg [**Hospital1 **]. It is
recommended that she continue the keppra for at least six
months.
.
RESP
Following her arrival at the [**Hospital1 18**], the patient developed agonal
breathing and was intubated for airway protection. She was
successfully extubated within 48 hours. She continued to have
intermittent difficulty with her respiratory status, likely due
to her COPD and pneumonia. Her nebulizers were increased in
frequency to q4h and she did require 2-3L O2 via NC. Her O2 was
weaned off and she is currently doing well on room air.
.
CVS
In the inital part of the hospitalization, the patient's blood
pressure dropped, requiring the support or pressors. The
hypotension was thought to be related to analgesics and the
sedatives required for intubation. She has been normotensive
for several days and her home beta blocker and ace-inhibitor
were restarted. An echocardiogram (TTE and TEE) were performed;
please see results section for details.
.
ID
To address the urinary tract infection diagnosed prior to
admission, ceftriaxone and pyridium were administered. Blood
cultures ([**2108-1-22**]) showed no growth. She completed a ten day
course of ceftriaxone (switched to cefpoxidime on day #8) given
her recent pneumonia as well as urinary tract infection.
Medications on Admission:
ranexa
hctz
metoprolol
plavix
singulair
lisinopril
ASA
crestor
mucinex
colace
senna
zantac
MVI
Buspar
carafate
ativan
APAP
albuterol
advair
spiriva
miralax
robitussin
maalox
Niroglycerin SL
Levaquin
prednisone
.
Allergies: opoid-morphine related medications
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours).
5. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for Fever/pain.
15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
17. Verapamil 120 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
18. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for headache.
19. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Left parietal subarachnoid hemorrhage
Bilateral parieto-occipital infarcts
Likely cerebral vasoconstriction syndrome (Call [**Last Name (un) 8273**])
Discharge Condition:
A&Ox3, speech fluent. Naming, repetition, comprehension itact.
EOMI, VFF, face symmetric, tongue midline. Moves all
extremities antigravity and against resistance. Sensation
intact to light touch.
Discharge Instructions:
You were admitted for evaluation of headache, seizure, and
right-sided weakness. You were found to have a bleed in the
left side of your brain. A repeat CT scan showed infarcts on
both sides of your brain. This may have been due to a cerebral
vasoconstriction syndrome.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] (neurology). You may call
([**Telephone/Fax (1) 7394**] to schedule an appointment within 4-6 weeks.
We would recommend that you have a follow up MRI of your brain
in three months.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"486",
"5990",
"2761",
"4019",
"41401",
"V4582",
"412",
"496",
"2724",
"V1582"
] |
Admission Date: [**2105-6-16**] Discharge Date: [**2105-6-25**]
Date of Birth: [**2052-5-3**] Sex: M
Service: MEDICAL INTENSIVE CARE UNIT
CHIEF COMPLAINT: Staph endocarditis and respiratory failure.
He was transferred from [**Hospital 1474**] Hospital on [**6-16**]. His
nine day Intensive Care Unit course was notable for sepsis,
respiratory failure, right pneumothorax requiring two chest
tube placements, difficulty oxygenation, and acidosis
secondary to his respiratory failure.
For the two days prior to his death, patient's blood pressure
had slowly been going down. The family is aware of the
terminal and irreversibility of Mr. [**Known lastname 48642**] condition on
[**6-25**] at 10 am, the patient's heart rate stopped. CPR as
not indicated at the decision of the Medical team, and at
10:12 am, Mr. [**Known lastname **] was pronounced dead. His aunt and
daughter were notified. The decision about an autopsy is
pending at this point in time.
CAUSE OF DEATH: Cardiac arrest secondary to acidosis,
secondary to respiratory arrest caused by chronic obstructive
pulmonary disease and pneumothoraces.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Last Name (NamePattern1) 8228**]
MEDQUIST36
D: [**2105-6-25**] 11:07
T: [**2105-7-3**] 12:50
JOB#: [**Job Number 51571**]
|
[
"0389",
"5845",
"5070"
] |
Admission Date: [**2169-4-17**] Discharge Date: [**2169-4-25**]
Service: CARDIOTHORACIC SURGERY
CHIEF COMPLAINT: Severe aortic stenosis, congestive heart
failure
HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old
male who was admitted to [**Hospital3 1443**] Hospital on
transferred to [**Hospital3 **] on [**2169-4-17**] with a diagnosis of
severe aortic stenosis and congestive heart failure.
PAST MEDICAL HISTORY:
1. Asthma
2. Diabetes mellitus
3. Left lower extremity deep venous thrombosis in
4. Bell's palsy, right face
5. Hematuria
6. Status post transurethral resection of the prostate
MEDICATIONS:
1. Digoxin
2. Coumadin 4 mg
3. Mucomyst
4. Insulin
HOSPITAL COURSE: The patient was admitted to this hospital
on [**2169-4-17**]. He underwent catheterization which showed an
ejection fraction of 35%, severe aortic stenosis with a valve
ADL of 0.7 cm square. She underwent an elective aortic valve
replacement on [**2169-4-18**] with a #21 pericardial valve
postoperatively. He was extubated on the day of surgery.
On postoperative day 1, his chest tubes were discontinued.
He was transferred to a regular floor on postoperative day 1.
During the night of postoperative day 1 during a brief period
of confusion, the patient self discontinued his pacing wires
and his Foley catheter. The Foley catheter had to be
reinserted the following morning because of inability to pass
urine. He was restarted on his Coumadin for deep venous
thrombosis prophylaxis on postoperative day 2. He is
currently ambulating and will be ready for discharge soon to
a rehabilitation facility.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg qd x1 week
2. KCL 20 milliequivalents qd x1 week
3. Colace 100 mg [**Hospital1 **]
4. Zantac 150 mg [**Hospital1 **]
5. Aspirin EC 325 mg qd
6. Insulin 8 units NPH q a.m., 4 units q p.m.
7. Albuterol metered dose inhaler 2 puffs qid
8. Coumadin 4 mg qd
9. Lopressor 25 mg [**Hospital1 **]
10. Captopril 6.25 mg tid
11. Regular insulin sliding scale
FOLLOW UP: Primary care physician in two weeks from
discharge, with Dr. [**Last Name (STitle) **] four weeks from discharge.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2169-4-21**] 14:17
T: [**2169-4-21**] 14:39
JOB#: [**Job Number 40697**]
|
[
"4280",
"4241",
"41401",
"49390",
"25000"
] |
Admission Date: [**2197-12-3**] Discharge Date: [**2197-12-11**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4309**]
Chief Complaint:
FEVER, Altered mental Status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 year old male with history of [**Last Name (un) 309**] Body Dementia, Complex
partial seizure, stroke, Barrett's, Arrives with increased
confusion, responing only to sternal rub. Reportedly, patient
was just diagnosed with PNA the other day by Old Soldiers [**Name8 (MD) **]
MD. Daughter also reports loss of alertness and mobility, and
that he also had a fever of 101, and was given tylenol. Daughter
( of note HCP, as well as [**Name8 (MD) **] [**MD Number(3) 108111**] nursing facility),
reports altered MS, not taking keppra for partial tonic clonic.
Treated for PNA w/ azitha and levo.
Family also noted that he gets severe hyponatremia on any other
anti-seizure medication, but Keppra is ok.
.
In the ED, initial vs were: 98.3 108 118/66 18 98% RA. Patient
had had a CXR, showing possible right middle lobe PNA, and was
started on Vanc/Zosyn combination.
.
He had an ABG, showing pH 7.48 pCO2-36 pO2-72 HCO3-28.
He had a CT scan of the head, with Wet read negative for
pathology
He had a CXR done showing possible PNA.
He had an EKG - unchanged to prior, with old infarct, and some
pvcs.
He was seen by neurology, who felt that the patient is likely
delirious in setting of history of LBD, now with pneumonia.
Cannot rule out ongoing seizure activity and also myoclonic
jerks noted on exam. Please change Keppra to IV if not taking PO
meds. Please get EEG. Will follow on consult service.
.
Prior to transfer, his vitals were temp 99.8 HR 80, BP 120/68 RR
22 Satting 100% on Room air.
.
On the floor, the patient only responded to voice, but was
oriented to family members and names.
.
Review of sytems: unable to ascertain, as patient is not
answering questions.
Past Medical History:
1. Complex partial seizure.
2. DVT and PE.
3. History of GI bleeding.
4. Barrett's esophagus.
5. Stroke.
6. Left inguinal hernia status post herniorrhaphy.
7. Status post partial amputation of left fourth finger.
8. Asbestos exposure.
9. Mild obstructive lung disease on PFTs.
10. Seasonal allergies.
11. Asthma.
12. Hypertension.
13. Sleep apnea.
14. Basal cell carcinoma.
15. Venous stasis.
16. Autonomic dysfunction and orthostatic hypotension.
17. Dementia of [**Last Name (un) 309**] body.
18. Cervical spondylosis
19. Shingles.
20. Elevated PSA of 13 (family decided not to pursue it)
Social History:
The patient lives at home with his wife. [**Name (NI) **] does not have any
services. His daughter [**Name (NI) 108112**] is a nurse practitioner [**First Name (Titles) 1023**] [**Last Name (Titles) 108113**]s his medical care and also is a healthcare proxy. [**Name (NI) **]
does not drink alcohol and he is a former smoker. He is able to
perform feeding, ambulating with a walker, toileting, but needs
help with dressing and bathing, and other instrumental
activities of daily living.
Family History:
-Father: colon cancer
-Mother: died of "old age"
-Sisters: [**Name2 (NI) **] CA
Physical Exam:
VS: T: 97.3, P: 87, BP: 149/65, RR: 14, 98% on 4L NC
HEENT: Sclera anicteric, MMM, oropharynx clear, mild erythema
around eyes.
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro:Nonfocal exam. Moving all extremities. Gets very agitated
when apply nailbed pressure. Left four finger partially missing.
mild myoclonus.
Pertinent Results:
Admission labs:
[**2197-12-3**] 01:20PM BLOOD WBC-11.7*# RBC-3.64* Hgb-11.1* Hct-33.4*
MCV-92 MCH-30.4 MCHC-33.2# RDW-12.7 Plt Ct-367#
[**2197-12-3**] 01:20PM BLOOD PT-16.1* PTT-27.0 INR(PT)-1.5*
[**2197-12-3**] 01:20PM BLOOD Glucose-118* UreaN-29* Creat-1.0 Na-138
K-4.9 Cl-100 HCO3-24 AnGap-19
[**2197-12-3**] 01:20PM BLOOD ALT-39 AST-45* CK(CPK)-104 AlkPhos-103
TotBili-0.6
[**2197-12-3**] 01:20PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
[**2197-12-5**] 06:00AM BLOOD Vanco-21.6*
[**2197-12-3**] 01:06PM BLOOD pO2-72* pCO2-36 pH-7.48* calTCO2-28 Base
XS-3
[**2197-12-3**] 01:25PM BLOOD Lactate-1.7
.
Imaging:
.
CT HEAD without contrast:
IMPRESSION: No evidence of acute intracranial hemorrhage or mass
effect.
Correlate clinically to decide on the need for further workup.
.
CXR
IMPRESSION: Increased density in the right lung base may reflect
aspiration or pneumonia in appropriate clinical circumstance
.
ECG
Sinus rhythm. Atrial premature beats and ventricular premature
beats. Compared
to the previous tracing of [**2197-9-27**] the atrial and ventricular
premature
depolarizations are new. Otherwise, no other interval change.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] J.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
102 120 98 344/417 61 -6 17
.
EEG
FINDINGS:
ABNORMALITY #1: The background was slow and disorganized
throughout the
recording reaching a maximum 5.5-6 Hz frequency at times.
BACKGROUND: As described above in Abnormality #1.
HYPERVENTILATION: Was not performed.
INTERMITTENT PHOTIC STIMULATION: Stepped photic stimulation from
[**1-22**]
flashes per second (fps) produced no activation of the record.
SLEEP: No clear state changes were seen.
CARDIAC MONITOR: A single EKG channel showed an irregular rhythm
throughout the recording.
IMPRESSION: Abnormal routine EEG due to the presence of a slow,
disorganized background, reaching a maximum frequency in the
theta
frequency range. This finding suggests the presence of a
moderate
encephalopathy which is non-specific in etiology but indicates
diffuse
cerebral dysfunction. No epileptiform features were seen.
.
Discharge labs:
[**2197-12-11**] 07:00AM BLOOD WBC-10.5 RBC-3.51* Hgb-10.4* Hct-31.5*
MCV-90 MCH-29.8 MCHC-33.1 RDW-12.5 Plt Ct-550*
[**2197-12-11**] 07:00AM BLOOD Plt Ct-550*
[**2197-12-11**] 07:00AM BLOOD Glucose-92 UreaN-9 Creat-1.2 Na-143 K-3.5
Cl-106 HCO3-31 AnGap-10
[**2197-12-3**] 01:20PM BLOOD ALT-39 AST-45* CK(CPK)-104 AlkPhos-103
TotBili-0.6
[**2197-12-11**] 07:00AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.2
.
Transitional issues:
Please call the hospital for a pending keppra level from
[**2197-12-10**]
Brief Hospital Course:
Mr. [**Known lastname 60272**] is an 87 yo M with a history of possible [**Last Name (un) 309**] Body
dementia, autonomic dysfunction, HTN, previous CVA, who was
admitted to the ICU with altered mental status, and leukocytosis
and fevers, and evidence of pneumonia on Xray.
#Acute mental status change: Likely secondary from infection
and hospital acquired pneumonia. Given history of seizures,
post-ictal state was considered as well but there were no
evidence of seizures on EEG. Neurology evaluated the patient
but was confident that seizure was not occurring and that it was
not contributing to the altered mental status. We concluded that
acute delirium superimposed on chronic dementia was the most
likely cause of the altered mental status. The patient remained
somewhat somnolent throughout his stay until the last day, when
he became alert and was able to sit in a chair and eat his meal.
The patient was discharged at his baseline mental status, able
to eat and get out of bed.
#HCAP: patient admitted with leukocytosis, fever and CXR
findings consistent with pneumonia. He was treated with
Vanco/Zosyn for HCAP for 8 days. He completed his course 1 day
before discharge and remained asymptomatic.
#. HISTORY OF SEIZURES: on levitiracetam 750 mm po BID at home,
increased to 1000 mg po BID with the supervision of neurology.
EEG showed that the patient was not having any active seizures,
and patient's mental status was at baseline on discharge.
# Nutrition: During [**Hospital 228**] hospital stay, his waxing and
[**Doctor Last Name 688**] mental status made it difficult for him to consistently
eat. His nutrition was supplanted by ensure when the patient
was awake enough to be fed safely. By discharge, patient was
awake and able to feed himself.
#HISTORY OF STROKE: continued on aspirin.
#. GERD/BARRETTS: continued on omeprazole.
#. HYPERLIPIDEMIA: continued on zocor
Medications on Admission:
1. Donepezil 15mg daily
2. fludrocortisone 0.1mg (2tabs) daily
3. Levetiracetam - 750 mg [**Hospital1 **] (per daughter- had been recorded
as 1000 mg po BID)
4. Omeprazole 20 ER
5. Seroquel 25mg ([**12-25**] tablet PRN agitation)
6. Zoloft 100mg daily
7. Aspirin 325 daily
8. Calcium/VitD3 500-400 Chewable
9. Vit B12 - 100mcg ER
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
5. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. donepezil 5 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
8. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)) as needed for agitation.
9. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Zoloft 100 mg Tablet Sig: One (1) Tablet PO once a day.
11. Calcium 500 + D (D3) 500-125 mg-unit Tablet Oral
12. Vitamin B-12 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
13. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
14. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
Soldiers Home in [**State 350**] - [**Location (un) **]
Discharge Diagnosis:
Acute delirium
Chronic dementia
Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 60272**], you presented to us with altered mental status and
a pneumonia was found to be in your lungs. We started you on
appropriate antibiotics and watched you carefully in the ICU for
a few days. Once we determined that you were medically stable,
we transferred you to the general floor for further monitoring.
While with us, we had the neurologists see you to evaluate for
possible seizure activity in the brain. Electroencephalograph
found no evidence of altered brain waves. The neurologists
determined that you were not having seizures. We also had the
geriatricians see you, to evaluate for other causes of altered
mental status. Our conclusion was that the pneumonia had caused
an acute delirium which superimposed on your baseline dementia.
Once your antibiotic therapy had completed, we discharged you
back to your extended care facility and you were in stable
condition.
The following changes have been made to your medications:
Increase keppra to 1000mg by mouth twice a day.
Followup Instructions:
Department: GERONTOLOGY
When: THURSDAY [**2198-1-11**] at 1 PM
With: [**Last Name (un) 3895**] [**First Name8 (NamePattern2) 3896**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2197-12-11**]
|
[
"0389",
"486",
"2724",
"53081"
] |
Admission Date: [**2143-10-24**] Discharge Date: [**2143-10-29**]
Service: NEUROSURGERY
Allergies:
IV Dye, Iodine Containing
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
per daughter, some change in MS, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 84 yo M with hx of prior intraparenchymal hemorrhage,
presents now with new right temporo-occipital intraparenchymal
hemorrhage. Pt had been in NH at baseline health until Mon when
the daughter felt that he seemed a little "spaced out" at times
and not focusing. She also felt he was weak, in that he was
having trouble feeding himself, was dragging his feet when
walking, and was over stiff. She states a [**First Name3 (LF) 72787**] was done at that
time, which was supposedly normal, but she was later told a
bleed
was apprecaited and the pt was transferred here (it is acutally
unclear if he had more than one [**Name (NI) 72787**] since Mon). Despite these
complaints, during interview in the ER, the daughter felt that
her father was largely at his baseline mental status. She states
that is at baseline disoriented and has an aphasia.
Past Medical History:
dementia
hypercholesterolemia
HTN
NIDDM
bleeding ulcers s/p "stomach operation"
s/p appy
Denies prior stroke.
Social History:
Lives with wife in [**Name (NI) 7661**]. At baseline, oriented x2 not to
place, walks without assistance. Daughter in the area. No tob,
etoh or drugs.
Family History:
nc
Physical Exam:
PHYSICAL EXAM:
O: T:100.8F BP: 200/77 HR: 84 R 21 O2Sats 97%RA
Gen: awake, alert, comfortable, NAD.
HEENT: Pupils: 2-->1 mm B/L EOMs: full
Neck: Supple.
Lungs: mild ronchi bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, but not cooperative with exam,
normal affect. Inattentive.
Orientation: Oriented to "hospital," when given multiple choice,
but not to person or date
Language: Speech fluent. Appears to have some comprehension.
Unable to repete.
No dysarthria.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields unable to be formally tested.
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 not tested (would not
cooperate).
XII: not tested (would not cooperate).
Motor: Normal bulk bilaterally. Tone seemed increased, esp in
LLE, but could not tell if he was just resisting me. No abnormal
movements, tremors. Strength could not formally be tested, but
he
had at least anti-gravity strength in the UE and LE B/L.
Sensation: Intact to light touch, temperature bilaterally. Would
not cooperate with other modalities.
Reflexes: B T Br Pa Ac
Right 1 0 0 1 0
Left 1 0 0 1 0
Would not allow babinski testing
Coordination: would not cooperate.
Pertinent Results:
[**Doctor First Name 72787**] [**2143-10-24**]:
new right occiptal hemorrhage with no midline shift.
left frontal encephalomalcia
9/12Large area of intraparenchymal hematoma in the right
temporo-occipital region, unchanged measuring approximately 2.9
in the transverse dimension. Extension into the atrium and
occipital [**Doctor Last Name 534**] of the right lateral ventricle with
nonvisualization of these portions of the right lateral
ventricle, unchanged. No significant change in the surrounding
the edema, or mass effect on the tentorium cerebelli. No new
hemorrhage or no mass effect.
[**10-28**] Slight decreased density of the large intraparenchymal
hematoma,
consistent with natural evolution of blood products. There is
otherwise no
significant interval change from prior study.
Brief Hospital Course:
Pt was admitted to the neurosurgery service and monitored
closely in ICU. he had repeat CT which was stable. After
discussion with daughter - HCP - he was made DNR/DNI. He was
transferred to neuro stepdown. His blood pressure medications
have been adjusted to keep systolic <180. This may need further
adjustment at rehab in combination with pt's long standing
cardiologist.
Medications on Admission:
Medications prior to admission:
Metoprolol 50 mg PO BID
Metformin (dose unknown)
Depakote (dose unknown, but daughter states he is being weaned
off)
Hydralazine PRN HTN
(full list of meds unknown, but daughter states she will get a
list from the NH)
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
5. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO TID (3
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO TID (3
times a day).
8. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for sbp>170.
9. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 7661**] health and rehab
Discharge Diagnosis:
Cerebral hemorrhage
Discharge Condition:
stable
Discharge Instructions:
?????? Take your pain medicine as prescribed
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**First Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITH OR WITHOUT CONTRAST
Completed by:[**2143-10-29**]
|
[
"4280",
"2720",
"4019"
] |
Admission Date: [**2145-1-26**] Discharge Date: [**2145-2-3**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Low back and leg pain
Major Surgical or Invasive Procedure:
L1-L4 laminectomy and T12-L4 instrumented fusion
History of Present Illness:
Persistent pain after conservative management of L2 burst
fracture.
Past Medical History:
OSA on Bipap at night [**12-21**] at 2L
Idiopathic Cardiomyopathy (Last EF 55% ~6 months ago)
S/P ICD for recurrent VT in [**2125**]
BPH s/p TURP
AAA
Anxiety
HTN
Social History:
Former psychologist. Lives at home with wife. Smoked until age
40 but quit since (~20 pack-year). Average 2 drinks/night
usually wine or beer. No illicit drugs or substances. Patient
denies any traveling outside MA in the last 6 months.
Family History:
Patient denies any history of cancer, DM or CAD.
Physical Exam:
[**5-17**] /5 BLE, SILT
Refelxes 2+ BLE,
Bilteral upper extremities [**6-16**]
Upper lumbar spine tenderness.
Pertinent Results:
[**2145-1-26**] 09:00PM TYPE-ART PO2-91 PCO2-38 PH-7.41 TOTAL CO2-25
BASE XS-0
[**2145-1-26**] 03:35PM TYPE-ART PO2-152* PCO2-41 PH-7.38 TOTAL
CO2-25 BASE XS-0
[**2145-1-26**] 03:35PM freeCa-1.14
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure. 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
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#6. 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.
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO Q 12H (Every
12 Hours).
5. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for Anxiety.
6. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours) as
needed for pain.
7. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for Pain.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
10. Mexiletine 200 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
L2 burst fracture with lumbar canal stenosis
Discharge Condition:
Stable
Discharge Instructions:
You have undergone the following operation: Lumbar Decompression
With Fusion
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:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Limit 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 may 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.
- 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.
- Follow up:
o Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o At the 2-week visit we will check your incision, take baseline
X-rays and answer any questions. We may at that time start
physical therapy.
o We will then see you at 6 weeks from the day of the operation
and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Ambulation with assistance to make him independent ambulator.
Treatments Frequency:
Physical therapy to improve mobilization
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2145-2-15**] 10:00
Completed by:[**2145-2-2**]
|
[
"4280",
"40390",
"5859",
"32723",
"2449",
"2875",
"V1582"
] |
Admission Date: [**2189-9-25**] Discharge Date: [**2189-12-18**]
Date of Birth: [**2189-9-25**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 53965**], his first
name is [**Name (NI) **], is an 1180 gram baby boy [**Name2 (NI) **] at 27 and 1/7
weeks gestational age who was admitted to the Neonatal
Intensive Care Unit for management of prematurity. The
infant was [**Name2 (NI) **] to a 23 year-old gravida 2 para 0 to 1 mother
with a past obstetrical history notable for one therapeutic
abortion. The past medical history of the mother was
unremarkable. The prenatal screens showed a maternal blood
type of O positive, antibody negative, hepatitis B surface
antigen negative, RPR nonreactive, Rubella immune and GBS
unknown.
For this pregnancy the last menstrual period was [**2189-3-19**]
for an estimated delivery date of [**2188-12-24**] and an
estimated gestational age at delivery of 27 and 1/7 weeks.
The pregnancy was complicated by preterm labor with an
admission at 24 and 4/7 weeks. The preterm labor was
responsive to tocolysis. Betamethasone was administered at
that time. However, cervical dilation progressed and the
mother proceeded to spontaneous vaginal delivery. There were
no maternal fevers or other clinical evidence of
chorioamnionitis. Intrapartum antibiotics were administered
for preterm labor and unknown GBS status. Rupture of
membranes occurred at delivery yielding clear amniotic fluid.
The infant cried at delivery with resuscitation and required
facial CPAP and free flow oxygen for respiratory distress and
central cyanosis. Apgar scores were 7 and 8.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight was 1180
grams, which is 75th percentile. Head circumference was 25.5
cm, which is the 25th to 50th percentile. Length was 37.5 cm,
which is the 40th percentile. Initial physical examination
revealed a nondysmorphic infant with an intact palate,
bilateral red reflex, moderate nasal flaring and retractions
with decreased breath sounds bilaterally, regular cardiac
rate and rhythm with no murmur. The abdominal examination
was benign with a three vessel umbilical cord. The
genitourinary examination was normal with an examination
consistent with a male preterm infant. Testes were
undescended bilaterally. There was a normal neurological
examination.
HOSPITAL COURSE:
1. Respiratory: The baby was intubated on admission to the
Neonatal Intensive Care Unit and received one dose of
Surfactant before being extubated by day of life number one.
He remained on CPAP until day of life six, when he was
weaned to nasal cannula. However, after having increased
apnea of prematurity he returned to CPAP on day of life 12,
but was able to be subsequently weaned off of CPAP into room
air by day of life 18. He continues in room air currently.
[**Known lastname **] was started on caffeine for presumed apnea of
prematurity on day of life one. Caffeine continued until day
of life 51 and was discontinued on [**11-16**]. His apnea of
prematurity has resolved.
On day of life 66, [**2189-11-30**], otolaryngology (ORL) from
[**Hospital3 1810**] visited [**Known lastname **] for consultation for
desaturations and intermittent stridor, sometimes associated
with feedings. A bedside examination revealed laryngomalacia
and findings consistent with gastroesophageal reflux (full
erythematous arytenoids). ORL suggested a modified barium
swallow and a direct laryngoscopy/bronchoscopy to follow-up on
potential additional pathology, however, due to [**Known lastname 43967**]
improvement we did not perform these procedures during this
hospital stay. However, these procedures can be considered in
consultation with ORL if [**Known lastname 43967**] clinical course were to
change or if new clinical concerns were to arise. He will
currently have intermittent stridor especially with activity,
however, this does not cause any cardiorespiratory compromise
and he has been without any cardiorespiratory events or
desaturations over the past five days.
2. Cardiovascular: [**Known lastname **] has been stable from a
cardiovascular standpoint since admission. He has not
required volume or vasopressor support. Within the first
week of life an intermittent murmur was heard. An
echocardiogram done on day of life seven revealed no patent
ductus arteriosis. The murmur did persist and is thought to
be consistent with a peripheral pulmonic stenosis murmur or a
PPS murmur. A couple of days prior to discharge, consultation
by the Cardiology Service at [**Hospital3 1810**] was
obtained. During their assessment they could not appreciate
this intermittent murmur and recommended no further
evaluation or cardiology follow up.
3. Fluids, electrolytes and nutrition: [**Known lastname **] was
initially NPO and received total parenteral nutrition for the
first week of life while enteral feeds were advanced without
incident. There have been no significant problems with
feeding intolerance. He is currently tolerating po ad lib of
breast milk 20 with minimum intakes of 150 cc per kilogram
per day. His discharge weight is 3570 grams.
He is receiving ferrous sulfate (concentration of 25 mg per
ml) at 0.6 ml po q daily. He is also receiving multivitamins
as Vi-Daylin at 1 ml po q day.
Due to the clinical signs and otolaryngology findings of
gastroesophageal reflux, he was also started on Ranitidine at
a dose of 2 mg per kilogram per dose, which equals 7 mg PO
every eight hours and he is on Metoclopramide or Reglan at
approximately .1 mg per kilogram per dose, which equals a
total dose of 0.3 mg po q 8.
4. Hematology: [**Known lastname 43967**] admission hematocrit was 43. He
did receive a packed red blood cell transfusion on [**2189-10-15**] for a hematocrit of 25. His last hematocrit checked
on day of life 66, [**11-30**], was a hematocrit of 28.8 and a
reticulocyte count of 2.8%.
[**Known lastname **] was also started on phototherapy on his third day of
life for a bilirubin of 6.5, which was his peak bilirubin.
Phototherapy was discontinued on day of life 10. His last
bilirubin was 4.3/0.3 on day of life 11 on [**10-7**].
5. Infectious disease: [**Known lastname **] was started on a 48 hour
sepsis evaluation upon admission for prematurity and
respiratory distress. The initial CBC showed a white blood
cell count of 10.9 with 26 polymorphonucleocytes and 0%
bands. Hematocrit was 43 and platelets were 232. He was
maintained on Ampicillin and Gentamycin for 48 hours until
blood cultures were negative. There have been no further
infectious disease concerns.
6. Neurology: Because of prematurity [**Known lastname **] had a head
ultrasound on day of life seven, which showed a left grade
one germinal matrix hemorrhage. Repeat head ultrasounds on
day of life 14, 30 and lastly on [**2189-11-30**] all showed
resolution of this germinal matrix hemorrhage with no
evidence of periventricular leukomalacia.
7. Sensory: Automated auditory brain stem response testing
was done to evaluate hearing, which [**Known lastname **] passed. In
addition, due to his prematurity he was evaluated by
ophthalmology for retinopathy of prematurity. He had four
examinations while in Neonatal Intensive Care Unit. The
first two on [**10-27**] and [**11-15**] revealed immature retinas. On
[**2189-11-30**] mild retinopathy of prematurity was noted -
right eye stage one zone and three eye remained immature in
zone three. His final examination in the Neonatal Intensive
Care Unit on [**2189-12-14**] revealed mature retina
bilaterally with no evidence of retinopathy of prematurity.
Follow up is recommended in eight months time since the last
examination.
8. Routine health care maintenance: State newborn
screenings were sent per protocol with no concern of
abnormalities on his most recent evaluation.
He received his vaccinations. He has received dose one of
hepatitis B vaccine on [**2189-11-13**] and dose two one month
later on [**2189-12-18**]. He has also received dose one of
DtAP and HIB on [**2189-11-23**] and dose one of IPV and
Pneumococcal 7-valent conjugant vaccine or Prevnar on [**2189-11-25**]. He also received Synagis for RSV prophylaxis during
this season and he received his first dose on [**2189-11-28**]. He will need to have Synagis administered on a monthly
basis throughout the RSV season, which is considered to be
through [**2190-2-18**].
Parents would like [**Known lastname **] circumsized, however, due to
scrotal edema, this was deferred to be evaluated as an
outpatient at a later date. We gave the parents the phone
number for the Urology Service at [**Hospital3 1810**].
9. Psycho/social: The [**Hospital1 69**]
social worker, [**Name (NI) 4457**] [**Name (NI) 36244**], was involved with the family.
The social worker can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY CARE PROVIDER/PEDIATRICIAN: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2855**] [**Last Name (NamePattern1) **] at
[**Street Address(2) 52736**] in [**Hospital1 6687**], phone number [**Telephone/Fax (1) 38070**],
fax number [**Telephone/Fax (1) 49370**]. There will also be a pediatrician
who visits [**Hospital1 6687**] who will also be following [**Known lastname **]. Her
name is Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of 7A1 [**Last Name (NamePattern1) **], [**Location (un) 54017**]
[**Numeric Identifier 50263**], phone number [**Telephone/Fax (1) 37501**], fax number
[**Telephone/Fax (1) 51142**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge will be breast milk 20 po ad lib by
the breast or by the bottle with expressed breast milk.
2. Medications:
(a)ferrous sulfate (concentration 25 mg per
ml) at 0.6 ml po q day, which is approximately 4 mg per
kilogram per day of elemental iron;
(b)Vi-Daylin 1 ml po q day;
(c)Metoclopramide or Reglan at 0.3 mg po q 8, which is
approximately 0.1 mg per kilogram per dose; and
(d)Ranitidine or Zantac at 7 mg po q 8, which is
approximately 2 mg per kilogram per dose.
3. Car seat positioning screening was done prior to
discharge and the infant passed.
4. State newborn screening was sent per protocol with no
persistent abnormalities.
5. Immunizations received, again hepatitis B dose one on
[**2189-11-13**], dose two [**2189-12-18**]. DTAP [**2189-11-23**]. HIB
[**2189-11-23**]. IPV [**2189-11-25**]. Prevnar [**2189-11-25**]. Synagis [**2189-11-28**].
6. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet of any of the following
three criteria, (1)[**Month (only) **] at less then 32 weeks, (2)[**Month (only) **]
between 32 and 35 weeks with two or three of the following;
day care during RSV season, smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings, or (3) with chronic lung disease.
Influenza immunizations should be considered annually in the
fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age the family and other
caregivers should be considered for immunization against
influenza to protect the infant.
FOLLOW UP APPOINTMENTS RECOMMENDED:
1. Otolaryngology at [**Hospital3 1810**] (Dr. [**Last Name (STitle) 174**] -
[**Telephone/Fax (1) 36478**].
2. Ophthalmology at [**Hospital3 1810**] (Dr. [**Last Name (STitle) **]) -
[**Telephone/Fax (1) 54018**].
3. Urology at [**Hospital3 1810**] - [**Telephone/Fax (1) 45268**].
4. Infant Follow-Up Program at [**Hospital1 **] - [**Telephone/Fax (1) 37126**].
5. [**Hospital3 **] and Island early intervention program -
[**Telephone/Fax (1) 38557**].
6. VNA - [**Hospital6 18346**] Community and Home Health
Dept. - [**Telephone/Fax (1) 49371**].
DISCHARGE DIAGNOSES:
1. Prematurity 27 and 1/7 weeks.
2. Respiratory distress syndrome.
3. Apnea of prematurity.
4. Anemia of prematurity.
5. Left grade one germinal matrix hemorrhage.
6. Physiologic hyperbilirubinemia.
7. Retinopathy of prematurity.
8. Laryngomalacia.
9. Intermittent murmur consistent with peripheral pulmonic
stenosis.
[**First Name8 (NamePattern2) 39464**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 54019**]
MEDQUIST36
D: [**2189-12-18**] 11:12
T: [**2189-12-18**] 11:34
JOB#: [**Job Number 54020**]
|
[
"7742"
] |
Admission Date: [**2123-6-4**] Discharge Date: [**2123-6-10**]
Date of Birth: [**2094-1-18**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
drug overdose
Major Surgical or Invasive Procedure:
Exploratory laparotomy, gastrotomy
History of Present Illness:
HISTORY OF PRESENTING ILLNESS
This patient is a 29 year old female who complains of OD.
Patient was transferred from an outside hospital. Patient
initially presented with both lethargy and new onset atrial
fibrillation. During the course of the patient's visit it
was found that the patient had ingested multiple packets of
unknown substance believed to be either cocaine or heroin in
[**Location (un) 13366**] approximately 5 days ago. The patient was noted to
have a functional gastric outlet
obstruction, and was transferred to our facility for further
management. The patient was started on a diltiazem drip for
management of atrial fibrillation.
En route to our facility, the patient was given
benzodiazepines to protect against seizures. Following this,
the patient developed respiratory depression and
hypotension. She was intubated and started on peripheral
Levophed
Past Medical History:
none
Social History:
Social History: Just arrived from [**Location 89033**]
Family History:
nc
Physical Exam:
PHYSICAL EXAMINATION
HR: 120s BP: 88/60 Resp: 18T O(2)Sat: 97% Normal
Constitutional: Intubated
HEENT: Normocephalic, atraumatic
OP with endotracheal tube
Chest: Breath sounds bilateral
Cardiovascular: Normal first and second heart sounds,
tachycardic
Abdominal: Soft, Nondistended, absent bowel sounds.
Skin: Warm and dry
Neuro: GCS 3T
Pertinent Results:
[**2123-6-9**] 04:50AM BLOOD WBC-11.8* RBC-3.64* Hgb-11.5* Hct-33.1*
MCV-91 MCH-31.6 MCHC-34.8 RDW-13.4 Plt Ct-258
[**2123-6-8**] 06:10AM BLOOD WBC-10.1 RBC-3.49* Hgb-11.2* Hct-32.8*
MCV-94 MCH-32.0 MCHC-34.1 RDW-13.3 Plt Ct-216
[**2123-6-7**] 06:00AM BLOOD WBC-14.9* RBC-3.75* Hgb-12.0 Hct-34.1*
MCV-91 MCH-32.0 MCHC-35.2* RDW-13.3 Plt Ct-196
[**2123-6-4**] 03:30PM BLOOD WBC-22.0* RBC-4.15* Hgb-12.9 Hct-39.8
MCV-96 MCH-31.1 MCHC-32.4 RDW-13.3 Plt Ct-288
[**2123-6-9**] 04:50AM BLOOD Plt Ct-258
[**2123-6-8**] 06:10AM BLOOD Plt Ct-216
[**2123-6-5**] 03:52AM BLOOD PT-14.7* PTT-37.0* INR(PT)-1.3*
[**2123-6-4**] 03:30PM BLOOD Fibrino-264
[**2123-6-9**] 04:50AM BLOOD Glucose-98 UreaN-4* Creat-0.4 Na-135
K-3.5 Cl-99 HCO3-26 AnGap-14
[**2123-6-8**] 06:10AM BLOOD Glucose-121* UreaN-4* Creat-0.6 Na-137
K-3.5 Cl-100 HCO3-30 AnGap-11
[**2123-6-4**] 08:38PM BLOOD Glucose-79 UreaN-6 Creat-0.5 Na-139 K-3.7
Cl-110* HCO3-21* AnGap-12
[**2123-6-5**] 03:52AM BLOOD CK(CPK)-574*
[**2123-6-4**] 08:38PM BLOOD CK(CPK)-263*
[**2123-6-5**] 03:52AM BLOOD CK-MB-11* MB Indx-1.9 cTropnT-<0.01
[**2123-6-4**] 08:38PM BLOOD CK-MB-13* MB Indx-4.9 cTropnT-<0.01
[**2123-6-9**] 04:50AM BLOOD Calcium-7.8* Phos-3.1 Mg-1.7
[**2123-6-8**] 06:10AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.9
[**2123-6-4**] 03:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2123-6-4**] 08:47PM BLOOD Lactate-1.9
[**2123-6-4**] 08:47PM BLOOD freeCa-1.01*
[**2123-6-4**]: chest x-ray:
IMPRESSION:
No acute cardiopulmonary pathology.
Distended stomach full of heterogeneous material, rounded
opacities may
represent drug packets, in keeping with clinical history.
[**2123-6-4**]: x-ray abdomen:
FINDINGS: The NG tube tip is in the stomach. Lateral decubitus
film
demonstrates some air-fluid levels in the colon. Supine film
shows gas in the colon. No free air is visualized. Skin staples
are seen in the mid abdomen
[**2123-6-5**]: EKG:
Sinus tachycardia. Otherwise, tracing is within normal limits.
No previous
tracing available for comparison
[**2123-6-5**]: chest x-ray:
FINDINGS: The ET tube is 4 cm above the carina. Left IJ line tip
is in the
SVC. NG tube is still slightly high with proximal port at the GE
junction.
There is increased opacity measuring 3.7 cm centered around the
tip of the
left IJ line projecting over the region of the distal SVC. There
is also
increased opacity in the right upper lung. This finding was
called to the
trauma team at the time of dictating this report (Dr. [**Last Name (STitle) **].
IMPRESSION:
1. New increased opacity in the right upper lung of unclear
etiology.
2. NG tube still slightly too high.
[**2123-6-5**]: chest x-ray:
FINDINGS: Lobulated opacity seen on the film from earlier the
same day is no longer visualized. There is increased opacity
bilaterally consistent with effusions layering posteriorly and
some alveolar edema. There is bilateral pulmonary vascular
redistribution. NG tube tip is in the stomach. ET tube tip is
0.8 cm above the carina. Skin staples are again seen projecting
over the upper abdomen.
[**2123-6-7**]: echo:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). There is mild regional left
ventricular systolic dysfunction with probable mild basal to mid
inferior hypokinesis. Transmitral and tissue Doppler imaging
suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Assessment of regional
wall motion abnormalities is difficult. The basal to mid
inferior wall is probably mildly hypokinetic. The apical
segments are not well seen. No significant valvular abnormality
seen.
Brief Hospital Course:
29 year old female admitted to the acute care service from an
outside hospital with increased lethargy and new onset of atrial
fibrillation. She reported ingestion of drug packets. She was
intubated upon transport related to increasing somnolence and
hypotension. She required pressor support and an anti-arrhythmic
[**Doctor Last Name 360**] for control of her rapid heart rate. Upon admission, she
underwent radiographic imaging and was found to have a distended
stomach full of heterogeneous material and few rounded opacities
representing drug packets. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube was placed for
stomach decompression. Because of her clinical story and
presentation, toxicology and gastroenterology were consulted and
made recommendations for her management. She was emergently
taken to the operating room where she underwent an exploratory
laparotomy, gastrotomy and removal of narcotic packets. Her
operative course was stable. She was monitored in the intensive
care unit after her procedure and required additional
intravenous fluids. She had placment of a central venous line
for additional access. Her pressors were weaned off. She was
extubated on POD #1. She underwent a bedside echocardiogram
which showed a stunned myocardium (EF 30-40%) likely due to
large catecholamine release. She had a repeat echocardiogram
done which raised the suspicion of myocardial dysfunction,
EF=>55%.
She was transferred to the surgical floor on POD #2. Her cardiac
status was monitored because of her history of atrial
fibrillation upon admission to the hosptial. She has had
occasional episodes of increased heart rate to 100, which have
resolved spontaneously. Her [**Last Name (un) **]-gastric tube was discontinued
on POD# 3 and she slowly regained bowel function. She
progressed from clear liquids to a regular diet. Her foley
catheter was discontinued and she is voiding without difficulty.
She was seen by the Social worker who provided her with
additional support.
Her vital signs are stable and she is afebrile. She is
tolertating a regular diet.
Her abdominal wound is clean with intact staples. She is
preparing for discharge with instructions to follow up in the
acute care clinic in 2 weeks for removal of the staples.
Medications on Admission:
none
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stool.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
polysubstance overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after ingestion of drug
packets. You were taken to the operating room for an
exploratory laparotomy and gastrotomy. You are now preparing
for discharge with the following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items [**9-25**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Followup Instructions:
Please follow up with in the acute care clinic in 2 weeks for
staple removal. You can schedule your appointment by calling #
[**Telephone/Fax (1) 600**]
|
[
"42731"
] |
Admission Date: [**2150-11-3**] Discharge Date: [**2151-2-17**]
Date of Birth: [**2075-1-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Surgical Wound Debridement
History of Present Illness:
Mr. [**Known lastname 77792**] is a 75 with chronic respiratory failure s/p
tracheostomy, type II diabetes, peripheral vascular disease s/p
right BKA, CAD, atrial fibrillation, and ESRD on dialysis who
presented on [**2150-11-3**] from his chronic rehab facility with
hypotension to the 70s systolic with associated cough and sputum
production. Since [**2150-11-3**] he has had multiple ICU transfers for
hypotension and somnolence.
.
On DOA on [**2150-11-3**], he presented with BP of 50/33 and it was
presumed to be sepsis from large known sacral decubitus ulcer
which was felt to be infected. He was admitted to the [**Hospital Unit Name 153**] for
concern for sepsis. He was in the [**Hospital Unit Name 153**] from [**2150-11-3**] to
[**2150-11-26**]. In [**Hospital Unit Name 153**] he had a broad infectious workup. Multiple
blood cultures were negative. Both sputum and urine cultures
were positive for acinetobacter. He was treated with a
prolonged course of daptomycin, meropenem and PO vancomycin.
Antibiotics were discontinued on [**2150-11-26**] prior to transfer to
the floor. While in the ICU his blood pressures were
persistently in the 70s to 80s systolic but he was afebrile and
was noted to be mentating appropriately. His blood pressures
were noted to be particularly sensitive to narcotic pain
medications. He was followed closely by the renal, infectious
disease and plastic surgery services. He initially required
CVVH given his labile blood pressures but was ultimately
transitioned back to intermittent hemodialysis. His back wound
was debrided on multiple occassions by plastic surgery. His
back wound was noted to be consistently contaminated by fecal
material despite flexiseal use. Diverting colostomy was
recommended but was declined by the patient. He was transferred
to the floor on [**2150-11-26**] for further management.
.
On [**2150-11-29**] he was transferred back to the MICU for hypotension.
He was not febrile, new cultures failed to reveal a source. He
was started back on daptomycin, meropenem and PO vancomycin. He
also received stress dose steroids. His hypotension resolved
with this regimen. He was transferred back to the floor with
blood pressures in the 90s to 110s systolic. The patient did
well on the floor until [**12-8**] when 2 hours after receiving 10 mg
oxycodone to control sacral decub pain in setting of dressing
change he became unresponsive.
Narcan did imporve his alertness but the medical staff was
unable to obtain reliable vital measurements and in setting of
worsening productive sputum and worsening leukocytosis, patient
was transferred to ICU were he was monitored for 2 days. The
patient returned to the medicine floor on [**12-10**]. However, on
[**12-12**] he again became hypotensive and returned to the ICU, again
likely multifactorial. Midodrine was restarted and uptitrated to
15mg tid. He received one unit of PRBCs with hemodialysis for
colloid volume resuscitation. He was transferred back to the
floor on [**12-14**].
.
On review of systems he does not note any pain/discomfort
anywhere. He denies chest pain, shortness of breath, nausea,
vomiting, abdominal pain, dysuria, leg pain.
Past Medical History:
# DM2
# CRI (baseline 2.5)- recently started on HD
# CHF - EF 50-55% [**3-24**]
# Trached and Vent Dependent [**1-18**] PNA in [**12-24**]
hypercarbic/hypoxic respiratory failure, bronchoscopy on [**9-10**].
He diffuse airway edema consistent with volume overload. There
were no significant secretions and a full survey of the airways
reveals all airways were patent without any endobronchial
lesions. His trach was
felt to be in appropriate position without any obstruction.
There was no tracheobronchomalacia.
# PNA [**4-23**] (Stenotrophomonas - Bactrim sensitive)
and Acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to
FQ, ceftaz, cefepime)
# MRSA PNA
# ESBL Klebsiella UTI [**3-24**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
# Coccyx Ulcers
# MGUS
Social History:
Used to live with wife, who is HCP. Now at [**Hospital1 **].
Family History:
Non-Contributory
Physical Exam:
Review of systems:
ROS is is negative except for what is mentioned in the HPI
.
EXAM
Vitals: 971., 115/40, 69, 16, 96%/40% FM
GEN: NAD, lying in bed, +trach, obese, awake, alert,
HEENT:PERRLA, EOMI, anicteric, MMM
neck: +trach in place, c/d/I, supple, unable to assess for JVP.
Chest/Pulmonary:b/l +poor respiratory effort, CTAB anteriorly.
R.sided HD catheter
Heart: s1s2 distant heart sounds, unable to appreciate m/r/g.
Abdomen: +bs, obese, soft, NT, ND
Ext: s/p R.BKA, wound at stub. L.leg dusky, dark in color, dry
skin, faint pulses. R.midline c/d/i. 3+body edema.
Back: +stage 4 sacral decub, with multiple surrounding decubs of
various stages. +evidence of zoster infection/dermatomal
vesicular rash.
Neuro: AOx3
Pertinent Results:
[**2150-12-14**] 03:04AM BLOOD WBC-21.3* RBC-2.72* Hgb-8.3* Hct-25.7*
MCV-95 MCH-30.4 MCHC-32.1 RDW-22.5* Plt Ct-232
[**2150-11-3**] 07:40PM BLOOD WBC-13.2*# RBC-3.27* Hgb-9.1* Hct-29.7*
MCV-91 MCH-27.8 MCHC-30.6* RDW-17.7* Plt Ct-415#
[**2150-12-14**] 03:04AM BLOOD PT-24.6* PTT-64.0* [**Month/Day/Year 263**](PT)-2.4*
[**2150-12-14**] 03:04AM BLOOD Glucose-74 UreaN-22* Creat-1.9*# Na-146*
K-3.3 Cl-110* HCO3-24 AnGap-15
[**2150-12-14**] 03:04AM BLOOD Calcium-8.8 Phos-2.1*# Mg-1.9
[**2150-12-13**] 08:28AM BLOOD Tobra-3.1*
.
CXR [**11-3**]
IMPRESSION: Cardiomegaly with bilateral small pleural effusions,
left greater than right. Retrocardiac opacity may represent a
combination of atelectasis and pleural effusions. Cannot rule
out pneumonia. Followup is recommended.
.
FOOT 2 VIEWS LEFT PORT Study Date of [**2150-11-4**] 10:04 AM
FINDINGS: No previous images. There has been resection of the
phalanges of
the fourth and fifth digits as well as a substantial portion of
the fifth
metatarsal in a patient with vascular calcification consistent
with diabetes. Specifically, no evidence of erosion of the
calcaneus, though there is evidence of an adjacent ulcer. Small
posterior calcaneal spur.
.
TTE (Complete) Done [**2150-11-9**]
The left atrial volume is increased. The left atrium is dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Left ventricular systolic function is hyperdynamic (EF>75%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2150-4-4**],
mild symmetric LVH is present, left ventricular cavity size is
smaller and overall left ventricular systolic function has
improved. The degree of mitral regurgitation has increased
slightly. Moderate pulmonary artery systolic hypertension can be
seen on the current study.
.
[**2150-11-4**] 11:33 am SWAB Source: Stool.
**FINAL REPORT [**2150-11-8**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2150-11-8**]):
ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
ENTEROCOCCUS SP.
|
VANCOMYCIN------------ >256 R
.
[**2150-11-10**] 4:51 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2150-11-13**]**
MRSA SCREEN (Final [**2150-11-13**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
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
_________________________________________________________
POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
.
[**2150-11-20**] 6:10 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2150-11-20**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Preliminary):
.
[**2150-11-29**] 7:49 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2150-12-3**]**
GRAM STAIN (Final [**2150-11-29**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2150-12-3**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFEPIME-------------- =>64 R 32 R
CEFTAZIDIME----------- =>64 R 4 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R 4 S
IMIPENEM-------------- 8 I
MEROPENEM------------- =>16 R
PIPERACILLIN---------- 16 S
PIPERACILLIN/TAZO----- 32 S
TOBRAMYCIN------------ 8 I <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2150-12-12**] 11:48 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2150-12-12**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH.
COLISITIN AND TIGECYCLINE REQUESTED BY DR.[**Last Name (STitle) **].
[**Doctor Last Name **],[**2150-12-17**].
COLISTIN AND Tigecycline REQUEST SENT TO [**Hospital1 4534**]
[**2150-12-21**].
ACINETOBACTER BAUMANNII COMPLEX. HEAVY GROWTH.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
TO ADD TIGECYCLINE ,DURAPENEM AND COLISTIN PER DR.
[**First Name (STitle) **] PAGER
[**Numeric Identifier 36772**] [**2150-12-14**].
DURAPENEM RESISTANT AT >32 MCG/ML Sensitivity testing
performed
by Etest.
TIGECYCLINE AND COLISTIN SENT TO [**Hospital1 4534**] LABORATORIES FOR
SENSITIVITY.
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH. SECOND
MORPHOLOGY.
COLISTIN AND TIGECYCLINE REQUESTED BY DR. [**Last Name (STitle) **].
[**Doctor Last Name **],[**2150-12-17**].
COLISTIN AND Tigecycline REQUEST SENT TO [**Hospital1 4534**]
[**2150-12-21**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| ACINETOBACTER BAUMANNII
COMPLEX
| | PSEUDOMONAS
AERUGINOSA
| | |
AMPICILLIN/SULBACTAM-- =>32 R
CEFEPIME-------------- 32 R =>64 R 8 S
CEFTAZIDIME----------- 32 R 4 S
CIPROFLOXACIN--------- =>4 R =>4 R =>4 R
GENTAMICIN------------ 4 S 2 S 4 S
IMIPENEM-------------- =>16 R
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN---------- 32 S <=4 S
PIPERACILLIN/TAZO----- 64 S 8 S
TOBRAMYCIN------------ <=1 S <=1 S <=1 S
TRIMETHOPRIM/SULFA---- 2 S
LEGIONELLA CULTURE (Final [**2150-12-19**]): NO LEGIONELLA
ISOLATED.
FUNGAL CULTURE (Preliminary):
YEAST.
.
[**2150-12-18**] 3:16 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2150-12-21**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Preliminary):
.
Brief Hospital Course:
Mr [**Known lastname 77792**] is a 76 year old man with a chronic trach, s/p multiple
admissions, End-stage renal disease, coronary artery disease,
atrial fibrillation, type two diabetes and a plasma cell
dyscrasia admitted originally with hypotension and sepsis from
an infected sacral decub with prolonged hospitalization course
involving multiple transfers back and forth between the ICU and
floor for hypercapneic respiratory failure secondary to narcotic
pain medication.
.
# Stage IV Decubitus Ulcer: Overall, the patient has a very
severe stage 4 sacral decubitus ulcer and multi-drug resistant
organisms. He completed a 6 week course of Meropenem on [**2151-1-11**]
for empiric coverage. A diverting colostomy was performed on
[**2151-1-6**] to prevent fecal contamination of the wound and to
facilitate any possible wound healing. For pain control during
wound dressing was managed with various regimens transitioned to
IV morphine eventually.
# Hypotension: Pt was noted to have a baseline of sBP in the 70s
to 80s. On his original day of admission it was thought that it
may be a component of sepsis however his BP has persisted even
with resolution of sepsis. Pt has been asymptomatic and
mentating well with his above noted systolic pressures. His
baseline low BP is most likely due to autonomic dysfunction
given his negative work up and lack of clinical findings.
[**Name (NI) **] pt did require intermittent low dose Levophed
as pt's BP was decreased to the mid 60s most likely secondary to
hypovolemia. Pt was started and continued on midodrine 15 mg po
tid. Throughout [**Month (only) 956**], BP's ranged from 60's/20's- 100's/40's
thought likley to be [**1-18**] chronic sepsis and autonomic
dysfuntion.
#Pseudomonal Pneumonia: The patient was diagnosed with a
possible drug-resistant pseudomonal pneumonia which was treated
with a 14 day course of tobramycin finishing [**12-22**]. Following
treatment pt showed a negative sputum culture on [**12-26**], pt has
not shown any positive blood cultures since admission.
# ESRD: Pt was briefly on CVVH for fluid removal for several
days in early [**Month (only) 956**]. Otherwise, he was maintained on MWF HD.
By the last week of [**Month (only) 956**], his pressures were unable to
tolerate fluid removal during HD.
# Presumed C.Diff: Pt was started empirically on PO Vancomycin
given his course on antibiotics, however they were discontinued
given lack of diarrhea and C. diff negative toxin assays.
# Chronic Respiratory Failure: He has experienced several
transfers between floor status and the ICU for hypercapneic
respiratory failure. Pt is very sensitive to pain medication,
particularly Oxycodone. For his decub ulcer pain pt was trialed
on Oxycodone of 10mg and became somnelent. Pt has been
transitioned to Fentanyl patch 100mcg for baseline pain control
plus morphine for dressing changes. During [**Month (only) 956**], his
respiratory failure worstened and he was put on ventilator for
support.
# Coronary Artery Disease: Last echocardiogram with preserved
ejection fraction. Had troponin leak on admission which peaked
at 0.53. Pt was continued on simvastatin, his beta blockers were
held given his low pressures.
# Atrial Fibrillation: Pt's A. fib during hospitalization has
been rate controlled. Due to his [**Country **] score 2 pt was continued
on Coumadin in house, given his supratherapeutic [**Country 263**] pt's
Coumadin was held. In early [**Month (only) 956**], coumadin was discontinued
all together due to his comorbid conditions and risk of bleeding
from multiple ulcers on feet and sacrum.
# Type II Diabetes: Pt has diabetes and has been noted to have
lower blood sugars following his surgery. His Lantus originally
at 28 was transitioned down to 15. Given his recent surgery it
was thought he most likely had some malabsorption from bowel
edema. Lantus was changed to 15units daily without any further
hypogycemia.
# Peripheral Vascular Disease: s/p BKA on right with left heel
ulcer on leg. Also left second toe ulcer. Was followed by
vascular surgery. Left amputation was considered given chronic
cyanosis but pt was too unstable for this.
# Plasma Cell Dyscrasia: Known IgA kappa on electrophoresis,
bone marrow with 5-10% plasma cells. Also with known
retroperitoneal mass s/p non-diagnostic FNA and needle core
biopsy indicating lymphoid tissue with quiescent germinal
centers.
# Pain Control: Patient with significant pain from sacral
ulcer. Unfortunately blood pressures and respiratory failure
occur with his narcotic use. Pain consult was obtained however
recommendations were not favourable given their side effects.
He is maintained on the fentanyl patch and trying out morphine
concentrate prn before dressing changes.
# Upper gastrointestinal bleeding: Patient with guaiac positive
NG aspirates on [**11-24**]. He has had no subsequent gross bleeding
as well as no bleeding out of the ostomy. Following surgery pt's
Hct was noted to be 19 and he received 1u PRBC. He increased his
Hct appropriately and his subsequent Hcts were noted to be in
the mid 20s which is his baseline. Pt was continued on PPI
threrapy.
# Goals of care: [**2151-2-2**] a family meeting was held with ICU team
at which the family was informed that there were no further
medical or surgical options for treatment. Code status was
changed to DNR/DNI and it was made clear to the family that
CVVH, pressors or any escalation in care were not indicated. No
further cultures, radiologic studies were ordered. Pt continued
to get MWF blood draws prior to dialysis but pt quickly became
unable to tolerate fluid removal due to low BPs during dialysis.
Pain was controlled PRN and narcotics were not held in setting
of hypotension. On [**2151-2-16**] another conversation with the family
and the ICU team took place, at which time the family was
informed that Mr [**Known lastname 77795**] blood pressure would not tolerate
additional dialysis. The family decided that the pt would be
CMO, and a morphine drip was initiated. On [**2151-2-17**] at 11:45 pt
passed away from cardiac arrest.
Medications on Admission:
epoetin alfa 20,000 units with HD
famiotidine 20mg daily
recent course with fluconazole/levoflox
metoprolol 12.5mg [**Hospital1 **]
zofran 4mg IV q6h prn nausea
percocet 5/325 mg 1-2 tabs, q4h prn pain
senna
sevelamer 800mg TID
simvastatin 10mg daily
vanco 1g with HD at [**Hospital1 **]
Discharge Medications:
None
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
End stage renal failure
Sepsis
Stage 4 Decubitus Ulcer
Upper GI Bleeding
Pneumonia
Hypoxemia
Hypotension
Altered Mental Status
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2151-2-18**]
|
[
"42731",
"99592",
"2767",
"0389",
"40391",
"5849",
"2760",
"5070",
"5990"
] |
Admission Date: [**2158-8-28**] Discharge Date: [**2158-9-5**]
Date of Birth: [**2091-9-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
relatively asymptomatic
Major Surgical or Invasive Procedure:
[**2158-8-29**] AVR ( 27mm [**Company 1543**] Mosaic porcine valve)
History of Present Illness:
66 yo male with known AI/bicuspid AV and increasing LV
dimensions. Cath showed clean coronaries. Referred for AVR.
Past Medical History:
AI
overactive bladder
HTN
BPH
hypercholesterolemia
Past Surgical History:
repair cleft lip
pilonidal cystectomy
L eye muscle surgery
tonsillectomy
Social History:
Occupation:dentist
Last Dental Exam:several months ago
Lives with: wife [**Name (NI) **]: Caucasian
Tobacco: 5 PYH/ quit [**2117**] ETOH: several drinks per month
Family History:
(parents/children/siblings CAD < 55 y/o): Father
+CHF
Physical Exam:
Pulse:61 Resp: 20 O2 sat:
B/P Right:112/70 Left: 112/72
Height: 68" Weight: 162 #
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera, OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 2/6 SEM with faint
disatolic
murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM or CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema -trace BLE
Varicosities: None [x]
Neuro: Grossly intact, nonfocal exam, MAE [**3-28**] strengths
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: murmur radiates to both carotids
Pertinent Results:
[**2158-9-4**] 05:15AM BLOOD WBC-5.5 RBC-3.35* Hgb-10.0* Hct-29.9*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.1 Plt Ct-161
[**2158-8-31**] 04:59AM BLOOD PT-13.7* PTT-31.0 INR(PT)-1.2*
[**2158-9-4**] 05:15AM BLOOD Glucose-98 UreaN-16 Creat-1.0 Na-141
K-4.1 Cl-107 HCO3-26 AnGap-12
PA AND LATERAL VIEWS OF THE CHEST.
REASON FOR EXAM: S/P AVR.
Comparison is made to prior study [**2158-8-31**].
Mild cardiomegaly is stable. Small bilateral pleural effusions
with adjacent atelectasis, left greater than right, are
improved. There is no CHF or pneumothorax.
Ill-defined opacity in the anterior segment right upper lobe is
new, could be atelectasis, attention in this area should be
performed in the followup
studies to exclude developing infection. Sternal wires are
aligned. The
patient is status post AVR.
The study and the report were reviewed by the staff radiologist.
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 51318**] (Complete)
Done [**2158-8-29**] at 3:17:54 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2091-9-26**]
Age (years): 66 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease and ? Ascending aortic
dilatation
ICD-9 Codes: 424.1
Test Information
Date/Time: [**2158-8-29**] at 15:17 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW04-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 55% >= 55%
Aorta - Ascending: *4.0 cm <= 3.4 cm
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Moderately dilated
ascending aorta.
AORTIC VALVE: Bicuspid aortic valve. No AS. Moderate to severe
(3+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is moderately dilated. The aortic valve is
bicuspid. There is no aortic valve stenosis. Moderate to severe
(3+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. There is no pericardial effusion. Dr.
[**Last Name (STitle) **] was notified in person of the results [**First Name9 (NamePattern2) 51319**] [**Known lastname **]
before bypass.
POST-BYPASS:
Preserved biventricular functin LVEF >55%.
There is a bioprosthetic valve in the aortic position (#27 per
surgeons) No AI or perivalvular leaks, Peak gradient less than 6
mm Hg on multiple measurements.
Aortic contours are intact.
Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2158-8-30**] 14:59
Brief Hospital Course:
Admitted [**8-28**] for cardiac cath which showed clean coronaries.
Underwent surgery with Dr. [**Last Name (STitle) **] on [**2158-8-29**] for aortic valve
replacement (#27mm [**Company 1543**] mosaic). He was transferred to the
CVICU in stable condition on phenylephrine and propofol drips.
Extubated that evening and transferred to the stepdown unit on
POD#2. He was started on a low dose betablocker which was
titrated gently due to asymptomatic hypotension. He was diuresed
toward his pre-op weight. His chest tubes and temporary pacing
wires were removed per protocol. He was evaluated by physical
therpay for strength and consitioning and was cleared for
discharge. He had some asymptomatic hypotension and his beta
blocker was decreased. He continued to progress and was
discharged to home is stable condition on POD #7.
Medications on Admission:
ASA 160 mg daily
Clonazepam at bedtime
simvastatin 20 mg daily
Flomax 0.4mg daily
Inderal 20mg [**Hospital1 **]
Vit. D 1000 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
Disp:*75 Tablet(s)* Refills:*2*
8. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
9. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain/muscle spasm.
Disp:*100 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 40198**] VNA
Discharge Diagnosis:
Aortic Insifficiency s/p AVR (porcine)
overactive bladder
Hypertension
BPH
hypercholesterolemia
Discharge Condition:
good
Discharge Instructions:
no lotions, creams, ointments or powders on any incision
shower daily and pat incision dry
no driving for one month AND off all narcotics
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
Followup Instructions:
Please schedule the following appointments:
Dr. [**Last Name (STitle) **] in [**11-25**] weeks
Dr. [**First Name (STitle) 1124**] in [**12-27**] weeks
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2158-9-5**]
|
[
"4241",
"5119",
"2859",
"2720"
] |
Admission Date: [**2101-8-31**] Discharge Date: [**2101-9-16**]
Date of Birth: [**2024-8-2**] Sex: M
Service: GENERAL SURGERY BLUE
CHIEF COMPLAINT: Cholangitis.
HISTORY OF PRESENT ILLNESS: This is a 77 year old man with a
history of obstructive jaundice since [**2101-5-26**]. In [**2101-5-26**],
the patient was discovered to have painless jaundice. A
endoscopic retrograde cholangiopancreatography was performed
and stent was placed. Several days later, the stent eroded
and the patient developed an acute abdomen. He underwent an
exploratory laparotomy by Dr. [**First Name (STitle) **], during which the stent
was removed and a repair of the duodenal perforation was
performed as well as placement of an 8French T-tube. The
patient was in his usual state of health until one day prior
to admission when his T-tube accidentally fell out of his
side. He also complained of some low grade fevers while he
was at home. So the patient had been in his usual state of
health until one day prior to admission when apparently the
T-tube came out. He denies any pain and he did have the low
grade fevers up to 101.7. He denies any nausea, vomiting,
diarrhea or constipation.
PAST MEDICAL HISTORY: In addition to the suspected ampullary
adenocarcinoma, the patient also has hypertension and
hypercholesterolemia. He has the prior surgical history of
the exploratory laparotomy in [**2101-5-26**].
MEDICATIONS ON ADMISSION: He takes no medications at home.
ALLERGIES: He has no known drug allergies.
SOCIAL HISTORY: He lives with his wife and daughter. [**Name (NI) **]
does have a positive smoking history. No alcohol use.
PHYSICAL EXAMINATION: The patient on presentation was
afebrile with a heart rate of 112, blood pressure 99/69,
respiratory rate 18, oxygen saturation 96%. The patient did
not seem in any acute distress. He had a regular rate and
rhythm and lungs were clear to auscultation bilaterally. His
abdomen was soft, nontender, nondistended. The right upper
quadrant T-tube site was in place without any drainage. He
did have a J-tube in the left upper quadrant. His
extremities were warm with no edema.
LABORATORY DATA: His laboratories showed a white blood cell
count of 8.9, hematocrit 35.3, platelet count 345,000. He
did a left shift of his white blood cell count with 90%
neutrophils. Sodium was 133, potassium 4.1, chloride 96,
bicarbonate 25, blood urea nitrogen 38, creatinine 1.4 and
glucose 145. His current liver function tests revealed ALT
193, AST 182, alkaline phosphatase 640, total bilirubin 1.1,
amylase 55, lipase 41. Coagulation factors showed prothrombin
time 12.4, partial thromboplastin time 26.6, INR 1.0.
Incidentally, his CA19-9 level is 82.
HOSPITAL COURSE: The patient was admitted to surgery and
given intravenous antibiotics, Linezolid, Fluconazole and
Levofloxacin and a CAT scan was performed. The CAT scan
showed a significant amount of intrahepatic ductal dilatation
with a persistence of the mass in the porta hepatis
compressing the hepatic duct. There were no fluid or air
collections indicating abscesses and stable abdominal aortic
aneurysm. The patient was followed with serial examinations
over the next 24 hours but unfortunately on hospital day two,
the patient acutely decompensated with shortness of breath,
decreasing oxygen saturation with increasing heart rate to
approximately 160. On physical examination, the patient had
wet sounding lungs and looked in significant distress. He
was transferred to the Intensive Care Unit where a Swan-Ganz
catheter was placed. The patient was also intubated. An
echocardiogram at this time revealed an ejection fraction of
only 25% with diffuse left ventricular hypokinesis. Troponin
levels were increased at this time. A chest x-ray showed
marked bilateral pleural effusions which was confirmed in a
CTA that was performed afterwards that also showed the
bilateral pleural effusions but did not show any sign of
pulmonary embolus. Over the next few days, the patient
received multiple transfusions with packed red blood cells
and required pressors for hemodynamic stabilization. On
[**2101-9-6**], which was hospital day seven, the patient was doing
better hemodynamically and was finally extubated which he
tolerated well. In addition, tube feeds were begun at this
time. On [**2101-9-11**], hospital day twelve, the patient was
transferred to the floor. At this time, he was already on
goal tube feeds. He appeared well. He appeared chronically
ill but was stable with respect to his pulmonary status and
his respiratory status, his pulmonary status and
cardiovascular status and hemodynamically he was also stable.
On [**2101-9-14**], cholangiography was performed. This revealed an
obstructive stricture in the common bile duct with associated
dilation of the intrahepatic ducts. Multiple biopsies were
sent that did not reveal any tumor. A percutaneous biliary
drain was placed traversing the strictured area. This drain
was left to drainage and drained well. It drained bilious
material afterwards. The bilious material was sent for
culture and grew back Enterococcus. This Enterococcus was
sensitive to Vancomycin. It should be noted that this is the
only positive culture that the patient had during his
hospital stay. On the day of discharge, the patient appeared
well and was tolerating his tube feeds without complication.
His heart rate was regular rate and rhythm, lungs were clear
to auscultation bilaterally. The abdomen was soft,
nontender, nondistended with the drain in place draining
bilious material. The patient's extremities were warm with
no cyanosis, clubbing or edema. Although the patient had
been seen by physical therapy and was recommended for
rehabilitation, the patient and his family refused
rehabilitation and the patient was discharged home in stable
condition on [**2101-9-16**], hospital day number seventeen.
FINAL DIAGNOSES:
1. Status post percutaneous transhepatic catheter placement.
2. Hypoxia and respiratory distress requiring intubation.
3. Congestive heart failure.
4. Myocardial injury.
5. Atrial fibrillation.
6. Chronic blood loss anemia requiring transfusion.
7. Hypokalemia.
8. Hypomagnesemia.
9. Hemodynamic monitoring with Swan-Ganz catheter.
MEDICATIONS ON DISCHARGE:
1. Levofloxacin 500 mg p.o. q24hours for one week.
2. Fluconazole 400 mg p.o. once daily for one week.
3. He was also recommended to start his prior medications
that he was taking before admission.
He could not remember these so he was recommended to
follow-up as soon as possible with his primary care physician
to coordinate his home medication regimen for hypertension
and hypercholesterolemia.
In addition, he was recommended to follow-up with Dr.[**Name (NI) 32606**] office to arrange a follow-up appointment in about
two weeks.
The patient was recommended to continue his tube feeds at
home with the same rate that he was taking before this
admission.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Last Name (NamePattern1) 48473**]
MEDQUIST36
D: [**2101-10-8**] 12:22
T: [**2101-10-8**] 13:30
JOB#: [**Job Number 48474**]
|
[
"4240",
"4280",
"42731",
"0389"
] |
Admission Date: [**2198-12-12**] Discharge Date: [**2198-12-26**]
Service: NEUROLOGY
Allergies:
Penicillins / Egg
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Transfer from OSH for pontine hemorrhage
Major Surgical or Invasive Procedure:
PEG Placement
History of Present Illness:
Patient is a [**Age over 90 **] yo RHW s/p pacemaker for tachybrady syndrome
who lives in independent/[**Hospital3 **] facility who reports to
have bilateral weakness and increased difficulty walking. She
reports that she walks with either cane or walker at baseline
but
she has been having difficulty getting up out of sitting
position
(chair or toilet) for the past 2 weeks. She denies any other
issues including visual problems, speech trouble, swallowing
trouble or numbness. She went to [**Location (un) 745**] [**Location (un) 3678**] this morning
and was found to have 12mm X 19mm central pontine hemorrhage
hence transferred here for further evaluation. Of note, unable
to load the head image because its CT head of a wrong patient.
Per patient, she has not had any falls. Her last fall was over
1
year ago. She does note that she had a HA about 7 to 10 days
ago
but unable to describe it further. She also notes that she has
been having more mucus but no trouble swallowing. She also
coughs intermittently but no fever/chills, N/V/D or sick
contact.
She also feels that her voice is lower ("more man-like") for the
past 6 months.
Of note, patient lives in assisted/independent living facility
where she gets some assistance with ADLs including showers but
cooks own meals and takes own meds.
Patient appears to give decent hx but may need corroboration
given patient reports to have gone to [**Location (un) 745**] [**Location (un) 3678**] yesterday
when in fact, she went today.
Past Medical History:
1. s/p pacemaker in [**2194**] for tachy/brady syndrome
2. Arthritis
3. GERD
4. Osteoporosis
5. s/p appendectomy
6. s/p T&A
7. Bilateral cataract repair
8. HTN
9. IBS
10. Basal Cell CA excised from the nose int he [**2168**]'s
11. Bilateral cataracts
12. Lactose intolerance
13. Lumbar disc disease
14. Venous insufficiency. Chronic LE venous stasis and
dermatitis.
Social History:
Lives in independent facility - walks with cane or walker.
Receives some assistance with ADLs including showers but cooks
for oneself and takes own meds. Never married and no children.
Next of [**Doctor First Name **] is Judge [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **]/POA [**Telephone/Fax (1) 96651**] or
[**Telephone/Fax (1) 96652**], code is DNR/DNI.
Family History:
Patient's older sister lived to 99. Mother and father with
cancer?
Physical Exam:
Per Admitting resident
T 98.6 BP 130/86 HR 70 RR 18 O2Sat 96% RA
Gen: Lying in bed, NAD - thin but comfortable appearing woman.
HEENT: NC/AT, moist oral mucosa but some white plaque on tongue.
Neck: No carotid or vertebral bruit
CV: RRR, 3/6 SEM best heard on RUSB.
Lung: Clear
Abd: +BS, soft, nontender
Ext: No edema but some venous stasis skin changes in both LEs.
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, hospital, but thinks its [**Month (only) **]
although corrects herself to [**Month (only) 1096**] and knows its [**2197**]. Also
known [**Last Name (un) 2753**] is president. Attentive, says DOW backwards.
Speech
is fluent with normal comprehension and repetition; naming
intact. No dysarthria. No right left confusion. No evidence of
apraxia or neglect.
Cranial Nerves:
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV & VI: Extraocular movements intact bilaterally but some
upgaze limitation, no nystagmus.
V: Sensation intact to LT and PP.
VII: Facial movement symmetric.
VIII: Decreased hearing, worse on L.
X: Palate elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline, movements intact
Motor:
Diffuse atrophy. No observed myoclonus or tremor. No asterixis
or pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WE FE FF IP H Q DF PF
R 5- 5- 5 5 5 5 5 5 5 5 *
L 5- 5- 5 5 5 5 5 5 5 5 *
*Unable to test PF because patient reports severe pain to
touching bottom of feet.
Sensation: Intact to light touch, vibration, cold and
proprioception throughout but decreased PP loss in stocking
distribution, worse on L than R.
Reflexes:
+2 and symmetric for UEs but none for patellar or Achilles.
Toes upgoing bilaterally
Coordination: Some endpoint dysmetria with FTF.
Gait: Stands with assistance but unsteady gait, unable to stand
on own.
Pertinent Results:
[**2198-12-17**] 06:20AM BLOOD WBC-8.5 RBC-3.71* Hgb-11.7* Hct-35.0*
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.6 Plt Ct-238
[**2198-12-16**] 06:40AM BLOOD WBC-11.5* RBC-3.89* Hgb-12.1 Hct-35.8*
MCV-92 MCH-31.0 MCHC-33.7 RDW-13.5 Plt Ct-213
[**2198-12-15**] 06:15AM BLOOD Neuts-81.0* Lymphs-14.3* Monos-3.8
Eos-0.6 Baso-0.3
[**2198-12-17**] 06:20AM BLOOD Plt Ct-238
[**2198-12-17**] 06:20AM BLOOD PT-16.3* PTT-31.3 INR(PT)-1.4*
[**2198-12-17**] 06:20AM BLOOD Glucose-151* UreaN-21* Creat-0.9 Na-143
K-3.4 Cl-112* HCO3-16* AnGap-18
[**2198-12-16**] 06:40AM BLOOD Glucose-64* UreaN-23* Creat-1.0 Na-144
K-3.6 Cl-111* HCO3-15* AnGap-22*
[**2198-12-17**] 06:20AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.0
[**2198-12-13**] 04:31AM BLOOD %HbA1c-6.0*
[**2198-12-13**] 04:31AM BLOOD Triglyc-83 HDL-46 CHOL/HD-3.7 LDLcalc-107
[**2198-12-13**] 04:31AM BLOOD TSH-0.94
[**2198-12-15**] 06:15AM BLOOD WBC-9.5 RBC-4.02* Hgb-12.8 Hct-37.4
MCV-93 MCH-31.9 MCHC-34.3 RDW-13.3 Plt Ct-238
[**2198-12-17**] 06:20AM BLOOD WBC-8.5 RBC-3.71* Hgb-11.7* Hct-35.0*
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.6 Plt Ct-238
[**2198-12-19**] 05:25AM BLOOD WBC-8.9 RBC-4.17* Hgb-12.8 Hct-38.4
MCV-92 MCH-30.7 MCHC-33.4 RDW-13.4 Plt Ct-229
[**2198-12-20**] 04:10PM BLOOD WBC-7.8 RBC-4.15* Hgb-13.0 Hct-38.3
MCV-92 MCH-31.3 MCHC-34.0 RDW-13.6 Plt Ct-210
[**2198-12-15**] 06:15AM BLOOD PT-14.4* PTT-28.0 INR(PT)-1.3*
[**2198-12-17**] 06:20AM BLOOD PT-16.3* PTT-31.3 INR(PT)-1.4*
[**2198-12-20**] 04:10PM BLOOD PT-16.7* PTT-35.1* INR(PT)-1.5*
[**2198-12-14**] 05:10AM BLOOD Glucose-76 UreaN-24* Creat-1.2* Na-142
K-3.7 Cl-108 HCO3-24 AnGap-14
[**2198-12-15**] 06:15AM BLOOD Glucose-79 UreaN-23* Creat-1.1 Na-143
K-3.6 Cl-108 HCO3-20* AnGap-19
[**2198-12-17**] 06:20AM BLOOD Glucose-151* UreaN-21* Creat-0.9 Na-143
K-3.4 Cl-112* HCO3-16* AnGap-18
[**2198-12-19**] 05:25AM BLOOD Glucose-176* UreaN-14 Creat-0.8 Na-142
K-3.6 Cl-109* HCO3-25 AnGap-12
[**2198-12-19**] 10:01AM BLOOD CK(CPK)-131
[**2198-12-19**] 09:40PM BLOOD CK(CPK)-121
[**2198-12-20**] 09:45AM BLOOD CK(CPK)-102
[**2198-12-19**] 10:01AM BLOOD CK-MB-7 cTropnT-0.35*
[**2198-12-19**] 05:20PM BLOOD CK-MB-6 cTropnT-0.38*
[**2198-12-19**] 09:40PM BLOOD CK-MB-5 cTropnT-0.42*
[**2198-12-20**] 09:45AM BLOOD CK-MB-5
[**2198-12-14**] 05:10AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2
[**2198-12-16**] 06:40AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1
[**2198-12-18**] 04:50AM BLOOD Calcium-8.1* Phos-1.6* Mg-1.8
[**2198-12-20**] 04:10PM BLOOD Calcium-8.8 Phos-3.0# Mg-1.7
[**2198-12-13**] 04:31AM BLOOD %HbA1c-6.0*
[**2198-12-13**] 04:31AM BLOOD Triglyc-83 HDL-46 CHOL/HD-3.7 LDLcalc-107
[**2198-12-17**] 06:47AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-100 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2198-12-14**] 09:15AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-0.2 pH-5.5 Leuks-NEG
[**2198-12-14**] 09:15AM URINE RBC->50 WBC-0 Bacteri-FEW Yeast-NONE
Epi-0
Na levels
[**12-24**], 8.45 am ,120
[**12-24**], 9.25 pm, 119
[**12-25**], 8.50 am, 120
[**12-25**], 9.30 pm, 121
[**12-26**], 3.35 am, 125
[**12-26**], 9.05 am, 125
Imaging:
CT head [**12-12**]:
1. 16 x 17-mm parenchymal hemorrhage in the central pons, with
mild mass
effect, but patent basilar cisterns. No other area of
intracranial
hemorrhage.
2. Chronic small vessel change.
CT [**12-13**]:
There is no change in a pontine hemorrhage
measuring 1.6 x 1.5 cm (2A:10). There is mild mass effect, but
the basilar
cisterns appear patent. There is no new site of hemorrhage
identified. There
is no shift of midline structures, or evidence of infarction.
There is
prominence of the ventricles and sulci consistent with
age-related parenchymal
involutional change. There is also a pattern of periventricular
hypodensity
consistent with chronic small vessel ischemic change. The
visualized
paranasal sinuses and soft tissues appear unremarkable.
IMPRESSION: No significant change in pontine hemorrhage.
CT [**12-14**]:
Unchanged pontine hemorrhage.
CT [**12-24**]
1. Decrease in size of pontine bleed.
2. Soft tissue prominence in the region of the anterior
communicating artery
may represent anterior communicating artery aneurysm which has
been stable
since [**2194**]; however, if clinically relevant, a CTA or MRA may be
considered
for further evaluation.
CT abdomen [**12-25**] (for placement of G tube)
pending at this time
CXR [**12-14**]
There is mild cardiomegaly. Left transvenous pacemaker leads
terminate in
standard position in the right atrium and right ventricle. Small
bilateral
pleural effusions are larger on the left side, unchanged from
prior studies.
Left lower lobe retrocardiac opacity has increased due to
increasing
atelectasis and an ill-defined faint opacity superior to the
heart is
consistent with aspiration given the provided clinical history.
CXR: [**12-16**]
As compared to the previous examination, the pre-existing small
left-sided pleural effusion has increased. Also increased is the
subsequent retrocardiac atelectasis and blunting of the left
costophrenic sinus. In the right lung, no change is seen.
Unchanged course and position of the pacemaker leads.
CXR [**12-24**]
IMPRESSION: Although left basilar aeration has improved
slightly, opacity at
the right base has slightly worsened, which could represent a
combination of
effusion, atelectasis, and/or infection.
TTE [**12-20**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with basal inferior
hypokinesis. The remaining segments contract normally (LVEF =
50%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets are moderately thickened.
There is moderate aortic valve stenosis (valve area 1.0-1.2cm2).
Mild (1+) aortic regurgitation is seen. Mild to moderate ([**12-29**]+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Moderate calcific aortic stenosis. Mild aortic
regurgitation. Mild to moderate mitral regurgitation. Mild
pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2195-10-16**],
aortic stenosis has progressed slightly (by velocities). There
is now mild aortic regurgitation. Regional wall motion
abnormality is similar on the two studies
Brief Hospital Course:
ICU stay-
Patient is a [**Age over 90 **]yo walker/cane dependent RHW with hx of
tachybrady syndrome s/p pacemaker and likely HTN given on
metoprolol who lives in assisted/independent living facility who
had increased weakness in legs over past 2 weeks without any hx
of falls or trauma and found to have central pontine hemorrhage
at OSH. Patient transferred here for further care but her
initial head CT unable to be uploaded because patient sent
withwrong patient's imaging. However, per report, it measured
12X19mm.
The patient was initially admitted to the ICU given concern of
the location of the bleed. Remarkably, excpet for mild
inattentiveness, the patient had a normal neurological exam.
Given her stability she was transferred to the floor on
[**2198-12-13**].
Floor stay [**12-13**]- [**12-26**]
Neuro
She was closely monitered for development of any new new
neurological signs or symptoms. She was found to drowsy and
confusded on [**12-14**], hence repeat CT scan as well as infective
work up was obtained -UA and CXR which showed lower zone opacity
on left side possibly aspiration. She was seen by Physical and
Occupational therapy who recommended a long term facility for
placement. She was noted to be more drowsy on [**12-24**], hence a
repeat CT head was done which did not show any change in her
bleed. Over all neurologically she remained stable during her
stay.
ID
She was diagnosed with pna on [**12-14**]. Infectious disease recs
were taken and she was started on broad spectrum antibiotics,
given her current ICU stay and high risk of aspiration. She is
allergic to penicillin and hence was started on meropenem,
vancomycin, flagyl IV. She never had fever and responded to IV
antibiotics, her mental status improved and hse became more
alert. She recieved a total of 7 days of antibiotics per ID
recs. Her repeat CXR on [**12-24**] did show a small opacity on RLZ
but it was thought to be atelactasis. She did not have clinical
signs of infection like fever, leucocytosis. This was discussed
with ID and it was decided to hold off on antibiotics and
moniter her clinically.
CVS
She had intermittent tachycardia (has known tachy-brady
syndrome). She was started on meteoprolol and IV metoprolol as
well prn tachycardia. On [**12-19**], she had transient but repetitive
episodes of tachycardia, following which she had mild troponin
leak (0.35-0.42), however CK and CKMB were normal. cardiology
consult was obtained and it was felt that her troponin leak is
mostly due to demand ischemia rather than infarct given normal
CKMB. She was not a candidate for anticoagulation given pontine
bleed and intervention ,given Code status and unfavourable
general medical condition. Aspirin 81 mg was started on [**12-20**]
given underlying cardiac condition. metoprolol was incraesed to
37.5 TID and she underwent 2 D ECHO for assesment of cardiac
function.
GI/Nutrition
Sheb had difficulty in swallow fucntion most likely as a result
of pontine bleed. She failed speech and swallow evaluation and
NG tube was attempted which was difficult owing to strong cough
reflex and absent/ mild gag response. She underwent IR guided NG
placement [**12-18**] which she pulled out and again underwent IR
guided placement on [**12-20**]. nutrition recs were followed for Tube
feeds for adequate calories and hydration. She was finally
considered for PEG tube which was placed on [**12-25**] for nutrition.
Fluids/electrolyes
She was noted to have hyponatremia on [**12-24**]. Her Na dropped from
130 to 120 over period of [**12-29**] days. However she did not have
change in her mental status from her baseline. Work up for
hyponatremia revealed possible SIADH as mechanism. medicine and
renal consults were obtained for management of hyponatremia who
suggested frequent Na checks, free fluid restriction. This
should be closely followed up after discharge. Her TSH was
slightly high and free T4 was ordered which is slightly high s/o
sick euthyroid syndrome
General care
She was monitered on telemerty, with regular neuro checks, DVT
prophy with SC heparin, Stress ulcer proph, PT/OT evaluation.
The goal of care was discussed with health care proxy and PCP
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 656**] and plan was formulated in accordnace with that.
Physical Exam at discharge-
drowsy, responds to verbal commands, she is usually oriented to
person and time and tells that she is in hospital but cannot
tell name of the hospital. Her comprehension is normal and
speech is fluent with intact repetition.
She does not have any other neurological deficts.
Issues pending at discharge-
1. Na needs to be followed closely and she needs to be on fluid
restriction, with Na checked every day for 3-4 days amd salt
tablets need to be adjusted as per na level and fluid status
2. Repeat Thyroid tests in [**4-2**] weeks
Medications on Admission:
1. Omeprazole 20mg daily
2. ASA 325mg daily
3. Metoprolol 25mg daily
4. Loperamide 2mg PRN
5. Lactulose PRN
6. Tylenol PRN
7. Furosemide 20mg PRN
8. Tums PRN
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection twice a day.
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO Q8H
(every 8 hours).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Sodium Chloride (Bulk) Granules Sig: One (1)
Miscellaneous [**Hospital1 **] (2 times a day) for 1 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 5277**] - [**Location (un) 745**]
Discharge Diagnosis:
1) Pontine hemorrhage
2) Hypertension
3) Pneumonia
4) Hyponatremia, secondary to SIADH
5) Tachybrady syndrome
6) Demand Ischemia
7) Hyperlipemia
Discharge Condition:
Mental Status:Confused - oriented to person, but not place,
fluent speach, no dysarthria, hypometric facial movements
Level of Consciousness: awake, intermittently drowsy arousable
Motor: antigravity throughout
Sensory: limited exam due to mental status
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
.
1) You were admitted for evaluation of stroke. You had CT/A scan
of your head which showed a hemorrhage in pontine area
(brainstem), likely due to a vascular malformation.
2) Please take your medicines as prescribed. please call 911 or
your doctor if you develop any concerning symptoms.
3) PENDING ISSUES AT DISCHARGE:
-Please have the sodium checked daily for 3-4 days and adjust
salt tabs as needed
-Please have repeat thyroid studies in [**4-2**] weeks
Followup Instructions:
Please follow up in neurology clinic as-
Scheduled Appointments :
Provider [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2199-1-16**] 3:00
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"5070",
"4019",
"2724",
"41401",
"4241",
"412",
"53081"
] |
Admission Date: [**2104-8-25**] Discharge Date: [**2104-8-27**]
Date of Birth: [**2069-5-6**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 35-year-old
male with type 1 diabetes mellitus who presented to an
outside hospital on [**8-25**] where he was found to have
hyperglycemia with blood glucose greater than 1000 and DKA.
The patient has multiple psychiatric problems and lives in a
group home. He took his insulin on the morning of [**8-22**] and
then left his group home without his medications to stay with
a friend. Over the weekend he attended a party where he
consumed approximately three drinks and in total was without
insulin for more than 72 hours. He presented to outside
hospital with lethargy and nausea and vomiting where he was
found to be in DKA. ABG showed PH of 7.35, PCO3 33, PO2 75.
He was admitted initially to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY: Insulin dependent diabetes mellitus,
schizo-affective disorder, bipolar disease, hypertension,
hypercholesterolemia, hypothyroidism secondary to Lithium.
ALLERGIES: No known drug allergies.
MEDICATIONS: NPH Insulin 32 units q a.m. and 12 units q
h.s., Regular insulin 2-14 units [**Hospital1 **] depending on blood sugar
level, Glucophage 500 mg po bid, Levoxyl 100 mg po q a.m.,
Zestril 10 mg po q a.m., MVI one po q a.m., Aspirin 325 mg po
q a.m., Lipitor 10 mg po q a.m., Depakote 1500 mg po bid,
Cogentin 0.5 mg po bid, Prolixin oral solution 5 mg po bid,
Prolixin 5 mg oral solution prn, Prolixin Depo injection q 2
weeks, last shot was more than one month ago.
SOCIAL HISTORY: Lives at group home, smokes 2-3 packs per
day, uses alcohol three times a week and has three drinks
each time he uses alcohol, remote history of Cocaine use.
PHYSICAL EXAMINATION: In general he was sleepy but arousable
and in no acute distress. Temperature 97.5, blood pressure
138/64, pulse 92, respirations 20, O2 saturation 97% on room
air. HEENT: Pupils are equal, round, and reactive to light,
oropharynx was clear. Neck supple, no lymphadenopathy.
Lungs clear to auscultation bilaterally with no rales or
wheezes. Heart, regular rate and rhythm without murmurs.
Abdomen soft, nontender, non distended, positive bowel
sounds. Extremities, no edema. Neuro, arousable, moves all
extremities, will not cooperate with further exam.
LABORATORY DATA: From outside hospital initially, white
blood cells 28.2, hematocrit 43.9, platelet count 345,000.
Differential, 87% polys, 8% lymphocytes, 5% monocytes. ABG
revealed PH of 7.14, PCO2 24, PO2 111. Initial Chem 7 showed
sodium 121, potassium 7.6, chloride 74, CO2 11, BUN 40,
creatinine 1.8 and glucose 1,098. This was repeated after
administration of insulin and the sodium was 135, potassium
5.0, chloride 88, CO2 12, BUN 37, creatinine 1.7 and glucose
657. Calcium 10.8, albumin 4.1, alkaline phosphatase 126,
AST 15, ALT 15, total bilirubin 0.6, moderate acetone,
Valproate level less than 3.0, ethanol level was less than
10. Repeat ABG performed at [**Hospital1 188**] showed PH 7.35, PCO3 33 and PO2 75 on room air. EKG
showed normal sinus rhythm at 108 beats per minute with
normal axis, normal intervals, moderate peaked T waves and no
other ST-T wave abnormalities. Chest x-ray from outside
hospital was negative by report.
IMPRESSION: This is a 35-year-old male with type 1 diabetes
who presented to an outside hospital with hyperglycemia and
hyperkalemia as well as DKA after refraining from taking
insulin for 72 hours.
HOSPITAL COURSE:
1. Endocrine: The patient's high glucose, low Ph, moderate
serum ketones and anion gap of 35 were consistent with DKA,
clearly precipitated by several days of insulin non
compliance. Repeat labs on arrival to [**Hospital1 190**] after one dose of 10 units of IV insulin and
three hourly doses of 6 units of IV insulin showed
significant improvement. The patient was treated in the
Medical Intensive Care Unit with an insulin drip at 4 units
per hour until the patient's glucose normalized and he was
then transitioned to subcu insulin. His Glucophage was
initially continued but on informal consultation with [**Hospital **]
Clinic, it was decided to discontinue this. On his last day
of hospitalization, his blood glucose ranged from 138 to 217.
We discharged him on the same insulin regimen that he was on
initially. The importance of his taking his insulin was
communicated to him.
We continued the patient's Levoxyl for hypothyroidism.
2. Fluids, Electrolytes & Nutrition: The patient tolerated
a diabetic diet. We repleted his phosphate. His potassium
normalized upon treatment with insulin.
3. Infectious Disease: It was noted that patient had
elevated white blood cell count. This was thought likely a
reactive leukocytosis given no signs, symptoms or evidence of
infection.
4. Psychiatry: Formal psychiatric consultation was obtained
due to his history as well as the fact that he seemed
unmotivated to care for his diabetes with regular
administration of insulin. With the help of the psychiatry
consultant, the patient agrees to make a contract with his
group home to ensure closer glucose monitoring and better
insulin compliance. A message was left with the patient's
primary psychiatrist who was on vacation at the time of this
hospitalization. It was thought that he was not psychotic
regarding his diabetes and was not intending to harm himself
by not taking his insulin. Therefore, there was no acute
need for inpatient psychiatric hospitalization and it was
thought that there was no contraindication to him being
discharged to the group home from which he came.
We continued the patient's Depakote and checked his Valproate
level. This was 45, just slightly subtherapeutic. We
continued the patient's Prolixin and Cogentin.
5. Cardiovascular: We continued the patient's Zestril,
Aspirin and Lipitor.
CONDITION ON DISCHARGE: Good.
DISCHARGE STATUS: Discharged to group home with instructions
to follow-up with his primary psychiatrist.
DISCHARGE DIAGNOSIS:
1. Diabetic ketoacidosis.
2. Medication non adherence.
3. Hypertension.
4. Schizo-affective disorder.
5. Hypothyroidism.
6. Hyperlipidemia.
7. Hypertension.
[**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**]
Dictated By:[**Doctor Last Name 34991**]
MEDQUIST36
D: [**2104-9-23**] 20:08
T: [**2104-9-27**] 08:04
JOB#: [**Job Number 108591**]
|
[
"4019",
"2724",
"2449"
] |
Admission Date: [**2149-10-12**] Discharge Date: [**2149-10-22**]
Date of Birth: [**2088-9-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
1. Tagged red blood cell scan
2. Colonoscopy
3. Upper endoscopy
4. Transthoracic echocardiography
5. Transesophageal echocardiography
History of Present Illness:
61 y M with a history of metastatic lung cancer to his right
hip, liver (with question as to whether the lung is primary)
being treated with carboplatin and gemcytabine (last dose 11/3)
who was in his usual state of health until [**2149-10-8**] when he began
to feel weak. He felt progressively weaker and felt dizzy on
[**2149-10-10**]. He had no shortness of breath or chest pain, nausea,
vomiting, abdominal pain or other symptoms. No falls. On
[**2149-10-11**] he had loose stool containing red blood clots. He had
previously never had so much bright red blood per rectum, but
states that he has had some since starting his chemotherapy. No
black or tarry stools, no hematemesis or hematuria. He went to
[**Hospital3 3583**], where he was found to have a Hct on
presentation of 13.4 (one week earlier it had been 34.) He was
in shock with SBP 70s, HR 130s. His platelets on admission were
10,000, and his WBC were 3.5. He underwent a tagged RBC scan
which reportedly revealed blood in the R side of the abdomen,
felt likely to be in the R colon, although not believed to be a
brisk or large bleed. His HR remained in the 110s as did his
SBP. He was transferred to the [**Hospital1 **] for a discussion of possible
IR embolization versus colonoscopy versus surgical options.
During his stay there he received 4u FFP (coags were reportedly
normal throughout), 9u PRBC and 14 bags of platelets. On
transfer his platelets were 54K, Hct 18K with one unit hung in
the ambulance, and WBC 2.8.
.
On [**2149-10-13**], he was admitted to the MICU with VS: T 100.2 BP
94/60 P 94-110 RR14, 100% on 2L. He received 3 U pRBC, with a
stable post-transfusion crit of 27-30 over the last 3 days. A
tagged RBC scan showed no evidence of active gastrointestinal
hemorrhage. He received a colonoscopy once his neutropenia ([**1-2**]
chemotherapy) resolved, which showed cecal ulcers (radiation vs.
ischemia vs. Crohn's), sigmoid diverticulosis, internal
hemmorhoids, but no bleeding. An EGD showed patchy gastritis,
few small erosions in duodenal bulb, believed to be unlikely to
rebleed. He was transferred to the floor for further management.
.
ROS: pt denies sob/cp/abd pain, n/v, MS complaints, F/C. No
other complaints.
Past Medical History:
- lung ca metastatic to R hip/liver: Oncologist = [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 50949**]
[**0-0-**]
- lymphoma in R groin lymph node s/p resection in [**2146**]
- s/p R lung lobectomy [**2146**]
- PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 47403**]
Social History:
The patient lives at home with his wife and one son. [**Name (NI) **] is a
retired nuclear plant worker. He has not smoked in the past 3
years, but has a prior 2pack per day history for "a long time."
He denies EtOH or other drug use.
Family History:
noncontributory
Physical Exam:
100.2, HR 96, BP 93/53, O2 100% on 2LNC, RR 22
GEN: NAD, pale, pleasant, conversant
HEENT: NCAT, conjunctivae pink, PERRLA, no OP injection
Neck: JVP flat, no LAD
Cor: s1s2, no r/g/m, rrr
Pulm: CTAB
Abd: NTND, +BS, no organomegaly
Ext: no c/c/e, w/w/p, 1+dp pulses bilat
Skin: no rashes, no stasis changes
Pertinent Results:
[**2149-10-12**] 10:56PM GLUCOSE-91 UREA N-25* CREAT-0.8 SODIUM-138
POTASSIUM-3.0* CHLORIDE-107 TOTAL CO2-25 ANION GAP-9
[**2149-10-12**] 10:56PM CALCIUM-6.2* PHOSPHATE-1.9* MAGNESIUM-1.5*
[**2149-10-12**] 10:56PM WBC-1.4* RBC-2.58* HGB-8.3* HCT-21.7* MCV-84
MCH-32.0 MCHC-38.0* RDW-14.2
[**2149-10-12**] 10:56PM NEUTS-40* BANDS-2 LYMPHS-47* MONOS-7 EOS-2
BASOS-0 ATYPS-2* METAS-0 MYELOS-0 NUC RBCS-1*
[**2149-10-12**] 10:56PM PLT SMR-VERY LOW PLT COUNT-56*
[**2149-10-12**] 10:56PM PT-13.3* PTT-29.0 INR(PT)-1.2*
[**2149-10-12**] 10:56PM GRAN CT-588*
.
Tagged RBC scan [**2149-10-13**]: IMPRESSION: No evidence of active
gastrointestinal hemorrhage. Additional delayed or repeat
imaging may be useful if the patient later shows clinical signs
of active bleeding.
.
EGD: Findings: Esophagus: Normal esophagus.
Stomach:
Mucosa: Patchy erythema and granularity of the mucosa were
noted in the antrum. These findings are compatible with patchy
gastritis.
Duodenum:
Mucosa: A few small erosins of the mucosa was noted in the
distal bulb and anterior bulb.
Impression: Erythema and granularity in the antrum compatible
with patchy gastritis
A few small erosins in the distal bulb and anterior bulb
Recommendations: Patient unlikely to rebleed from these lesions.
Check serology for H. pylori. Continue PPI.
.
Colonoscopy: Findings:
Protruding Lesions Grade 1 internal hemorrhoids were noted.
Excavated Lesions A few diverticula with small openings were
seen in the sigmoid colon.Diverticulosis appeared to be of mild
severity. Three ulcers ranging in size from 11 mm to 5 mm were
found in the cecum. They were not bleeding. Cold forceps
biopsies were performed for histology at the ulcers cecum.
Impression: Ulcers in the cecum (biopsy)
Diverticulosis of the sigmoid colon
Grade 1 internal hemorrhoids
Recommendations: Await patholgu. Lesion could be secondary to
ischemia, radiation damage or Crohn's disease
.
CXR [**2149-10-15**]: FINDINGS: Compared with 11/13, there is a new
vague opacity seen just lateral to the right hilar mass. This
could represent aspiration or infiltrate. The remainder of the
lung fields are grossly clear.
.
CT CHEST [**2152-10-18**]:
Findings are most consistent with pulmonary, hepatic, and
adrenal
metastatic disease with concomittant pulmonary lymphangitic
carcinomatosis.
Diffuse tiny lung nodules can also be seen with disseminated
infection. Bilateral pleural effusions. There is partial
collapse of the right middle lobe likely incident to airway
compression and narrowing.
[**2149-10-21**] 04:50AM BLOOD WBC-16.9* RBC-3.16* Hgb-9.9* Hct-27.9*
MCV-88 MCH-31.5 MCHC-35.6* RDW-15.6* Plt Ct-272
[**2149-10-20**] 05:15AM BLOOD Neuts-64 Bands-1 Lymphs-12* Monos-20*
Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-0
[**2149-10-21**] 04:50AM BLOOD Plt Ct-272
[**2149-10-21**] 04:50AM BLOOD Glucose-87 UreaN-7 Creat-0.5 Na-133 K-3.8
Cl-95* HCO3-29 AnGap-13
[**2149-10-21**] 04:50AM BLOOD Calcium-8.0* Phos-3.2 Mg-1.6
Brief Hospital Course:
# GI bleed: The patient presented initially to [**Hospital3 3583**]
with BRBPR, where he received blood products. A tagged RBC scan
suggested a right-sided colonic source. He arrived at the [**Hospital1 **]
with a hematocrit of 21.7 and received 3U of pRBCs. During his
stay at the [**Hospital1 **] he did not rebleed, and his Hct remained stable
at 27-30. An EGD showed patchy gastritis and a few small
erosions in duodenal bulb, which did not appear to be a likely
source of the bleeding. He was started on a PPI. H. pylori
serology was negative. Colonoscopy showed cecal ulcers, sigmoid
divertics, and internal hemmorhoids. Given the results of the
tagged RBC scan, the most likely source of bleeding seemed to be
the cecal ulcers ([**1-2**] radiation vs. ischemia vs. Crohn's).
Pathology from the colonoscopy was pending at the time of
discharge... In terms of coagulation status, the patient's
platelets were >50K during his stay at the [**Hospital1 **], with an upward
trend. His INR was 1.2-1.7 during his admission. Given his
abnormal coagulation studies, we held heparin for DVT
prophylaxis (he did wear pneumoboots). By the time of discharge
the patient's hematocrit was stable and he was asymptomatic.
.
# Pancytopenia. The patient had been pancytopenic [**1-2**]
gemcitabine. By report the patient received GCSF x 1 at [**Hospital1 3325**]. On admission to the [**Hospital1 **] his ANC was 588, but his white
count increased steadily, and by [**2149-10-14**] his ANC was 2090 and
WBCs were >3. His platelets on admission to the [**Hospital1 **] were 56, but
this count also increased over the next several days and was
>150 by the day of discharge. By the time of discharge, the
patient was no longer pancytopenic.
.
# Fever. After endoscopy, the patient had a fever at 101.2. He
developed a mild cough productive of yellow sputum, and a CXR
suggested an aspiration or infiltrate. In addition, the patient
had a Foley for several days and a U/A was mildly positive with
trace leuks, [**2-2**] RBC, [**5-10**] WBC, and few bacteria. A urine Cx
taken [**2149-10-15**] grew enterococci and coag neg staph. His foley
catheter was removed. We started him on a 10-day course of
levaquin 500 mg PO qd. Blood culture from [**2149-10-15**] was positive
(1/2 bottles) for MRSA (sensitive to rifampin, tetracycline,
gentamicin). He was started on vancomycin. Overnight he became
tachycardic and hypotensive with a few runs of NSVT.
Azithromycin and cefepime were added to his antibiotic regimen.
His vital signs responded well to small fluid boluses. However,
over the next 2 days his fever began to spike to 101.5.
Multiple repeat blood cultures were drawn and a CT of his chest
was obtained. There was a question of a post-obstructive
pneumonia that was discussed with radiology and interventional
pulmonology. Upon further discussion, this was ruled out and
deemed to be a small narrowing of the right middle lobe bronchus
with subsegmental collapse of the lobe. An infectious disease
consult was also obtained. They recommended IV vancomycin and
cefepime for 14 days and then subsequent blood cultures to
ensure that the bacteria was cleared from the blood. They also
recommended echocardiography of the heart (most TTE and TEE) in
order to make sure there were no vegetations on the heart
valves. Both a TTE and a TEE were performed which on preliminary
read showed no vegetations on the valves. The ID fellow will
follow up on these results and the blood cultures in clinic 2
weeks after discharge. Lastly, there was a discussion with the
general surgeons, the line nurses, the ID team and the primary
medicine team about removing the port cath. It was decided to
leave the port in place, continue IV antibiotics and repeat
cultures. If cultures continue to be positive after 2 weeks of
vancomycin and cefepime, port removal will need to be
re-addressed.
.
# R hip pain: The patient continued his outpatient regimen of
fentanyl and oxycontin. He continued to have significant pain
which impaired his ability to ambulate, so we increased his dose
of oxycontin to and treated him with oxycodone prn. By the time
of discharge, he felt that his pain was at its baseline. It was
recommended to his oncologist that he consider using a new
narcotic regimen and possibly incorporating methadone.
.
# Follow-up: The patient has been scheduled to follow up with Dr
[**Last Name (STitle) 11382**] on [**11-5**]. Prior to this appointment, he will
have 2 sets of blood cultures drawn on [**11-3**] and 6th. His
last dose of vancomycin and cefepime should be [**11-5**].
While at home, he will follow his temperatures and contact his
PMD if his temperature elevates above 100.0. He will have
follow up with his oncologist Dr [**Last Name (STitle) 50949**]. Dr [**Last Name (STitle) 50949**] was spoken
to on the day prior to discharge and informed about his course.
He will scheduled an outpatient follow up within the next week.
He will draw labs: vancomycin trough, cbc, ast, alt, and
creatinine q weekly and have them faxed to Dr [**Last Name (STitle) 11382**].
Medications on Admission:
oxycontin 140mg po bid
fentanyl tp 150mcg tp q72h
voltaren prn
last gemcitabine/carboplatin?, last [**2149-10-3**]
Discharge Medications:
1. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
2. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Seven (7)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*14 Capsule(s)* Refills:*0*
6. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain/fever.
8. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous
twice a day for 14 days.
Disp:*24 doses* Refills:*0*
9. Cefepime 2 g Piggyback Sig: Two (2) grams Intravenous every
twelve (12) hours for 14 days: continue for a total of 14 days
starting from [**2149-10-22**].
Disp:*28 doses* Refills:*0*
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: [**2-2**] ml
Intravenous daily and prn as needed: via SASH.
Disp:*30 ml* Refills:*0*
11. Normal Saline Flush 0.9 % Syringe Sig: Five (5) ml Injection
daily and prn: via SASH.
Disp:*30 syringes* Refills:*0*
12. wheelchair with elevating leg rest
Patient needs wheelchair with elevating leg rest to improve
functional mobility
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
Primary diagnosis:
1. Gastrointestinal bleed
2. Anemia
3. Colonic ulcers
4. Diverticulosis
5. Gastritis
6. Duodenal erosions
7. Bacteremia
.
Secondary diagnosis:
1. Lung cancer with metastasis to right hip and liver
2. Lymphoma s/p resection
3. s/p right lung lobectomy
Discharge Condition:
stable
Discharge Instructions:
You have been hospitalized for gastrointestinal bleeding. You
were transfused at [**Hospital3 3583**] and also at [**Hospital3 **]
Hospital. Your blood count (hematocrit) was stable after the
transfusions. You initially had a low white count and low
platelet count, but these counts recovered into the normal range
after a few days. Your bleeding was most likely from the right
side of your colon. A colonoscopy showed ulcers, diverticulosis
(small weakenings of the colon wall), and hemorrhoids. Pathology
results from the colonoscopy are still pending at the time of
your discharge. Dr. [**Last Name (STitle) 50949**] will follow up on the results with
you. An upper endoscopy showed mild inflammation in your stomach
and small erosions in your duodenum. You were given protonix, a
proton pump inhibitor, to treat the stomach inflammation.
.
You also had a fever and a cough. You were intially treated with
an antibiotic, levaquin, for the concern that this might be an
early lung infection, urinary tract infection, or infection in
your blood.
You then developed signs of an infection of your blood and your
blood cultures showed an infection. You were then prescribed
two new antibiotics Vancomycin and Cefipime which should be
continued for 2 weeks after discharge.
*** You should follow your daily temperatures at home and if
they rise above 100.0 you should call the ID fellow Dr [**Last Name (STitle) 11382**]
at [**Telephone/Fax (1) 3395**]. ***
Do call your doctor or return to the emergency room if you have
more bleeding, weakness, dizziness, chest pain, shortness of
breath, fever, chills, or other concerning symptoms.
Followup Instructions:
1. You have a scheduled appointment with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13076**], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2149-11-5**] 11:30. This appointment
is very important since she will be following up on your blood
cultures. She should also follow up on the final read of your
Transesophageal echocardiography from [**2149-10-22**].
2. You have been given 2 laboratory slips/ orders for blood
cultures for [**11-3**] and [**11-5**]. You can get these
labs drawn at the [**Hospital **] clinic in the [**Hospital Unit Name **] Basement Suite
G at [**Last Name (NamePattern1) 439**].
3. Dr [**Last Name (STitle) 50949**] will be contacting you to schedule an appointment
for the end of this week or beginning of next. Discuss with Dr
[**Last Name (STitle) 50949**] changing your pain management regimen. Consider possible
use of Methadone with fentanyl patch.
***You should have Dr [**Last Name (STitle) 50949**] draw the following labs weekly
including: Vancomycin trough, CBC, AST, ALT, and Creatinine.
Please fax the results to [**Telephone/Fax (1) 4591**].
|
[
"5990",
"42789",
"2851"
] |
Admission Date: [**2123-9-26**] Discharge Date: [**2123-9-28**]
Date of Birth: [**2071-2-5**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
etoh intoxication
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 52 yo male admitted yesterday to TSICU after
falling down the stairs in the setting of alcohol intoxication.
He was intubated for agitation to get C-spine imaging which was
negative. He self-extubated himself overnight and left AMA this
morning.
.
Since discharge, he drank a bottle of vodka. He was found int he
halls of his apartment building running around naket. His ETOH
is 319. He was given a banana bag.
.
He was found to be hypoxic to 90% on [**Last Name (LF) **], [**First Name3 (LF) **] was given
solumedrol, ceftriaxone, and levaquin, though his CXR was
negative. He was given haldol 25 mg IV for agitation. His QTC
was noted to be 444, so we was admitted to the ICU for
monitoring of his "QT prolongation".
.
Unable to obtain further history from patient due to
intoxication.
Past Medical History:
Alcohol abuse
H/o MI 7 years ago
Hypertension
Hepatitis C Virus
History of a positive PPD in [**5-19**]
Asymptomatic bradycardia
Depression
Anxiety
COPD
GERD
Hiatal Hernia
Social History:
Patient has a 40 pack year history of smoking. Drinks mutiple
bottles of alcohol daily. Denies any drug use or history of
IVDA. Has tatoos. Lives [**Street Address(1) 32165**] shelter.
Family History:
Denies any significant family history.
Physical Exam:
VS: RR 14, HR 120, BP 154/86, O2Sat 97% on 2LNC
Gen: moaning, cursing, in 4 point leather restraints
HEENT: pupils 4 mm, equal and reactive to light
CV: Tachycardic, no m/r/g
Pulm: Clear anteriorly, but limited due to patient moaning
Abd: soft, NT, ND, bowel sounds present
Ext: no peripheral edema, 4 point restraints
Neuro: moving all extremities, following commands, AxOx2 (does
not know where he is)
Pertinent Results:
[**2123-9-25**] 04:37PM FIBRINOGE-414*
[**2123-9-25**] 04:37PM PLT COUNT-270 LPLT-2+
[**2123-9-25**] 04:37PM PT-12.4 PTT-29.6 INR(PT)-1.0
[**2123-9-25**] 04:37PM WBC-9.1 RBC-5.54 HGB-16.9 HCT-47.3 MCV-85
MCH-30.5 MCHC-35.7* RDW-13.9
[**2123-9-25**] 04:37PM ASA-NEG ETHANOL-382* ACETMNPHN-6.6
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2123-9-25**] 04:37PM LIPASE-42
[**2123-9-25**] 04:37PM ALT(SGPT)-116* AST(SGOT)-162* ALK PHOS-72
AMYLASE-60 TOT BILI-0.3
[**2123-9-25**] 04:37PM estGFR-Using this
[**2123-9-25**] 04:37PM UREA N-15 CREAT-1.0
[**2123-9-25**] 04:52PM GLUCOSE-74 LACTATE-3.8* NA+-140 K+-11.4*
CL--97* TCO2-23
[**2123-9-25**] 04:52PM GLUCOSE-74 LACTATE-3.8* NA+-140 K+-11.4*
CL--97* TCO2-23
[**2123-9-25**] 05:50PM URINE RBC-<1 WBC-<1 BACTERIA-OCC YEAST-NONE
EPI-<1
[**2123-9-26**] 10:40PM ASA-NEG ETHANOL-319* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
CXR: PORTABLE SUPINE CHEST, ONE VIEW: Cardiomediastinal and
hilar contours are
unremarkable. Lung volumes are low. The lungs are clear without
focal
consolidation or pulmonary edema. There is no pleural effusion.
Osseous
structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Mr. [**Known lastname 7168**] is a 52 yo male with alcohol abuse, who was admitted
with alcohol intoxication, developed withdrawal symptoms, and
then left AMA.
.
Patient presents with acute alcohol intoxication. He was started
on Thiamine, MVI, and Diazepam per CIWA. He received benzos
every couple of hours for elevated CIWA. At 2200 on [**9-28**] the
patient chose to leave AMA. He stated his understanding that he
was leaving against medical advice and is at risk for seizures
or death.
.
The patient was continued on his home medications for seizure
d/o, hypertension and COPD during his hospitalization.
Medications on Admission:
Advair 500/50 [**Hospital1 **]
prilosec 20 [**Hospital1 **]
keppra 500 [**Hospital1 **]
buspar 15 [**Hospital1 **]
chantix 1 [**Hospital1 **]
trazodone 300 hs
hctz 25 daily
lactaid with meals
remeron 15 hs
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed for agitation.
4. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
6. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
EtOH intoxication
EtOH withdrawal
Discharge Condition:
Against medical advice
Discharge Instructions:
You are leaving AMA, you are at risk for seizures or death.
Followup Instructions:
Follow up with your doctor this week.
|
[
"2760",
"5180",
"496",
"4019",
"53081"
] |
Admission Date: [**2147-5-2**] Discharge Date: [**2147-5-4**]
Date of Birth: [**2109-11-26**] Sex: F
Service: SURGERY
Allergies:
No Drug Allergy Information on File
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
fulminant liver failure
Major Surgical or Invasive Procedure:
head bolt
History of Present Illness:
Mrs. [**Known lastname **] is a 37F with no significant PMH who presents
from an OSH with fulminant hepatic failure. She was in her USOH
until approximately [**4-26**]. She went out with some friends and
consumed substantial amounts of EtOH and used cocaine
intranasally. The next day, she developed myalgias and fatigue.
On [**4-28**], she had nausea, fevers and chills and later began
vomitting, no hematemesis. This continued for 2 days and was not
able to tolerate PO food. Her mother brought her to an OSH
because of her worsening fatigue/n/v and oliguria since [**4-29**].
Denies any melena/CP/SOB. Has mild ab discomfort. Denies any
recent travel. The pt reports taking unknown dietary
supplements.
She has been taking ibuprofen and acetaminophen intermittently,
although she can not rememeber the exact amounts (likely not
more
than 3g acetaminophen daily). She received acetylcysteine and
acyclovir at the OSh and was transferred for transplant
evaluation.
Past Medical History:
depression.anxiety
Social History:
Lives with 10 yo daughter. [**Name (NI) 1403**] at a day spa. Initiating
divorce proceedings [**12-31**] spousal infidelity. [**11-30**] PPD on and off
over last 15 years, reports [**11-30**] glasses of wine 4-5 times per
week, uses cocaine but never IV drugs.
Physical Exam:
Vitals: T: 95.9 BP: 138/84 P: 90 R: 19 SaO2: 99%RA
General: Drowsy, but easily rousable and attentive, A&Ox3,
appropriate, cooperative
HEENT: NCAT, PERRL, EOMI, no scleral icterus, MM dry
Neck: supple, no significant JVD
Pulmonary: CTAB
Cardiac: RRR, no murmurs,
Abdomen: soft, moderately tender throughout, no palpable
hepatosplenomegaly, no masses, no rebound/guarding
Extremities: no c/c/e, 2+ radial, DP pulses b/l
Skin: no rashes or lesions noted.
Pertinent Results:
[**2147-5-2**] 07:52AM BLOOD WBC-9.2 RBC-3.95* Hgb-12.7 Hct-36.0
MCV-91 MCH-32.1* MCHC-35.2* RDW-13.1 Plt Ct-125*
[**2147-5-4**] 09:46AM BLOOD WBC-4.0 RBC-2.82* Hgb-9.0* Hct-24.5*
MCV-87 MCH-31.9 MCHC-36.7* RDW-14.0 Plt Ct-48*
[**2147-5-2**] 07:52AM BLOOD PT-41.5* PTT-36.3* INR(PT)-4.5*
[**2147-5-3**] 02:57AM BLOOD PT-46.6* PTT-41.5* INR(PT)-5.2*
[**2147-5-3**] 12:01PM BLOOD PT-13.5* PTT-32.9 INR(PT)-1.2*
[**2147-5-4**] 09:46AM BLOOD PT-23.9* PTT-89.4* INR(PT)-2.3*
[**2147-5-2**] 07:52AM BLOOD Plt Ct-125*
[**2147-5-4**] 09:46AM BLOOD Plt Ct-48*
[**2147-5-2**] 07:52AM BLOOD Glucose-163* UreaN-47* Creat-7.3* Na-143
K-3.4 Cl-100 HCO3-19* AnGap-27*
[**2147-5-4**] 09:46AM BLOOD Glucose-106* UreaN-23* Creat-4.6* Na-139
K-3.5 Cl-93* HCO3-17* AnGap-33*
[**2147-5-2**] 07:52AM BLOOD ALT-6375* AST-3665* CK(CPK)-176*
AlkPhos-118* Amylase-32 TotBili-4.2*
[**2147-5-3**] 06:06AM BLOOD ALT-4870* AST-2127* LD(LDH)-1464*
AlkPhos-127* Amylase-32 TotBili-6.0*
[**2147-5-4**] 09:46AM BLOOD ALT-2085* AST-992* AlkPhos-131*
TotBili-6.4*
[**2147-5-2**] 07:52AM BLOOD calTIBC-211* Ferritn-GREATER TH TRF-162*
[**2147-5-2**] 07:52AM BLOOD Osmolal-311*
[**2147-5-4**] 01:35AM BLOOD Osmolal-302
[**2147-5-2**] 07:52AM BLOOD HBsAg-POSITIVE HBsAb-NEGATIVE HAV
Ab-POSITIVE IgM HBc-POSITIVE IgM HAV-NEGATIVE
[**2147-5-2**] 07:52AM BLOOD HIV Ab-NEGATIVE
[**2147-5-2**] 07:52AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2147-5-2**] 07:52AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6.0
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2147-5-2**] 07:52AM BLOOD HCV Ab-NEGATIVE
[**2147-5-2**] 08:55AM BLOOD Type-ART pO2-108* pCO2-33* pH-7.41
calTCO2-22 Base XS--2
[**2147-5-3**] 10:21AM BLOOD Type-ART Rates-24/ Tidal V-650 PEEP-5
FiO2-60 pO2-270* pCO2-23* pH-7.48* calTCO2-18* Base XS--3
Intubat-INTUBATED
[**2147-5-3**] 08:34PM BLOOD Type-ART Tidal V-650 PEEP-5 FiO2-60
pO2-234* pCO2-17* pH-7.45 calTCO2-12* Base XS--8
Intubat-INTUBATED
[**2147-5-4**] 09:58AM BLOOD Type-ART pO2-178* pCO2-26* pH-7.51*
calTCO2-21 Base XS-0
[**2147-5-2**] 08:55AM BLOOD Lactate-5.2*
[**2147-5-3**] 08:34PM BLOOD Lactate-11.2*
[**2147-5-4**] 09:58AM BLOOD Glucose-99 Lactate-7.4*
[**2147-5-2**] 08:15AM URINE RBC-10* WBC-27* Bacteri-FEW Yeast-NONE
Epi-8
[**2147-5-2**] 08:15AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-300 Ketone-10 Bilirub-MOD Urobiln-1 pH-6.0 Leuks-TR
[**2147-5-2**] 08:15AM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.018
[**2147-5-2**] 08:15AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
CT HEAD W/O CONTRAST [**2147-5-3**] 6:47 AM
CT HEAD W/O CONTRAST
Reason: evaluate for cerebral edema
IMPRESSION: No definite evidence for cerebral edema or other
acute intracranial process. However, the study is not sensitive
for mild or early cerebral edema and followup would be
recommended as clinically indicated.
BRAIN SCAN [**2147-5-4**]
BRAIN SCAN
Reason: 37 YEAR OLD WOMAN WITH FULMINANT HEPATIC FAILURE
RADIOPHARMECEUTICAL DATA:
24.6 mCi Tc-[**Age over 90 **]m Neurolite ([**2147-5-4**]);
HISTORY: 37 year-old woman with fulminant hepatic failure -
Please assess brain
perfusion in the setting of increased ICP.
INTERPRETATION: Following the intaveous injection of 24.6 mCi
Tc-[**Age over 90 **]m Neurolite,
dynamic flow and static images of the brain in multiple
projections were
obtained. There is no scintigraphic evidence of perfusion to the
cerebral
cortex.
The perfusion abnormalities noted above are consistent with
brain death.
IMPRESSION: Absent perfusion to the cerebral cortex on
scintigraphy is
consistent with the clinical history of brain death.
Brief Hospital Course:
ON admission patient had full serologies, labs, etc. drawn, echo
and liver u/s in anticipation of possible need for transplant.
She was sleepy but arousable all day, still not making urine.
Hepatology, renal, ID, and neurosurg consults were all obtained.
Overnight from [**Date range (1) 5568**] her mental status deteriorated, and she
was urgently intubated and sedated. In the am she had an HD line
place and was started on CVVH. A Head CT showed diffuse
cerebral edema and a head bolt was also placed that am for ICP
monitoring. Initial ICP was in the 30s but then remained in the
20s to high teens throughout the day. The patient was placed on
the transplant list as status 1 that day. That 2nd night of [**5-3**]
she deteriorated ON, had ICPs in the 40s, hypertensive. Was
placed in a pentobarb coma and started on mannitol in an effort
to decrease her ICPs. ICPs have been in the teens since. Head
CT showed worsening cerebral edema. Also, pupils were fixed and
dilated in the morning of [**5-4**], a change from bilaterally
reactive only 12 hours earlier. Neurology consult was then also
obtained for prognosis and her neurological condition. Brain
scan and EEG were c/w brain death. The family had been present
throughout. There was a family meeting with the transplant
attending and the decision was made to withdrawe care. The
patient expired at 1340 on [**2147-5-4**] with family present.
Discharge Disposition:
Expired
Discharge Diagnosis:
fulminant hepatic failure from hepatitis B
Discharge Condition:
death
Completed by:[**2147-5-4**]
|
[
"5849",
"51881",
"2762",
"311"
] |
Admission Date: [**2108-4-8**] Discharge Date: [**2108-5-2**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
right shoulder twitching, altered
mentation
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
The patient is a [**Age over 90 **] year old woman with a recent history of
frequent seizures with right face and shoulder twitching who
returns to [**Hospital1 18**] with reports of altered mentation and
recurrence
of right shoulder twitches.
Her history from her recent admission is as follows: on [**2108-2-18**]
she was found down at her residence and was noted to be
bradycardic, hypotensive, hypothermic, and lethargic. She was
transported to an ED at Upstate [**Location (un) **] Hospital in NY where
she had a cardiopulmonary arrest and was intubated and
resuscitated. The intubation was difficult and she was found to
have a mediastinal mass (multinodular goiter with papillary
microcarcinoma, which was removed). She had a complicated
hospital course with hospital-associated pneumonia, lung
collapse
s/p bronchoscopy, sepsis, corneal abrasion/chemosis,
perioperative anemia from blood loss, and then confusion. She
was
started on quetiapine initially for suspected ICU-related
delirium. However, she started showing clinical signs of
seizures
(sudden behavioral arrest, blank stare, eye deviation to the
left
and down) which resolved with low dose of lorazepam. Despite
reportedly unremarkable head imaging, she was thought to
potentially has PRES (unclear what the blood pressure
measurements were at the time). She was started on Levetiracetam
750 mg [**Hospital1 **] for seizure prevention. An EEG done at that time
reportedly suggested potential epileptiform foci but no seizures
were seen. She was discharged to a rehab but per her family did
not return to her prior highly functional baseline mental
status.
On [**2108-3-21**], she was even more lethargic than usual and did not
respond promptly to sternal rub. She was observed as having
right
face and right shoulder twitches with associated bowel/bladder
incontinence which ceased with diazepam 2.5 mg given twice. She
had a normal blood sugar of 81 at that time and otherwise normal
vital signs after the episode. She was transferred to
[**Hospital1 **]
for further management where she was given two loading doses of
Fosphenytoin 500 mg with some improvement in the focal motor
activity. Neurology was consulted there and recommended
increasing Levetiracetam to 1000 mg [**Hospital1 **] and continuing
Phenytoin.
She had an unremarkable NCHCT. She was found to have a UTI and
was started on Ceftriaxone on [**3-21**]. She was thought to
potentially have pneumonia as well, but chest imaging did not
reveal an infiltrate so this was stopped. An EEG was obtained
which potentially showed frequent left parasagittal epileptiform
discharges, so she was transferred to [**Hospital1 18**] for further care.
Upon arrival, her mental status was already improving, so
further
changes to medications were not made at that time. Her EEG
showed
frequent GPEDS and PLEDs. She continue to improve in mental
status, eventually was transitioned to a single [**Doctor Last Name 360**] again
(Levetiracetam 1000 [**Hospital1 **]), and was sent to [**Hospital 38**] Rehab in
stable condition.
Past Medical History:
[] Neurologic - Seizures (s/p cardiac arrest, ? hypoxic brain
injury), Recent ? Posterior Reversible Leukoencephalopathy
Syndrome (clinical diagnosis at onset of seizures)
[] MSK - Left hip fracture (s/p ORIF)
[] Cardiovascular - Recent cardiac arrest, HTN, HL, reportedly
CAD
[] Pulmonary - Recent hypoxic respiratory failure
[] Endocrine - Multinodular goiter with papillary carcinoma (s/p
resection, discovered during difficult intubation)
[] Ophthalmologic - Corneal abrasion/chemosis
Social History:
Until recently living independently, driving. Previously at [**Location (un) 22092**] on the [**Doctor Last Name **] but was at [**Hospital 38**] rehab post-[**Hospital1 **]
discharge. No tobacco, ETOH, or illicit drug use.
Family History:
Ovarian cancer (mother)
Physical Exam:
At admission:
VS T: 98.7 HR: 67 BP: 123/64 RR: 17 SaO2: 100% RA
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Lethargic, but easily arouses to voice and
keeps her eyes open for about a minute if continuously
stimulated
by voice or non-noxious stimuli. Smiles. Inattentive. Follows
midline commands (opens/closes eyes, sticks out tongue) but not
appendicular commands consistently. No verbalization.
- Cranial Nerves - [II] PERRL 3->2 brisk. VF full to threat.
[III, IV, VI] Tracks to the left but has difficult crossing
midline to the right. [V] Corneals present bilaterally. [VII] No
facial asymmetry at rest. [XII] Tongue midline.
- Motor - No tremor or asterixis or myoclonus currently. Extends
RUE to noxious. Flexion withdraws LUE to noxious. Triple flexes
both LE to noxious, R > L.
- Sensory - Response to noxious all four extremities.
- Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Gastroc]
L 2 2 2 2 2
R 2 2 2 2 1
Plantar response extensor bilaterally.
- Coordination - Unable to assess at the time of examination.
- Gait - Unable to assess at the time of examination.
DISCHARGE:
deceased
Pertinent Results:
[**2108-4-8**] 04:20PM BLOOD WBC-7.1 RBC-3.73* Hgb-11.2* Hct-36.7
MCV-98 MCH-30.0 MCHC-30.5* RDW-15.7* Plt Ct-455*
[**2108-4-9**] 06:20AM BLOOD WBC-4.0 RBC-3.12* Hgb-9.6* Hct-30.6*
MCV-98 MCH-30.7 MCHC-31.4 RDW-15.8* Plt Ct-345
[**2108-4-8**] 04:20PM BLOOD Neuts-75.4* Lymphs-15.8* Monos-5.2
Eos-3.4 Baso-0.2
[**2108-4-9**] 12:20PM BLOOD PT-11.2 PTT-64.5* INR(PT)-1.0
[**2108-4-8**] 04:20PM BLOOD Glucose-64* UreaN-16 Creat-0.8 Na-145
K-4.8 Cl-109* HCO3-20* AnGap-21*
[**2108-4-9**] 12:20PM BLOOD ALT-13 AST-26 CK(CPK)-103 AlkPhos-113*
TotBili-0.3
[**2108-4-9**] 06:20AM BLOOD CK-MB-8 cTropnT-0.13*
[**2108-4-9**] 12:20PM BLOOD CK-MB-15* MB Indx-14.6* cTropnT-0.20*
[**2108-4-8**] 04:20PM BLOOD Calcium-10.4* Phos-2.9 Mg-1.5*
[**2108-4-9**] 06:20AM BLOOD Phenyto-16.7
[**2108-4-9**] 06:23AM BLOOD Phenyto-18.7
[**2108-4-9**] 02:15PM BLOOD Type-ART pO2-365* pCO2-39 pH-7.37
calTCO2-23 Base XS--2
[**2108-4-8**] 05:20PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.012
[**2108-4-8**] 05:20PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2108-4-8**] 05:20PM URINE RBC-10* WBC-61* Bacteri-FEW Yeast-FEW
Epi-0
[**2108-4-8**] 05:20PM URINE CastHy-4*
[**2108-4-9**] 02:07PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2108-4-9**] 02:07PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2108-4-9**] 02:07PM URINE RBC-3* WBC-8* Bacteri-FEW Yeast-RARE
Epi-0
[**2108-4-9**] 02:07PM URINE CastHy-19*
MICRO data:
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
[**4-8**] CXR:
FINDINGS: Single portable frontal chest x-ray demonstrates no
acute
intrathoracic process. Blunting of the costophrenic angles with
fluid seen in the minor fissure represents trace bilateral
pleural effusions which are unchanged from prior study. The
cardiac silhouette is enlarged with stable left ventricular
predominance. Calcifications are again noted within the aortic
arch, as are clips within the left neck. There is no
pneumothorax. There are no suspicious osseous lesions.
IMPRESSION: Probable tiny bilateral pleural effusions, unchanged
from prior. No acute intrathoracic process.
[**4-9**] CXR:
IMPRESSION: AP chest compared to [**4-8**] at 4:21 p.m.:
New endotracheal tube ends at the level of the aortic apex,
between 4.5 cm from the carina, in standard placement. Lungs are
low in volume but clear. Moderate cardiomegaly is stable. There
is no pleural abnormality or evidence of central lymph node
enlargement. Thoracic aorta is heavily calcified but not focally
dilated.
[**4-9**] NCHCT:
FINDINGS: There is mild brain atrophy seen. There is no evidence
of midline shift or hydrocephalus. No evidence of intra- or
extra-axial hemorrhage seen.
IMPRESSION: No acute abnormalities.
MICU imaging:
CXR [**4-19**]:NG tube tip is out of view below the diaphragm likely
in the stomach. ET tube tip is in the standard position 3.9 cm
above the carina. Left PICC tip is in the lower SVC. There is
no pneumothorax. Moderate-to-large right and small-to- moderate
left pleural effusion are grossly unchanged allowing the
difference in positioning of the patient. Cardiomediastinal
contours are unchanged and there is mild vascular congestion.
CXR [**4-20**]: Endotracheal tube tip is 4 cm above the carina,
orogastric tube ends into the stomach, and left-sided PICC line
tip is in lower SVC. Since [**2108-4-19**], mild right pleural
effusion has improved, while left lower lung opacity, probably a
combination of effusion and atelectasis is better. Mild
pulmonary vascular engorgement is similar. Mildly enlarged
heart size, mediastinal and hilar contours are unchanged. No
new discrete opacities in the lungs
CXR [**4-21**]: IMPRESSION:
An enteric tube follows a course similar to the enteric tube in
place
yesterday, ending in the left upper quadrant, presumably but not
definitively in the stomach. There is no pneumothorax. Left
PIC line ends low in the SVC. Moderate cardiomegaly and small
bilateral pleural effusions have increased. Atelectasis at both
lung bases is stable.
Brief Hospital Course:
Ms. [**Known lastname 110651**] is a [**Age over 90 **]F with hx of cardiopulmonary arrest c/b
seizures presents from rehab with unresponsiveness and muscle
twitches concerning for seizure activity. Found to have a UTI
which likely lowered seizure threshold. Shortly after admission
patient was seen to have ongoing twitching despite increase
keppra dose and was loaded with Fosphenytoin with resultant
hypotension/bradycardia and transfer to the NeuroICU.
Neuro ICU course:
In the NeuroICU, she was intubated and started on Levophed for
hypotension. Neuro exam significant for increased level of
arousal since starting AEDs, but has since declined again. She
continues to have decreased movement on the left compared to
RUE. NCHCT unrevealing, EEG shows PLEDs. On [**4-19**] the patient
continued to be lethargic. She was noted to be tachypneic and O2
sats decreased from 99% on RA to 82%. Face mask and then
non-rebreather were placed initially with good response, but
again decreased to 79% on non-rebreather. Anesthesia was called
stat and the patient was intubated prior to transfer to MICU for
further care. The patient's son was called prior to intubation
and he confirmed full code.
# Respiratory failure: While in the MICU, the patient was
experiencing hypoxic respiratory failure precipitated by volume
overload evidenced by history of IVF administration and presence
of pleural effusions, improving with diuresis. Oxygenation
improved with diuresis, but AMS may have led to airway
compromise as she was minimally responsive off of sedation.
Successfully extubated on [**4-21**] and maintained on face mask for
24 hours prior to call out from the MICU.
On the floor, the patient was maintained on 40% face mask. She
initially remained DNR, but ok to intubate, but after
reassessing goals of care with the patient's son [**Name (NI) 382**], she was
made DNR/DNI and transitioned to CMO. Face mask was continued
for comfort.
# PNA - patient spiked a temperature to 101 on morning of [**4-20**].
Patient was empirically started on vanc/cefepime on [**4-20**] for
HCAP and potentially ventilator associated PNA. Sputum gram
stain grew out GPCs, and culture grew coagulase positive staph
aureus. Patient was continued on vanc/cefepime.
The patient's antibiotics were discontinued on the medicine
floor after she was made CMO.
# Hypotension: Patient has had intermittent hypotensive episodes
treated with gentle fluid bolus and minimal pressor requirement.
Weaned off pressors on [**4-20**]. Likely in the setting of sepsis
from PNA. Patient was treated with antibioitcs as above.
Patient was normotensive prior to transfer from MICU and
remained normotensive on the floor.
# Flash Pulmonary Edema: Prior to unit transfer, patient
received 2L IVF on the floor, overnight IVF and an additional
liter of IVF from meds given on the day of transfer. She
developed acute respiratory distress with sats to low 80's on
NRB. CXR showed worsening pleural effusions and pulmonary edema.
She received 20mg of IV lasix, was intubated, and transferred to
the unit. Recent Echo showed mild MR [**First Name (Titles) **] [**Last Name (Titles) **] 60%. Etiology of
pulmonary edema may be fluid overload in the setting of
diastolic dysfunction vs. acute MI, however CE down from
previous so unlikely. Patient underwent gentle diruresis and
respiratory status improved.
While on the floor, the patient was gently diuresed. However,
this was also stopped once the patient was made CMO.
# Seizure disorder: Patient is on valproate and levetiracetam
for seizure prophylaxis. She is also on continual EEG
monitoring. Balanced the therapeutic value of AED's with the
side affect of sedation/AMS. Neuro continued to follow the
patient while on the floor and decreased her medication doses.
Once she was made CMO, her AED's were converted to IV and were
continued for her comfort.
# h/o Cardiac arrest with anoxic injury: Patient had cardiac
arrest in [**Month (only) 958**] of this year with anoxic injury and subsequent
development of seizure disorder. Etiology is unclear but cards
eval considered prolonged QT-syndrome. QT prolonging agents
were avoided during this hospitalization.
# Hypernatremia: Patient with mildly elevated sodium levels
while in the MICU. Free water deficit calculated to be 1L. Was
treated with gentle D5W hydration. While on the floor, her
sodium levels remained within normal limits.
# Goals of care: Patient has a poor prognosis from a medical
standpoint given the recent cardiac arrest and complicated
hospital course involving three intubations and ICU admissions
over the past few months. Discussed goals of care with son, and
the likely negative outcome of a repeat cardiac arrest and
resuscitation would be outside of patient's wishes, and agrees
to DNR. The patient was ultimately also transitioned to DNI and
she was made CMO. Pall care consult was also obtained to help
optimize patient comfort.
Medications on Admission:
ASA 325 Daily
Levetiracetam 1000 [**Hospital1 **] (solution),
Metoprolol tartrate 25 [**Hospital1 **],
Bisacodyl 10 daily,
Heparin SC, Potassium 40 mEq daily,
Acetaminophen PRN, Docusate/Senna, Multivitamin
Discharge Medications:
NONE
Discharge Disposition:
Expired
Discharge Diagnosis:
primary diagnosis:
seizure disorder
hypoxic respiratory failure
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2108-5-3**]
|
[
"51881",
"5990",
"5119",
"2760",
"2762",
"4019",
"2724",
"2859",
"41401"
] |
Admission Date: [**2141-9-17**] Discharge Date: [**2141-9-20**]
Date of Birth: [**2063-7-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
diarrhea, vomiting, found to have elevated creatinine at primary
care physician's office
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr [**Known lastname **] is a 77 y/o African-American male with PMHx of
hypertension, gout on colchicine, osteoarthritis, and heavy
alcohol consumption who has recently been seen for nausea and
diarrhea, and found to have new acute renal failure on his labs.
.
Per the patient's history, he has had diarrhea off-and on since
starting colchicine, but this has been progressively worse over
the last 3-4 weeks with frequent bowel movements following meals
and also nocturnal bowel movements. He has had no bloody bowel
movements, nor melena though he reports them as darkened. He
also has had some nausea/vomiting following certain foods that
has been increasing in severity/frequency, but it not a
consistent feature. No hematemesis. This has also been over the
last month. He reports a 30 pound weight loss over the last 4
months with decreased appetite. He has also been having chronic
knee pain off and on for at least the last 5 years, either gouty
or chronic osteoarthritis (has had a knee replacement in the
past).
.
ROS is otherwise notable for mild dyspnea on exertion that is
not acutely new, and right leg>left leg that is old as well. He
reports pain on digital rectal exam and pain on bowel movement,
some prostatic symptoms of nocturia and frequency, but no
dysuria. He has had no fevers, headache, visual changes, or
abdominal pain.
.
In the ED, initial VS: 09:40 97.8 103 61/41 16 99, BP
verified and remained low though he was mentating well. He was
given 5L of crystalloid with improvement in HR to 60s, though
with BPs that were still marginal. Foley catheter was inserted
initially with little return, later putting out 300cc of clear
urine. CXR was performed without e/o pneumonia. He was guaiac
negative in the ED, though recently had been guaiac positive in
his PCP's office.
Past Medical History:
- Hypertension
- osteoporosis, s/p total knee replacement in left knee several
decades ago
- history of heavy alcohol consumption
- history of gout
- questionable depression
Social History:
Retired. Quit smoking 12 years ago. Drinks a pint of whiskey and
2 beers a day, but quit last Wednesday. CAGE questions negative.
Denies illicit drugs.
Family History:
Reports history of hypertension but no renal disease/disorders.
Physical Exam:
Vitals: T: 97.9, BP: 149/70, P: 61, RR: 22, O2sat: 97% RA
.
GENERAL: NAD, comfortable, laying in bed.
HEENT: NCAT, dry mucous membranes. Neck supply with no JVD.
CARDIAC: RRR with no m/r/g. Gynecomastia noted.
LUNG: CTA bilaterally with no w/r/r.
ABDOMEN: Soft, non-tender, non-distended, +BS in all 4
quadrants.
EXT: no pedal edema noted. Mild enlargement of right lower leg
compared to left, without overlying erythema or tenderness. No
palpable cords. Negative [**Last Name (un) **] sign.
NEURO: 5/5 strength in all 4 extremities. No asterixis.
DERM: No caput medusa. No capillary angiomas. No palmar
erythema.
Pertinent Results:
CBC:
[**2141-9-16**] 09:00AM BLOOD WBC-8.6 RBC-3.68* Hgb-11.2* Hct-34.2*
MCV-93 MCH-30.4 MCHC-32.6 RDW-14.5 Plt Ct-209
[**2141-9-17**] 09:50AM BLOOD WBC-11.3* RBC-3.60* Hgb-11.1* Hct-33.8*
MCV-94 MCH-30.8 MCHC-32.9 RDW-14.0 Plt Ct-225
[**2141-9-17**] 01:21PM BLOOD WBC-10.1 RBC-3.26* Hgb-10.2* Hct-31.0*
MCV-95 MCH-31.2 MCHC-32.8 RDW-14.2 Plt Ct-183
[**2141-9-17**] 11:09PM BLOOD WBC-9.7 RBC-3.26* Hgb-10.2* Hct-30.0*
MCV-92 MCH-31.4 MCHC-34.1 RDW-14.2 Plt Ct-189
[**2141-9-18**] 06:08AM BLOOD WBC-9.2 RBC-3.40* Hgb-10.1* Hct-31.2*
MCV-92 MCH-29.8 MCHC-32.4 RDW-14.4 Plt Ct-196
[**2141-9-19**] 06:00AM BLOOD WBC-11.7* RBC-3.43* Hgb-10.2* Hct-32.1*
MCV-94 MCH-29.7 MCHC-31.7 RDW-14.5 Plt Ct-197
[**2141-9-20**] 06:20AM BLOOD WBC-13.2* RBC-3.23* Hgb-9.9* Hct-30.9*
MCV-96 MCH-30.7 MCHC-32.1 RDW-14.1 Plt Ct-174
.
DIFFERENTIAL:
[**2141-9-17**] 09:50AM BLOOD Neuts-69.5 Lymphs-20.3 Monos-6.6 Eos-3.0
Baso-0.7
[**2141-9-16**] 09:00AM BLOOD Plt Ct-209
.
COAGULATION PROFILE:
[**2141-9-17**] 09:50AM BLOOD PT-14.4* PTT-31.5 INR(PT)-1.3*
[**2141-9-17**] 01:21PM BLOOD PT-15.1* PTT-33.1 INR(PT)-1.3*
[**2141-9-18**] 06:08AM BLOOD PT-14.8* PTT-32.3 INR(PT)-1.3*
[**2141-9-19**] 06:00AM BLOOD PT-15.7* PTT-33.9 INR(PT)-1.4*
[**2141-9-20**] 06:20AM BLOOD PT-15.8* PTT-34.5 INR(PT)-1.4*
.
ELECTROLYTES:
[**2141-9-16**] 09:00AM BLOOD UreaN-46* Creat-5.2*# Na-138 K-2.9* Cl-98
HCO3-22 AnGap-21*
[**2141-9-17**] 09:50AM BLOOD Glucose-124* UreaN-51* Creat-6.5*# Na-137
K-3.0* Cl-98 HCO3-24 AnGap-18
[**2141-9-17**] 01:21PM BLOOD Glucose-124* UreaN-44* Creat-4.9*# Na-138
K-3.3 Cl-106 HCO3-22 AnGap-13
[**2141-9-17**] 11:09PM BLOOD Glucose-114* UreaN-38* Creat-3.7*# Na-144
K-3.2* Cl-114* HCO3-20* AnGap-13
[**2141-9-18**] 06:08AM BLOOD Glucose-101 UreaN-32* Creat-2.8* Na-148*
K-3.4 Cl-115* HCO3-21* AnGap-15
[**2141-9-18**] 05:19PM BLOOD Glucose-112* UreaN-26* Creat-2.0* Na-148*
K-3.6 Cl-115* HCO3-25 AnGap-12
[**2141-9-19**] 06:00AM BLOOD Glucose-417* UreaN-17 Creat-1.4* Na-143
K-3.2* Cl-111* HCO3-23 AnGap-12
[**2141-9-19**] 07:15PM BLOOD Glucose-116* UreaN-13 Creat-1.3* Na-147*
K-4.5 Cl-112* HCO3-27 AnGap-13
[**2141-9-20**] 06:20AM BLOOD Glucose-91 UreaN-12 Creat-1.3* Na-148*
K-4.3 Cl-112* HCO3-29 AnGap-11
[**2141-9-17**] 09:50AM BLOOD Albumin-3.2* Calcium-8.5 Phos-4.1 Mg-1.5*
[**2141-9-20**] 06:20AM BLOOD Calcium-7.7* Phos-2.7 Mg-1.5*
UricAcd-8.8*
.
LIVER ENZYMES:
[**2141-9-16**] 09:00AM BLOOD TotBili-1.3 DirBili-0.7* IndBili-0.6
[**2141-9-17**] 09:50AM BLOOD ALT-43* AST-42* CK(CPK)-159 AlkPhos-120*
TotBili-1.2
[**2141-9-17**] 01:21PM BLOOD ALT-37 AST-40 LD(LDH)-189 AlkPhos-103
TotBili-1.1
[**2141-9-16**] 09:00AM BLOOD Lipase-34
.
CARDIAC ENZYMES:
[**2141-9-17**] 09:50AM BLOOD CK-MB-3
[**2141-9-17**] 09:50AM BLOOD cTropnT-0.04*
.
IRON STUDIES:
[**2141-9-16**] 09:00AM BLOOD calTIBC-142* VitB12-1434* Folate-9.2
Ferritn-GREATER TH TRF-109*
.
[**2141-9-16**] 09:00AM BLOOD %HbA1c-5.3
[**2141-9-17**] 01:21PM BLOOD TSH-1.1
[**2141-9-16**] 09:00AM BLOOD PSA-0.6
[**2141-9-17**] 10:05AM BLOOD Lactate-3.6* K-3.8
.
URINE DIPSTICK URINALYSIS Blood Nit Prot Gluc Ket Bili Urob pH
Leuks
[**2141-9-15**] 03:10PM NEG NEG 30 NEG NEG NEG NEG 8.5* LG
.
RBC WBC Bacteri Yeast Epi TransE RenalEp
[**2141-9-15**] 03:10PM 0 43* MANY NONE 1
.
[**2141-9-17**] 12:05PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005
[**2141-9-17**] 12:05PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2141-9-17**] 12:05PM URINE RBC-[**2-16**]* WBC-[**11-3**]* Bacteri-MOD
Yeast-NONE Epi-0-2
[**2141-9-17**] 01:21PM URINE RBC-[**2-16**]* WBC-[**5-24**]* Bacteri-RARE
Yeast-NONE Epi-0-2
[**2141-9-17**] 01:21PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2141-9-17**] 01:21PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2141-9-17**] 12:05PM URINE CastHy-0-2
[**2141-9-17**] 01:21PM URINE AmorphX-FEW
[**2141-9-17**] 01:21PM URINE Mucous-FEW
[**2141-9-17**] 12:05PM URINE Mucous-FEW
[**2141-9-17**] 01:21PM URINE Eos-POSITIVE
[**2141-9-17**] 01:21PM URINE Hours-RANDOM Creat-32 Na-65 Cl-66
TotProt-8 Prot/Cr-0.3*
[**2141-9-17**] 01:21PM URINE Osmolal-200
[**2141-9-19**] 03:57PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2141-9-19**] 03:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2141-9-19**] 03:57PM URINE Hours-RANDOM UreaN-386 Creat-72 Na-97
.
Triple Phosphate Crystals MANY
.
MICROBIOLOGY:
Blood Culture ([**2141-9-17**], [**2141-9-19**]): pending
.
URINE CULTURE (Final [**2141-9-19**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in MCG/ML
_______________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
STUDIES ([**2141-9-17**]): Urine sediment. Pyuria without casts
.
Stool ([**2141-9-19**]):
FECAL CULTURE (Pending):
-CAMPYLOBACTER CULTURE (Pending):
-FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2141-9-20**]):
-NO E.COLI 0157:H7 FOUND.
-CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-9-20**]):
-Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
ECG ([**2141-9-17**]):
Artifact is present. Sinus rhythm. Ventricular ectopy. Atrial
ectopy.
Non-specific ST-T wave changes. Low voltage in the limb leads.
Compared to
the previous tracing atrial and ventricular ectopy is new.
.
CXR ([**2141-9-17**]):
IMPRESSION: Prominent superior mediastinum likely secondary to
techinque,
patient position, and low long volumes. Otherwise,no acute
cardiopulmonary
process.
.
CXR ([**2141-9-18**]):
Cardiac size is normal. The mediastinum is widened mainly due to
tortuous and elongated aorta. Dilatation of the arch cannot be
totally excluded and CTA could be performed to better
evaluation. There is no evidence of pneumonia or CHF. Bilateral
pleural effusions are small. Biapical pleural thickening is
mild. There are moderate degenerative changes in the thoracic
spine.
.
Bilateral Lower Extremity Ultrasound ([**2141-9-20**]): Pending
Brief Hospital Course:
This is a 77 year old male with a PMH significant for
hypertension, osteoporosis, gout, daily heavy alcohol use who
presented with nausea and diarrhea for the last 3-4 weeks in the
setting of long-term colchicine use, found to be in acute renal
failure with hypotension that improved with IV hydration.
.
# Acute Renal Failure: Given response to fluids with increasing
urine output and falling creatinine, this was most consistent
with volume depletion secondary to chronic diarrhea, vomiting,
and poor po intake. Continued daily heavy alcohol consumption
and continued blood pressure medication intake in the setting of
hypotension are also likely contributors to acute renal injury.
Also concern for acute tubular necrosis secondary to hypotension
but urine sediment was without casts. Renal consulted and
followed patient in ICU. Patient was given over 5L of IVF in the
ICU. Fluid balance was carefully observed on the floor and urine
output normalized. Electrolytes (potassium and magnesium) were
repleted as necessary. Creatinine at the time of discharge 1.3,
down from a high of 6.5 on [**2141-9-17**].
.
# Hypotension/tachycardia: Most likely cause was intravascular
volume depletion as above, with decreased cardiac output given
preload and stroke volume. Improved with IVFs. Pt did not appear
septic and hypotension resolved with IVFs. Anti-hypertensives
were held on admission. Upon reaching the floor, patient
remained normotensive. Noted to be in sinus tachycardia
generally with heart rate in the low 100s with brief rises to
the 170s when ambulatory. Pressures remained stable and patient
was asymptomatic with no signs of ischemia on ECG. Tachycardia
thought secondary to reflex tachycardia from the holding of his
outpatient clonidine, diltiazem, amlodipine. Given that his
pressures remained stable, patient was initially started on
diltiazem 180mg PO daily and clonidine 0.1mg PO daily. Patient
to be discharged on diltiazem 180mg PO daily, clonidine 0.1mg PO
BID. Norvasc and Heart rates remained in the 80s by the time of
discharge.
.
# Diarrhea: Unclear etiology, but patient reported long-term
history of intermittent diarrhea since beginning colchicine
therapy. No reported medication changes in the last month to
explain his acute exacerbation, but patient may have a
superimposed gastroenteritis. Colchicine medication has been
held temporarily as patient does not appear to be having a gout
flare-up currently. TSH is now within normal limits. Patient
reported cessation of diarrhea since arriving to the floor.
Stool samples have been sent. At the time of discharge, c. diff
is negative and cultures are pending.
.
# Deep venous thrombosis: Patient had mild swelling of the right
calf, without overlying erythema, palpable cords, or tenderness.
[**Last Name (un) 5813**] sign negative. Lower extremity ultrasound revealed clot
in the right posterior tibial vein thrombosis. Patient was
started on lovenox 80mg SC injections [**Hospital1 **] for bridging to
coumadin therapy (first dose of 5mg coumadin PO). INR will need
to be checked daily at rehab and coumadin adjusted with goal INR
between [**1-17**].
.
# Urinary Tract Infection: Urine culture found to be growing e.
coli with 10,000-100,000 organisms. Ciprofloxacin was initiated
on [**2141-9-18**] with 250mg PO BID for planned 7 day course. Foley has
been discontinued. Will follow up with primary care physician.
.
# Alcohol Abuse: Heavy alcohol consumption. Patient unwilling to
discuss this further during this admission. CAGE questions
negative. Reported stopping alcohol consumption 5 days prior to
admission. CIWA scale not implemented due to low clinical
suspicion. Did not exhibit any signs of withdrawal. Will need
follow up discussion with primary care physician.
.
# Gout/Hyperuricemia: Colchicine stopped due to suspicion that
this medication may have explained recent diarrhea episode. Will
hold outpatient colchicine and allopurinol in setting of
resolving acute renal and resolving diarrhea. Pain was treated
with tylenol and codeine. Patient will follow up with primary
care physician in one week to consider reinitiation of
medications at that time. Also, patient scheduled to follow up
with ortho clinic in 2 weeks.
.
# Deconditioning: Likely secondary to gout/chronic
osteoarthritis. Per daughter, patient is having difficulty
getting up and down the stairs to his apartment. Seen by
physical therapy, who suggested that patient would benefit from
rehabilitation, as patient appeared to be functioning below
baseline. They also believed that prognosis was good for patient
to return to independent ambulation. Patient will be discharged
for rehabilitation.
.
# Mild Hypernatremia: Likely hypovolemic hypernatremia in the
setting intravascular volume depletion secondary to diarrhea.
Free water deficit was calculated and patient was encouraged to
take PO fluids for self-correction. Received one D5W bolus of
1L. Sodium at the time of discharge was 144.
.
# Elevated Ferritin: Likely related to anemia of chronic disease
and chronic alcohol consumption. Will suggest repeating once
renal failure resolves as well as acute illness. Unknown risk of
hemochromatosis, but clinically without diabetes or markedly
abnormal lfts. He has had elevated ferritins in the past
however. HLH is not suspected given absence of fever and
illness.
.
# Anemia: Likely due to alcohol consumption. Patient was guiac
negative in the ED, though reported to be positive in primary
care physician's office. Last colonoscopy was in [**2136**], showing
only hemorroids. Hematocrits were trended and stable during this
admission. Recommend outpatient follow up with consideration of
colonoscopy.
.
# Tortuosity on CXR: Per radiology, mediastinum widened mainly
due to tortuous and elongated aorta. Dilation of the arch cannot
be totally excluded and CTA could be performed for better
evaluation. Given low clinical suspicion and equal blood
pressures in the [**Last Name (LF) **], [**First Name3 (LF) **] defer to primary care physician the
decision to follow up with CT.
Medications on Admission:
ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet
- 1 Tablet(s) by mouth every six hours as needed as needed for
for pain \
AMLODIPINE - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day
CLONIDINE - 0.1 mg Tablet - 1 Tablet(s) by mouth in am, 2 in pm
if makes you too sleepy try one in am and 2 qhs
DILTIAZEM HCL - 300 mg Capsule, Sust. Release 24 hr - 1
Capsule(s) by mouth once a day
FLUOXETINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day for
depression
IBUPROFEN - 600 mg Tablet - 1 Tablet(s) by mouth three times a
day as needed for pain Same as MOTRIN
LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day for
blood pressure
POTASSIUM CHLORIDE - 20 mEq Tab Sust.Rel. Particle/Crystal - 1
Tab(s) by mouth twice a day take for only max of 2 days before
being seen
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO
every six (6) hours as needed for fever or pain.
3. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
4. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Outpatient Lab Work
At rehab, please check your INR daily. Also please check
sodium, potassium, magnesium, and renal function tests
(BUN/creatinine) daily.
6. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days: Please take 1 tablet every 12 hours
on [**10-9**], [**9-23**], [**9-24**].
7. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) mg
Subcutaneous Q12H (every 12 hours): Please take enoxaparin
injections twice a day until INR is between [**1-17**].
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM for 6 months: Your coumadin dose will be altered depending on
your INR. Your INR should be between 2 and 3.
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
Primary:
-Acute renal failure
-Gout
-Osteoarthritis
-Urinary tract infection
-Heavy alcohol consumption
.
Secondary:
-History of hypertension
Discharge Condition:
Vital signs stable, blood pressures stable.
Discharge Instructions:
You were admitted for chronic diarrhea in the setting of your
long-term colchicine medication and heavy alcohol consumption,
which likely contributed to your dehydration, low blood
pressures, and acute renal failure. You were temporarily
observed in the ICU due to your low blood pressures, which
normalized after you received several liters of IV fluids. When
you were transferred to the general medicine floor, your blood
pressures remained stable and your diarrhea improved. You were
also found to have a blood clot in your right lower leg. You
were started on a blood thinning medication and you will need to
take this medication for at least 3 months.
.
We made the following changes to your medication:
-STARTED lovenox 80mg subcutaneous injections twice a day
-STARTED coumadin 5mg by mouth daily; INR will need to be
checked daily and coumadin dose adjusted for goal INR between
[**1-17**]. You will need to take this medication for at least 6
months.
-STARTED ciprofloxacin 250mg by mouth twice a day with last
doses on [**2141-9-24**]
-STOPPED norvasc 2.5mg PO daily
-STOPPED lisinopril
-STOPPED colchicine
-DECREASED clonidine to 0.1mg by mouth twice a day
-DECREASED diltiazem to 180mg by mouth daily
.
Should you develop lightheadedness, dizziness, shortness of
breath, chest pain, poor urination, fever, chills, please
contact your primary care physician or go to the emergency room.
Followup Instructions:
-Please follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 8499**], on [**2141-9-27**] at 3PM. Phone: [**Telephone/Fax (1) 7976**]. You will
need to check your potassium, magnesium, and renal function
again at this time.
.
-Please follow up with the orthopedics clinic at [**Hospital1 **] [**Last Name (Titles) 516**], [**Location (un) **] [**Hospital Ward Name 23**] Center on [**10-4**], at 11:45AM. Phone: [**Telephone/Fax (1) 1228**]. You will also receive
x-rays at this time.
.
Please follow up with your gastroenterologist as previously
scheduled below:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2141-10-5**] 9:45
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 9394**] (ST-3) GI ROOMS Date/Time:[**2141-10-5**] 12:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2141-10-5**]
12:30
|
[
"5849",
"5990",
"4019"
] |
Admission Date: [**2157-8-5**] Discharge Date: [**2157-8-7**]
Date of Birth: Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
female who was seen in the Emergency Room on 88-28 for
hyperkalemia with a potassium of 6.2. An EKG at that time
showed minor T wave peaking and a potassium of 5.9. The
patient was now sent from her nursing home to the Emergency
Room for evaluation of new increase in BUN and creatinine to
70 and 2.5 respectively and an increase in her white blood
cell count to 29 and one day of lethargy and a temperature to
99. In the Emergency Room her temperature was 100.2, blood
pressure 97/48, she was given 4 liters of normal saline and
her blood pressure improved to 111/74. She was also given
Vancomycin, Ampicillin, Gentamycin and Flagyl.
Neo-Synephrine drip was started and an arterial line was
placed.
PAST MEDICAL HISTORY: Significant for MRSA urinary tract
infection, coronary artery disease, type 2 diabetes,
dementia, atrial fibrillation, congestive heart failure,
pulmonary embolus and osteoarthritis.
MEDICATIONS: On admission, Digoxin 0.125 mg, Coumadin,
Colace, Insulin, Prevacid, Tylenol, Zoloft, Lasix, Vasotec,
Aspirin, Lopressor.
PHYSICAL EXAMINATION: The patient weighed 110 lbs, heart
rate was 137, blood pressure 95-122/20-46 and her respiratory
rate was 16-29. She was satting greater than 90% on three
liters nasal cannula. She was on a Neo-Synephrine drip. She
was pleasantly disoriented. Her jugular venous pressure was
at 8 cm. Her oropharynx was dry. Her lungs revealed coarse
rales, left greater than right. Heart was tachycardic with
normal S1 and S2. Her abdomen was soft, nontender, non
distended with no bowel sounds. She had 1+ edema in her
legs.
LABORATORY DATA: On admission white count was 29, hematocrit
30 and platelet count 399,000 with a differential of 94%
polymorphonucleocytes, 3% lymphs and 1% monos. Her
chemistries revealed a sodium of 147 and a potassium of 3.9,
chloride 112, CO2 17, BUN 47 and creatinine 3.8 and glucose
179 with anion gap of 18. Chest x-ray revealed a left lower
lobe consolidation. Urine cultures from her previous ER
visit had grown proteus mirabilis. Blood cultures were
pending on admission.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit where she was supported with Neo-Synephrine and
continued with antibiotics for her hypotension. An
echocardiogram was read as showing decreased right
ventricular systolic function and a normal ejection fraction
and no major changes from previous echocardiogram. An EKG
showed no change from previous. The patient's blood cultures
grew out gram negative rods in [**3-9**] bottles and her urine
cultures grew out proteus. The patient's code status had
been in question on admission since she was DNR, DNI at the
nursing home but her brother had wanted her to be a full code
on admission. On [**8-7**] the house staff was called as the
patient had gone into asystolic and respiratory arrest. The
patient was found unresponsive and with no pulse and no
respirations. The patient's brother was [**Name (NI) 653**] and it was
decided not to resuscitate her. The patient's time of death
was 11:02 on [**2157-8-7**] secondary to cardiopulmonary arrest and
urosepsis.
DISCHARGE DIAGNOSIS:
1. Urosepsis.
2. Renal failure.
3. Dementia.
4. Coronary artery disease.
5. Type 2 diabetes.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Last Name (NamePattern1) 11548**]
MEDQUIST36
D: [**2157-10-15**] 06:08
T: [**2157-10-16**] 21:11
JOB#: [**Job Number 30796**]
|
[
"5990",
"2767",
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"41401",
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"4280"
] |
Admission Date: [**2182-6-12**] Discharge Date: [**2182-6-13**]
Date of Birth: [**2164-2-6**] Sex: M
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: The patient is an 18-year-old
gentleman involved in a motor vehicle accident where he was a
restrained driver of a car that hit a house concrete porch.
He was found on the scene on the front seat vomiting.
Initial [**Location (un) 2611**] coma score was 10. He was transferred to the
outside hospital where CT scan of the head showed evidence of
diffuse occipital injury specifically punctate hemorrhages,
lesions in his brain.
The patient was intubated for airway protection, and was
noted to have aspirated a large amount of emesis based on
suctioning from the endotracheal tube. Patient was then
transferred to [**Hospital1 69**].
PAST MEDICAL HISTORY:
1. Asthma.
2. Depression.
PAST SURGICAL HISTORY: None.
MEDICATIONS:
1. Albuterol.
2. Steroid inhaler.
3. [**Doctor First Name **].
4. Celexa.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is noted to use alcohol and
marijuana.
PHYSICAL EXAMINATION: Initially, vital signs are 127/70,
heart rate 62. Patient is intubated 100%, temperature of 96.
In general, the patient was intubated, sedated, and
paralyzed. Has a right occipital cephalohematoma posterior 3
mm bilaterally and midface is stable and no step-off.
Tympanic membranes are clear bilaterally. Septal hematoma.
Neck: Trachea is midline. Cardiovascular was regular, rate,
and rhythm. Respiratory: Bilateral breath sounds,
rhonchorous at the bases, no emphysema, and no crepitus.
Abdomen is soft, nontender, nondistended, positive bowel
sounds. Pelvic is stable to [**Doctor Last Name **]. Rectal was guaiac
negative. Extremities: No dislocation deformities, 2+
pulses throughout.
LABORATORIES: Initial hematocrit is 39.1, white blood cells
11.6, lactate 1.5, amylase 48, EtOH 240 at outside hospital
and 158 in the Emergency Department.
Patient had a CT scan of the head. This showed multiple
small interparenchymal hemorrhages consistent with [**Doctor First Name **]. CT
scan of the C spine had no fracture or dislocation. CT scan
of the abdomen, pelvis, and chest from the outside hospital
is negative. Chest x-ray here showed right upper lobe
collapse, but no hemothorax and no widening of the
mediastinum.
HOSPITAL COURSE: During the hospital course, the patient was
extubated. Patient was admitted to the Trauma Intensive Care
Unit, extubated the following day, and transferred to the
floor without any issues. Patient was transferred to the
floor the next day. The vital signs remained stable.
Patient neurologically had no lesions or no deficits. The
patient was alert and oriented times three throughout.
Patient was maintained in a hard collar until flex films were
obtained on [**6-13**] which are negative for any ligamentous
injury or malalignment, and it is thought that patient at
work would benefit from a neurobehavioral consult given the
brain injury as well as addiction consult given his alcohol
and marijuana use.
Neurosurgery was also originally consulted to assess the
diffuse axonal injury. They felt there was no operative
management required, and recommend neurochecks which were
fine. The patient had no focal neurological deficit, no
weaknesses, although there was some weakness of the left
extremity noted at the beginning, but that has since
resolved, and the patient has no focal finding. The left
foot was originally thought to be weaker than the right, but
that has since resolved.
Neurosurgery recommended repeat head CT scan to see if there
is any interval changes. There are no changes on repeat CT
scan. The patient is discharged out on ibuprofen as well as
a soft collar for comfort.
FOLLOW-UP INSTRUCTIONS: The patient is to followup with
Neurosurgery, Dr. [**First Name (STitle) **] in one month and patient can also follow
up with Trauma Surgery as needed.
DISCHARGE CONDITION: Good.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 2584**]
MEDQUIST36
D: [**2182-6-13**] 15:37
T: [**2182-6-19**] 09:58
JOB#: [**Job Number 46227**]
|
[
"5180",
"49390",
"311"
] |
Admission Date: [**2116-11-12**] Discharge Date: [**2116-11-18**]
Date of Birth: [**2056-10-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Rapid heart rate
Major Surgical or Invasive Procedure:
Cardioversion
History of Present Illness:
60yo woman with past medical history significant for
ventilator-dependent asthma/COPD with tracheostomy, CAD s/p MI,
diabetes, CHF w/ EF 25-30%, h/o multiple pneumonias including
pseudomonas and [**Hospital 34241**] transferred from [**Hospital3 672**] for
supraventricular tachycardia and found to be septic. She was
recently admitted to [**Hospital1 2177**] ([**11-2**]) with respiratory distress,
diagnosed with ventilator-associated pneumonia and sepsis with
hypotension to 60s/40. While at [**Hospital1 2177**], she was started on
vancomycin, gentamycin, and cefepime; urine cultures were neg.
Sputum pos for klebsiella ([**First Name9 (NamePattern2) 39751**] [**Last Name (un) **] to amikacin,
imipenum, zosyn) and pseudomonas (pseudomonas [**Last Name (un) 36**] resist to
cipro, levo, intermdi to gent). She was also treated with
pressors which were slowly weaned prior to discharge on [**2116-11-9**].
She was transferred to [**Hospital3 672**] Hospital Rehabilitation
Center on an antibiotics course of IV vancomycin, amikacin, and
cefepime. She was sent to [**Hospital1 18**] for SVT with HR 130-160
beginning at 1020am. She was given cardizem 20+25mg and
adenosine 6+12mg without confersion. She was also noted to have
a fever of 103.
On arrival to the ED, T104.6, HR 155, BP 140/75, RR 23/ SaO2
98%. She was given tylenol 650mg, hydrocortisone 100mg iv,
vancomycin (patient got cefepime and amikacin at rehab earlier
in the day). Adenosine 6mg IVP revealed underlying aflutter
which reverted back to SVT in the 150s. She was given an
additional 20mg IV diltiazem, HR remained in 150s and BP dropped
to 90s/50s. She was placed on a diltiazem drip.
.
On diltiazem drip patient rate remained in 150s, decision was
made to cardiovert patient and she returned back to sinus
rhythm.
Past Medical History:
1. Chronic respiratory failure, vent-dependent, weaned off the
ventilator at [**Hospital3 672**] in early [**10-12**] but placed back on
the ventilator at an unknown time.
- h/o severe asthma and chronic hypercarbia w/ baseline PCO2 in
the 70s, on chronic steroids
- s/p tracheostomy, last changed in [**7-12**] and associated with
trach malposition after that
2. CAD s/p MI
3. CHF, EF 25-30%
4. NIDDM
5. peripheral neuropathy
6. s/p [**Month/Day (1) 282**]
7. CRI, baseline Cr 1.5-2
8. schizoaffective d/o
9. steroid myopathy
10. ?bipolar d/o
Social History:
Living in the community in [**2115**], hospitalized since. H/o
tobacco. Has a caseworker in the community from dept of mental
health. Large family.
Family History:
noncontributory per report
Physical Exam:
VS: T 104.6, HR 157, BP 139/76, RR 24, SaO2 99% CPAP 5 FiO2 0.5
Tv 400 RR 25 (FiO2 increased from 0.4 and now on CPAP)
Gen: Obese african american female who is awake but does not
respond to commands. Patient unkept.
HEENT: PERRL, uncooperative with eye exam. Patient will not open
her mouth.
Neck: No JVD appreciated. Patient with left subclavian TLC
CV: Tachycardic, unable to tell if has murmur
Pulm: Course breath sounds ant/lat b/l
Abd: obese, [**Year (4 digits) 282**] tube in place. Foley in place.
Ext: + edema L>R with 2+ pitting edema in left, 1+ in right
Neuro: Patient awake, otherwise not responsive or follows
commands
Pertinent Results:
[**2116-11-12**] 01:05PM WBC-11.4* RBC-3.79* HGB-11.2* HCT-35.1*
MCV-93 MCH-29.5 MCHC-31.9 RDW-16.0*
[**2116-11-12**] 01:05PM NEUTS-96.2* LYMPHS-2.7* MONOS-0.9* EOS-0.1
BASOS-0
[**2116-11-12**] 01:05PM PLT COUNT-317
[**2116-11-12**] 01:05PM PT-13.5* PTT-29.8 INR(PT)-1.2
[**2116-11-12**] 01:05PM D-DIMER-[**2065**]*
[**2116-11-12**] 01:05PM TSH-0.45
[**2116-11-12**] 01:05PM GLUCOSE-337* UREA N-42* CREAT-1.8*
SODIUM-154* POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-31 ANION
GAP-17
[**2116-11-12**] 01:18PM LACTATE-2.5*
[**2116-11-12**] 01:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2116-11-12**] 01:25PM URINE RBC-[**12-27**]* WBC-0-2 BACTERIA-OCC
YEAST-NONE EPI-<1
[**2116-11-12**] 01:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2116-11-13**] 12:00AM ALT(SGPT)-22 AST(SGOT)-18 LD(LDH)-261*
CK(CPK)-151* ALK PHOS-62 AMYLASE-80 TOT BILI-0.3
[**2116-11-13**] 12:00AM LIPASE-53
[**2116-11-13**] 12:00AM ALBUMIN-2.7* CALCIUM-9.4 PHOSPHATE-2.9
MAGNESIUM-1.7
Labs on discharge [**2116-11-17**]:
[**2116-11-17**] 06:06AM BLOOD WBC-8.5 RBC-3.23* Hgb-9.5* Hct-28.9*
MCV-90 MCH-29.3 MCHC-32.7 RDW-15.2 Plt Ct-238
[**2116-11-17**] 06:06AM BLOOD Plt Ct-238
[**2116-11-17**] 06:06AM BLOOD PT-15.6* PTT-74.7* INR(PT)-1.7
[**2116-11-17**] 06:06AM BLOOD Glucose-117* UreaN-48* Creat-1.3* Na-146*
K-3.3 Cl-103 HCO3-38* AnGap-8
[**2116-11-17**] 06:06AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
[**2116-11-13**] 05:48AM BLOOD Free T4-0.9*
.
Micro:
RESPIRATORY CULTURE (Preliminary):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. HEAVY GROWTH.
OF THREE COLONIAL MORPHOLOGIES.
.
L SUBCLAVIAN CATH TIP CULTURE (Final [**2116-11-14**]):
DUE TO MIXED BACTERIAL TYPES ( >= 3 COLONY TYPES)
.
URINE CULTURE (Final [**2116-11-14**]): NO GROWTH.
Brief Hospital Course:
.
## Asthma/ventilation dependence - Patient after cardioversion
required to be on assist control vantilation. A chest xray
showed patchy opacities R>L and sputum culture was sent which
was consistent with Pseudomonas. patient was continued on
Amikacin and Cefepime which she was already on before she was
brought to [**Hospital1 18**]. A total 14 day course of cefepime will be
complete on [**11-21**] and amikacin was extended for 7 more days and
should be complete on [**11-21**]. Patient was conitnued on
vancomycin for MRSA PNA that she was already being treated for.
Her course of vancomycin was finished on [**2116-11-16**]. She quickly
improved on the ventilator with good O2Sat and was switched to
pressure support of [**11-11**] and [**6-11**] and then tried on trach mask
which she tolerated well. Patient was evaluated for possible PM
valve but it was noticed that she has [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 295**] air cuff and the
pilot to the air cuff has been removed. Not quite clear why
pilot to air cuff removed or if it was torn off. Patient has
been doing fine with current tracheostomy so deferred any
intervention of changing tracheostomy to facility who placed the
trach to evaluate. Please make sure patient trach changed if
need be.
.
## Cardiac:
1) Tachycardia - Patient cardioverted and quickly returned to
sinus rhythm with good rate and remained in sinus rhythm.
Patient was started on low dose Bblocker which was not able to
be titrated up given low HR and low BP. Could try to titrate up
BBlocker if HR and BP tolerate. She was started on
anticoagulation s/p cardioversion. She will need to be
anticoagulated for total 3 weeks. On discharge patient on
heparin gtt until INR theraputic at 2-3. would check daily INR
and titrate coumadin until INR stable and therputic. Can stop
coumadin after 3 weeks.
2) CHF - Patient with reported EF of 30%. Repeat CXR shows
persistant R sided pulmonary opacity/effusion. Restarted patient
on lasix 40mg IV bid. Can titrate up lasix up or down as
tolerated and would keep patient even to slightly negative. can
decrease lasix if blood pressure low. If patient blood pressure
stable she should be started on ACEI as tolerated outpatient
given her chronic renal insufficiency and diabetes.
.
## Fever - Patient intially febrile when admitted. Her fever
curve improved while in hospital and WBC returned to [**Location 213**]. CXR
shows b/l patchy infilitrate R>L which could represent
aspiration PNA. Patient treated for klebsiella,MRSA/Pseudomonas
PNA. Sputum cx here shows Pseudomonas. Patient had left IJ
placed and left subclavian removed (tip grew back > 3 colonies
of bacteria), which could have been source of fever. Patient
should complete antibiotic course as stated above.
.
## Hypotension - Patient blood pressure running 90-100. On
admission patient given hydrocortisone 100mg q8 as was on
prednisone outpatient. Tapered down to 75mg q8, and then
switched to prednisone 40mg daily. Would continue to 2 week
prednisone taper to off or low dose if patient needs chronic
steroids for COPD.
.
## Diabetes - Patient on 80am and 20pm NPH and RISS on
admission. Given patient gets continuous tube feeds changed NPH
to 60units am/pm and RISS. Can titrate NPH up and down as
needed.
.
## Hypernatremia - Patient intially hypernatremic with Na 154.
She was given free water via IV and [**Location 282**] tube and switched to
just free water via [**Location 282**] tube as her Na corrected. Would
continue to monitor Na and adjust free water flushed via [**Location 282**] as
needed.
.
## Hypothyroidsim - Patient found to have and borderline low TSH
and low freeT4 so was started on levothyroxine 50mcg. Patient
should have her thyroid function tests rechecked in 3 months.
.
## Chronic renal insufficiency - Most likely diabetic
nephropathy. Patient at baseline 1.5-2. Cre currently stable at
1.2
.
## Psych - Continued clozapine and valproic acid, and lexapro at
current dose. Valproic acid level 24 and clozaril level sent
out. Appreciate psych assistance.
.
## [**Location 282**] tube - Patient [**Location 282**] tube was noticed to be leaking. GI
was contact[**Name (NI) **] and [**Name2 (NI) 282**] tube fixed.
.
## Access - Patient left subclavian line was removed and noticed
to have puss. A new left IJ was placed. Once patient off
heparin gtt and IV antibiotics would consider removing central
line.
Medications on Admission:
lasix 80mg [**Hospital1 **]
lovenox 150mg sc qd x 10d beginning [**11-11**]
vancomycin 1000mg iv q48h, doses due [**11-12**], [**11-14**], [**11-16**]
amikacin 500mg iv q24h last dose 10/9
cefepime 2gm iv q12h 40mg qd (started [**11-7**], last dose 10/15)
lactulose 30gm [**Hospital1 **]
thiamine 100mg qd
montelukast 10mg qpm
atovaquone 1500mg q24h
FeSo4 300mg tid
clozapine 100mg qhs
valproic acid 750mg qam and 500mg qhs
simethicone 80mg [**Hospital1 **]
simvastatin 20mg qhs
MVI 15ml qd
ASA 81mg qd
oscal +D qd
glucerna at 55cc/hr
SSI
NPH 80units at 6a, 20units at 6p
lexapro 20mg qam
protonix 40mg qd
colace 100mg [**Hospital1 **]
Prednisone 40mg daily
Discharge Medications:
1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO Q 24H
(Every 24 Hours).
4. Clozapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO QAM (once
a day (in the morning)).
6. Valproate Sodium 250 mg/5 mL Syrup Sig: One (1) PO HS (at
bedtime).
7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day) as needed.
8. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
12. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
13. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO TID (3
times a day).
14. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
15. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
16. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily): Please give at least 30 minutes separate from
iron supplement.
17. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
19. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
20. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
21. Amikacin 250 mg/mL Solution Sig: Four Hundred (400) mg
Injection Q24H (every 24 hours) for 3 days.
22. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2
times a day).
23. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) Intravenous ASDIR (AS DIRECTED): Please continue
until INR theraputic .
24. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
25. Cefepime 2 g Piggyback Sig: One (1) Intravenous every
twelve (12) hours for 3 days.
26. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Sixty
(60) units Subcutaneous twice a day: Please titrate as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary Diagnosis:
Atrial Flutter s/p cardioversion
Pseudomonas Pneumonia
Hypernatremia
Central Line infection
Secondary Diagnosis:
Diabetes Mellitus
Schizoaffective disorder/Bipolar disorder
Asthma
COPD
Chronic renal insufficency
CHF
Discharge Condition:
Stable - Patient still on ventilator however appears to tolerate
trach mask and should be on trach mask if tolerates. Patient
currently being treated for Pseudomonas PNA with Amikacin and
cefepime.
Discharge Instructions:
Please continue to take medications as directed. While you were
in the hospital you were treated for a fast heart rhythm. You
were started on a medication called metoprolol which you should
continue. You were also started on blood thinning medication
which you should continue for total 3 weeks. You were also
found to have a pneumonia which you are on antibiotics for and
should continue. You were also found to have hypothyroidism and
should continue to take thyroid medications (levothyroxine) as
directed. Y
Followup Instructions:
Please follow up with your primary care doctors to [**Name5 (PTitle) **] over your
medications. You will need to have your thyroid function tests
rechecked in 3 months. You should also stay on anti-coagulation
medication for 3 weeks and have blood levels checked to make
sure on appropriate dose of coumadin.
Please follow up with your psychiatrist to go over your
psychiatry medications and make sure they are appropriate.
|
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Admission Date: [**2121-12-30**] Discharge Date: [**2122-1-28**]
Date of Birth: [**2060-3-15**] Sex: F
Service: NEUROSURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old
female who on the day of admission had severe headache with
positive nausea or vomiting. The patient was brought to an
outside hospital where head CT showed subarachnoid
hemorrhage, and the patient was transferred to [**Hospital6 1760**] for further management.
PHYSICAL EXAM: The patient was alert, attentive, oriented x
3. Pupils were 2 down to 3 mm, bilaterally reactive.
Positive meningismus. Neurologic status - motor - had 5/5
strength in all muscle groups. Her reflexes were symmetric.
Toes were mute.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit, BP kept less than 30, with q 1 h neuro checks, and
repeat head CT. The patient had angio which showed evidence
of a right MCA aneurysm which was not able to be coiled. The
patient was taken to the OR on [**2121-12-31**] for MCA aneurysm
clipping. There were no intraop complications. Postop, the
patient's vital signs were stable. She was intubated and
sedated on propofol. On postop check, she was extubated,
opening her eyes. Pupils equal, round and reactive to light.
EOMS were full. Face was symmetric. She had right orbital
edema. Moving all extremities. Following commands.
On [**1-1**], she was opening her eyes, attending to the
examiner, following commands briskly. Face was symmetric.
Pupils equal, round and reactive to light. Her verbal output
was very poor. She appeared to have good comprehension but
no verbal output. On [**1-2**], speech output problems were
improved. She was awake and following commands. Her vent
drain was leveled at 20 cm above the tragus. Blood pressure
was kept 130-150. Head CT on [**1-2**] showed no change with no
evidence of stroke or new hemorrhage.
On [**1-4**], she was opening her eyes. Speech was somewhat
dysarthric. She was oriented to place. She continued to
have right eye swelling. Face was symmetric. Preferred eyes
closed. No drift. Following simple commands.
On [**1-5**], the patient had duplex ultrasound of her lower
extremities to rule out DVT which was ruled out. She was on
Triple H therapy to prevent vasospasm. She spiked to 102.6
on [**2122-1-5**], was fully cultured, and continued to be
lethargic with left-sided weakness. Head CT was done and was
taken to angio on the 8 which showed good placement of the
aneurysm clip. There was no evidence of vasospasm on angio.
The patient continued to improve, opening her eyes to voice,
slightly more attentive on the 9. Continued with left facial
weakness, following commands, but inattentive at times, still
with left-sided drift, purposeful in following commands in
the right upper extremity.
She was seen by ENT who evaluated her vocal cords and found a
moderate to severe amount of supraglottic edema, left greater
than right, secondary to intubation. They recommended reflux
precautions and reassessment of her larynx in [**1-30**] weeks.
On [**1-8**], the patient's vent drain was raised to 15 cm above
the tragus. She was seen by speech and swallow service who
found the patient not appropriate for PO intake at that time,
aspiration risk to be high. The patient had an NG tube
placed for tube feeding. The patient was hyponatremic on a
3% saline drip, and on a fluid restriction, and in keeping
her blood pressures continued to be 170, to prevent
vasospasm.
On [**1-12**], the patient had a chest x-ray that showed mild left
lower lobe atelectasis. Head CT on the 14 showed decrease in
the amount of subarachnoid hemorrhage and intraventricular
hemorrhage.
On [**1-14**], the patient was awake, alert, oriented to place.
Face was symmetric. EOMS full. Continued with mild left upper
drift. Grasp was [**6-2**] on the right, [**5-3**] on the left. IPs -
strength was full. Vent drain was raised to 20 cm above the
tragus. Sodium was up to 137. Three percent saline was
discontinued. The patient continued to receive feeding
through her Dobbhoff tube.
The patient had a repeat angio on the 17 which again showed
stable clipping of right MCA aneurysm, and no evidence of
vasospasm. On [**1-17**], the patient's vent drain had been
clamped for 24 hours. A repeat head CT showed an increase in
hydrocephalus; therefore the vent drain was reopened. The
patient had repeat head CT on [**1-18**] which showed no change
from the 19. Ventricular size was unchanged. The drain was
DC'd on [**2122-1-20**]. Neurologically, the patient moving upper
extremities briskly and purposely, showing 2 fingers on the
right, showing thumb on the left, wiggling toes
spontaneously, stable neurologically.
The patient was transferred to the regular floor on
[**2122-1-20**]. She has remained neurologically stable, although
PO has been an issue. Repeat swallow eval on [**1-23**] showed
patient able to tolerate a regular diet. Change to puree
with thin liquids. While the patient was still having
difficulty cognitively chewing and swallowing food, it was
felt that changing her diet to puree with thin liquids would
assist with that. PO intake over the next couple of days has
improved. The patient was seen by physical therapy and
occupational therapy and found to require rehab prior to
discharge to home.
DISCHARGE MEDICATIONS:
1. Reglan 10 mg po tid.
2. Dilantin 100 mg po tid.
3. Heparin 5,000 U subcu q 12 h.
4. Percocet 1-2 tabs po q 4 h prn.
5. Famotidine 20 mg po bid.
6. Colace 100 mg po bid.
7. Folic acid 1 mg po qd.
8. Ferrous Sulfate 325 po qd.
9. Nystatin oral suspension 5 cc po qid prn.
DISCHARGE CONDITION: Stable.
FOLLOW-UP: With Dr. [**Last Name (STitle) 1132**] in 2 weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2122-1-27**] 13:54
T: [**2122-1-27**] 15:01
JOB#: [**Job Number 39858**]
|
[
"2761",
"5180",
"4019",
"25000"
] |
Admission Date: [**2197-6-2**] Discharge Date: [**2197-6-7**]
Date of Birth: [**2122-6-14**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Attending Info 90680**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
Endotracheal intubation
History of Present Illness:
74 F has hx COPD, SLE, recent SBO and resection, CAD with demand
myocardial necrosis event in [**1-5**], known systolic dysfunction
LVEF 45% last echo demonstrating inferolateral hypokinesis with
2+ MR, moderate [**Last Name (un) 6879**] w/ mild right ventricular cavity dilation,
[**2-5**] perfusion stress demonstrating medium area of myocardial
scar in the distribution of the LCX/OM coronary artery, with
mild associated peri-infarct ischemia who presents with several
days of volume overload since discharge from SBO resection being
treated at rehab with lasix 80 mg [**Hospital1 **], who had acute worsening
of shortness of breath yesterday morning requiring 3L NC of O2
to maintain O2 sat of 93%, no previous O2 requirement. Of note,
pt states this is how she felt during her NSTEMI event earlier
this year. She denies presence of chest pain, lightheadedness,
dizziness, palpitations, orthopnea. Endorses shortness of
breath, much worsening fatigue, typically pt very active, but
yesterday unable to do much of anything, also with cough.
.
In ED, 97.6 99 149/93 40 100% 15L nrb, got duonebs, solumedrol
125, azithromycin, tachypnea a little better, put on bipap 5/5
fi02 40% very wheezy on exam, got azithro for CHF flare, lasix
20IV. EKG demonstrated new V1, V2, V3 V4 concave down ST segment
elevation 2-3 mm which is all new compared to prior EKG,
worsened ST segment depression in V5 and V6, and worsened II,
III, and aVF ST segment depression. Pt was transferred for COPD
exacerbation. Recent vitals 80 102/64 20 100% on bipap fi02 40%
.
On arrival to [**Name (NI) 153**], pt reports feeling well, much improved
compared to earlier, breathing well on bipap. Denies chest pain.
Family reports pt with poor appetite since SBO but passing stool
and with flatus. No fevers, chills, sputum production. Given
concerning EKG changes, pt given 325 aspirin, started on
heparin, repeat EKG confirmed new changes, stat cardiology c/s
and echo performed. Echo demonstrated new LVEF 25% with moderate
to severe regional left ventricular systolic dysfunction, most
c/w multivessel CAD. Patient was transferred to the [**Hospital Ward Name **]
for cardiac catheterization and further evaluation of her
disease.
In the cath lab the patient was found to have a tight circumflex
and LAD lesion. The circ lesion was felt to be the culprit
lesion. The circ was ballooned and while trying to stent the
circ the patient went into PEA arrest. CPR started and one
round of epi given, intubated, IABP placed and dopamine started
ROSC occurred, and dopamine stopped. Circ was ballooned
multiple times, but difficulty getting stent deployed and LAD
went down transiently and patient pressures dropped so dopamine
started. Patient was stabilized on 5 mcg/kg/min of dopamine.
Able to place 1 bare metal stent from left main to LAD, no circ
stents placed. Reshooting the vessels showed good flow through
LAD, crcumflex and RCA was filling by collaterals. Venous
sheath still in place. During this event the patient was aware
of what was going on and was intubated for prophylaxis purposes
other than urgent need. Transferred to the CCU for further
management.
Past Medical History:
COPD (chronic obstructive pulmonary disease)
Coronary artery disease
NSTEMI (non-ST elevated myocardial infarction)
Systemic lupus
Dermatitis
GASTRIC ULCER: history of
GASTROINTESTINAL BLEEDING
EPICONDYLITIS, LATERAL HUMERAL
PULMONARY NODULES / LESIONS - MULT
COLONIC POLYP
DIVERTICULOSIS
MAMMOGRAM MICROCALCIFICATION
ARTHRALGIA - HAND-RT PISIFORM
TOBACCO DEPENDENCE
DEPRESSIVE DISORDER
HEARING LOSS, SENSORINEURAL
HYPERTENSION - ESSENTIAL
DUPUYTREN'S CONTRACTURE
HEADACHE, MIGRAINE
MENOPAUSE
POSITIVE PPD
Social History:
Smoking: Quit recently, 60 pack-year history
Alcohol: No
Adv Directives: DNR/DNI
Very active, lives at home, worked at [**Hospital1 **] as
behavioral counselor until this past summer. Now taking classes
at [**Hospital1 498**]. Was doing yoga and walking daily up until 3 weeks
ago.
Family History:
Depression, breast cancer, alcoholism
Physical Exam:
On Admission:
General: intubated and sedated, not opening eyes to command
HEENT: PERRL, sclera anicteric, contuctiva pink
Neck: supple, JVP unable to assess
CV: Regular rate and rhythm, normal S1 + S2, difficult to
auscultate heart sounds and murmurs over balloon pump sounds
Lungs: Clear to auscultation bilaterally in anterior lung fields
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: Foley in place
Ext: Warm, well perfused, 1+ pulses, no pitting edema
Neuro: PERRL, unable to assess other neuro exam due to sedation
On Discharge. Afebrile and no longer intubated. Alert and
oriented x3. Neuro exam nonfocal. Balloon pump and foley
removed. Exam otherwise unchanged.
Pertinent Results:
ADMISSION LABS:
[**2197-6-2**] 10:05AM BLOOD WBC-9.1 RBC-3.21* Hgb-9.7* Hct-30.9*
MCV-96 MCH-30.2 MCHC-31.4 RDW-16.5* Plt Ct-341#
[**2197-6-2**] 10:05AM BLOOD Neuts-85.6* Lymphs-10.8* Monos-3.1
Eos-0.2 Baso-0.3
[**2197-6-2**] 10:05AM BLOOD PT-18.2* PTT-30.5 INR(PT)-1.7*
[**2197-6-2**] 10:05AM BLOOD Glucose-137* UreaN-11 Creat-0.6 Na-132*
K-4.9 Cl-93* HCO3-29 AnGap-15
[**2197-6-2**] 10:05AM BLOOD CK(CPK)-131
[**2197-6-2**] 10:05AM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 108016**]*
[**2197-6-2**] 02:14PM BLOOD Calcium-8.8 Phos-3.2 Mg-1.4*
[**2197-6-2**] 02:21PM BLOOD Type-ART Temp-39.2 pO2-157* pCO2-43
pH-7.48* calTCO2-33* Base XS-8 Intubat-NOT INTUBA
CARDIAC ENZYME TREND:
[**2197-6-2**] 10:05AM BLOOD CK-MB-6 proBNP-[**Numeric Identifier 108016**]*
[**2197-6-2**] 10:05AM BLOOD cTropnT-0.03*
[**2197-6-2**] 02:14PM BLOOD CK-MB-6 cTropnT-0.03*
[**2197-6-2**] 08:30PM BLOOD CK-MB-6 cTropnT-0.06*
PERTINENT REPORTS:
TTE [**2197-6-2**]
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate to
severe regional left ventricular systolic dysfunction with
inferolateral, anterior and anteroseptal hypo- to akinesis. The
remaining segments contract normally (LVEF = 30%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. 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. Moderate (2+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate to severe regional left ventricular
systolic dysfunction, most c/w multivessel CAD. Moderate mitral
regurgitation. Mild pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2197-1-12**],
regional LV wall motion abnormalities in the LAD distribution
are new. The RCA (or dominant LCx)-supplied segments remain
hypokinetic. Overall LV systolic function has significantly
deteriorated. Findings discussed with Dr. [**Last Name (STitle) **] at
1545 hours on the day of the study
PTCA COMMENTS [**2197-6-2**]:
Initial angiography showed an origin 95% stenosis of the LCx
extending
back into LMCA. After discussion with referring cardiologist, we
planned
to treat this lesion with PTCA and stenting. Heparin was
continued with
therapeutic ACT. A 5F XB LAD 3.5 guiding catheter provided
adequate
though suboptimal support for the procedure. A Prowater wire
crossed the
lesion with minimal difficulty into distal LCx. The lesion was
dilated
with a 2.5x12mm Apex RX balloon at 12 atms however a waist
remained. We
further dilated the lesion with a 2.5x8mm NC Quantum apex Mr
balloon at
10 atms without complete expansion likely due to calcification
of the
artery. We then dilated the lesion with a 2.5x10mm Angiosculpt
EX
balloon at 14 atms for 30secs. After the balloon was deflated,
the blood
pressure was noted to be extremely low and PEA arrest noted. CPR
was
started and epinephrine given. A pulse returned and an IABP was
placed
from the RFA approach. Anesthesia proceeded to intubate the
patient. The
blood pressure improved and dopamine was stopped. Interval
angiography
showed little to no flow in the LCx. The Lcx was re-wire with
the
Prowater wire and flow was restored. The ostium of the LCx was
dilated
with a 1.5x12mm Apex Push balloon. We then attempted in multiple
different ways to deliver a stent to the ostium of the LCx,
however were
unsuccessful. A 3.0x15mm Integrity bms or a 3.0x12mm Integrity.
WE then
placed a Choice Floppy wire in the LCx as a buddy wire, but
again could
not deliver even a short 3.0x9mm integrity bms. We then
attempted to
dilate the lesion again with a 3.0x12mm NC Quantum apex balloon
however,
just as the balloon crossed the lesion (prior to inflation) the
patient
again became hypotensive requiring dopamine and angiography
showed slow
flow in the LAD. The balloon was immediately removed and the
wire was
redirected down the LAD. Integrilin was started at this point
(renally
dosed). The proximal LAD was dilated with the 3.0x12mm balloon
at 6 atms
for suspected LM dissection and flow was restored in the LM-LAD.
Given
suspicion for LM dissection, we decided to stent LM into LAD. A
3.0x22mm
RX Integrity BMS was deployed in LM into LAD at 12 atms. We then
re-wired the LCx through the strut and dilated the origin of the
LCx
with a 2.25x12mm NC Quantum apex balloon at 15 atms. With the
wire in
LAD we postdilated the proximal stent segment in LMCA with a
3.5x8mm NC
Quantum apex balloon at 12 and 16 atms.
Final angiography showed no residual stenosis in the LMCA or
LAD. There
was 60% residual stenosis in the origin LCx. There was no
angiographically apparent dissection and TIMI 3 flow in LAD and
LCx. The
patient's blood pressure improved and the patient was
transferred to
CCU.
TTE [**2197-6-5**]
Conclusions
The left atrium is mildly elongated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with hypokensis of the basal inferior and
inferolateral walls. The remaining segments contract normally
(LVEF = 45%). [Intrinisic left ventricular systolic function may
be more depressed given the severity of mitral regurgitation. ]
The estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate (2+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with reduced
regional function consistent with CAD (PDA or LCX distribution).
Moderate mitral regurgitation. Pulmonary artery hypertension.
Compared with the prior study (images reviewed) of [**2197-6-2**],
regional and global left ventricular systolic function have
improved. The estimated PA systolic pressure is now higher.
DISCHARGE LABS:
[**2197-6-7**] 06:28AM BLOOD WBC-6.8 RBC-3.47* Hgb-10.9* Hct-33.6*
MCV-97 MCH-31.4 MCHC-32.4 RDW-16.3* Plt Ct-217
[**2197-6-7**] 06:28AM BLOOD PT-15.0* PTT-28.3 INR(PT)-1.4*
[**2197-6-7**] 06:28AM BLOOD Glucose-81 UreaN-11 Creat-0.6 Na-138
K-3.9 Cl-97 HCO3-37* AnGap-8
[**2197-6-7**] 06:28AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.7
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
74 yo woman admitted with shortness of breath, found to have ST
elevations and new wall motion abnormality concerning for STEMI
who had PEA arrest during cardiac cath now s/p BMS to LM/LAD and
PTCA to the [**Hospital **] transferred to the CCU on dopamine, intubated,
sedated and with IABP.
# Cardiac Arrest: Patient with PEA arrest in the setting of
cardiac catheterization. There was some concern that while
accessing the left circumflex there was plaque that went off the
left main down the LAD resulting in PEA arrest. CPR was started,
epinephrine was given, and she was rescucitated within 5
minutes. Intra-aortic ballon pump (IABP) was placed and patient
was transferred to CCU on heparin and dopamine drips with normal
HR and SBP's in the 130's. Her IABP was removed on [**6-3**] after
there was blood noted in the pump tubing and heparin was
discontinued. Dopamine was discontinued the morning [**6-4**], and
she was extubated later that day without event. She remained
hemodynamically stable the remainder of her hospitalization.
# ST elevation myocardial infarction (STEMI): Pt presented with
shortness of breath, similar presentation to her NSTEMI in
[**Month (only) 404**]. She was noted to have STE anteriorly in V1 and V2 and q
waves V1-V3 with depressions in V5, V6, II, III, and AVF. Echo
revealed new wall motion abnormality in the distribution of the
LAD. She was brought emergently to the cath lab given concern
for STEMI. In the cath lab, she had severe occlusion of
circumflex with narrowing of his proximal LAD. She had bare
metal stent (BMS) placed to left main/left anterior descending
artery (LM/LAD) and angioplasty (PTCA) to circumflex (see report
for further details). She underwent PEA arrest and was
resuscitated as above. She was started on aspirin 325, plavix
75, and atorvastatin 80mg. Integrellin was started in the cath
suite and continued for 12 hours in the CCU. Metoprolol and
lisinopril were initially held in the setting of hypotension.
Metoprolol was started on [**6-4**] following the discontinuation of
the dopamine drip. Lisinopril was started on [**6-5**] and aspirin
was decreased to 81 mg daily. TTE showed mild regional left
ventricular systolic dysfunction with hypokensis of the basal
inferior and inferolateral walls and LVEF of 45%.
# Acute on chronic systolic and diastolic dysfunction: Patient
with bilateral pleural effusions and fluid overload on
presentation to CCU, likely due to acutely decreased LVEF as
seen on TTE on [**6-2**]. She was diuresed with 40mg IV before
transition to her home dose of 60mg daily. Repeat TTE showed
mild regional left ventricular systolic dysfunction with
hypokensis of the basal inferior and inferolateral walls and
LVEF of 45%. She was started on metoprolol and lisinopril as
above.
# Hct drop: Patient's HCT noted to drop to 24.1 from 30 in the
setting of heparin gtt, IABP with blood in tubing, and blood
loss during procedure. Heparin was stopped when IABP was
discontinued and she received 1 unit pRBC with appropriate
increase in her HCT. HCT remained stable during remainder of
hospitalization.
CHRONIC ISSUES:
# COPD: Continued albuterol and iptratroprium nebulizers as need
while in house. She was continued on her home dose of Spiriva on
discharge.
# Hyperlipidemia: Patient was continued on her home dose of
atorvastatin 80mg daily. She may continue to take her fish oil
upon discharge.
# SLE: Stable, continued hydroxychloroquine.
TRANSITIONAL ISSUES:
- Would check HCT on FU to ensure stability
- Would monitor volume status carefully and adjust lasix dosing
as needed
Medications on Admission:
Fish oil 1200 mg PO BID
Omeprazole 20 mg Po daily
Aspirin 81 mg PO daily
Metoprolol XL 25 mg daily
Atorvastatin 80 mg po daily
Duonebs q4h
Lasix 60 mg PO Qam and sometimes received 20mg prn
Recently stopped levaquin and flagyl on [**5-31**] for 7 day course.
COMPLETED.
Ativan 1 mg Q6h PRN anxiety and at bedtime
Lisinopril 2.5 mg Oral Tablet 1 TABLET PO DAILY
Nitroglycerin 0.4 mg Sublingual Tablet, Sublingual 1 tablet
sublingually as needed for chest pain; may repeat every 5 min x
3 doses (never used)
Hydroxychloroquine 200 mg Oral Tablet 1 tab daily
Citalopram 40 mg Oral Tablet TAKE ONE TABLET DAILY
Alendronate 35 mg Oral Tablet take 1 tablet every week
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or Wheeze
2. Fish Oil (Omega 3) 1200 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Aspirin EC 81 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg daily Disp #*30 Tablet Refills:*3
6. Atorvastatin 80 mg PO HS
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB or Wheeze
8. Lorazepam 2 mg PO HS:PRN sleep
9. Lisinopril 2.5 mg PO DAILY
Please hold for SBP < 100
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
[**Month (only) 116**] repeat every 5 minutes for 3 doses.
RX *Nitrostat 0.4 mg as directed for chest pain Disp #*25 Tablet
Refills:*0
11. Hydroxychloroquine Sulfate 200 mg PO DAILY Start: In am
12. Citalopram 40 mg PO DAILY Start: In am
13. Alendronate Sodium 35 mg PO 1X/WEEK (MO)
14. Tiotropium Bromide 1 CAP IH DAILY
15. Clopidogrel 75 mg PO DAILY
for the recommended duration
RX *Plavix 75 mg daily Disp #*90 Tablet Refills:*3
16. Furosemide 40 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
ST elevation myocardial infarction
Lupus
Mitral regurgitation
Emphysema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 6129**],
You were admitted to the hospital because you were having
shortness of breath. We found that you were having a heart
attack. We brought you to the cardiac catheterization lab and
placed a stent in one artery in your heart and opened up another
artery with a balloon angioplasty. During the procedure, you
heart briefly stopped pumping but we were able to resuscitate
you quickly. You temporarily had a pump placed to help your
heart pump blood and a breathing tube to help you breathe. Both
of these were removed and you have done very well since.
Followup Instructions:
Name: [**Last Name (LF) 14147**],[**First Name3 (LF) **] E.
Location: [**Location (un) 2274**] [**Location **] [**Location 29702**] Care
Address: 291 INDEPENDENCE DR, [**Location **],[**Numeric Identifier 1700**]
Phone: [**Telephone/Fax (1) 20035**]
****Please call Dr [**Last Name (STitle) **] office once you are home to book a
follow up appointment within a week of discharge.
Name: [**Name (NI) **], [**Name (NI) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Location (un) 2274**] [**Location (un) **]-Cardiology
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
***The office is working on an appt for you in the next [**1-28**]
weeks and will call you at home with the appt. IF you dont hear
from them by Friday, please call the office directly to book.
|
[
"2851",
"41401",
"4280",
"4019",
"2724",
"42789",
"4168",
"311",
"V1582"
] |
Admission Date: [**2133-5-31**] Discharge Date: [**2133-6-3**]
Date of Birth: [**2071-5-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Liver hematoma
Major Surgical or Invasive Procedure:
Left hepatic artery embolization
History of Present Illness:
Mr. [**Known lastname 35507**] is a 62yo male with PMH significant for hemophilia
A, HCC, HIV who is being transferred to the MICU for management
of hemoperitoneum. Of note, the patient was discharged from
[**Hospital1 18**] on [**5-29**] after being admitted for black stools which was
thought to [**1-31**] upper GI source. Per patient's wife, since being
discharged from the hospital on [**Month/Day (2) 2974**] he has been more tired
but did not have any abdominal pain until the morning. He woke
up this morning with severe abdominal pain. His wife also noted
blood in the toilet after he had a bowel movement. He was then
brought to [**Hospital1 18**] ED for further work-up.
In the ED his initial vitals were T 97.2 BP 107/55 AR 54 RR 18
O2 sat 95% RA. CT scan w/o contrast showed a hyperdensity within
the left lobe of the liver concerning for hemmorage from his
underlying malignancy. He received Vancomycin 1g, Levaquin 500mg
IV, Flagyl 500mg IV, and Refacto 1080 units, 2070 units. He also
received 2 units FFP and 2 units pRBCs.
He was immediately taken to IR for possible embolization of the
bleeding vessel. No bleeding vessel was found and the patient
was then transferred to the MICU for further monitoring.
Past Medical History:
1) Hemophilia A
- followed by Dr [**Last Name (STitle) 13933**], Drs [**Last Name (STitle) 2805**] and [**Name5 (PTitle) **]
- arthropathy in elbows, ankles, neck, on Ms Contin
- s/p multiple b/l knee replacements
2) HIV/AIDS
- followed by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6164**] at [**Hospital1 778**] ([**Telephone/Fax (1) 46100**]
- [**9-5**]: CD4% 9, CD4:221; CD8% 60, CD8:1412, CD4/CD8 0.2
3) HCV genotype II and IV
- followed by Dr [**Last Name (STitle) **]; relapsed [**9-3**] s/p peg interferon and
ribavirin for 48 weeks ([**Date range (1) 101752**]).
- EGD [**12/2131**]: Varices at the lower third of the esophagus. Mild
duodenitis.
4) HCC - diagnosed in [**1-6**], followed by Dr. [**Last Name (STitle) **], Dr.
[**First Name (STitle) **].
Social History:
Lives with wife. Is a former computer analyst. Founded an
international nonprofit organization. Currently working in real
estate. They have no children. Quit alcohol in [**2114**]. Denies
tobacco and prior intravenous drug use.
Family History:
Significant for hemophilia in brother (d of AIDS [**2110**]), other
relatives. [**Name (NI) **] and [**Name2 (NI) **] d. MVA, Fa w/ vascular dementia d. age 88.
Physical Exam:
vitals T 95.5 BP 126/63 AR RR 15 O2 sat 95% on 3L NC
Gen: Patient sleeping but arousable to voice, ashen appearing
HEENT: MMM
Heart: Sinus tachycardia, no audible m,r,g
Lungs: Poor air movement at the bases
Abdomen: Distended, tenderness in RUQ, mild guarding but no
rebounding
Extremities: Cachectic appearing
Neuro: +asterexis
Brief Hospital Course:
Mr. [**Known lastname 35507**] is a 62yo male with HIV, HCC, and HCV who presents
with worsening abdominal pain and found to be bleeding into his
liver.
1)Liver hematoma: Patient presented to emergency room with
severe abdominal pain. He was found to be bleeding into his
liver, likely from his HCC. This was confirmed on CT scan. He
presented similarly back in [**2-6**] and underwent successful
embolization. Embolization was attempted on day of admission but
no bleeding vessel was found. His Hct dropped approximately 10
points from his last admission. Upon transfer to the MICU his
hematocrit continued to drop and his INR remained elevated. He
required multiple transfusions of pRBCs and FFP with mild
improvement. When his Hct dropped to 20 he underwent a CT
abdomen with contrast which showed extravasation of contrast. He
was then brought to IR and his left hepatic artery was
embolized. Despite successful embolization, his condition
continued to decline. He became difficult to ventilate and his
Hct and coags did not normalize despite multiple transfusions.
After discussion with the patient's wife, the decision was made
to withdraw care and change code status to comfort measures
only. Patient expired on [**6-3**].
2)Respiratory: Patient was intubated in order to stabilize him
for the CT scan and IR embolization. He remained on the
ventilator and it became increasingly difficult to ventilate him
on the day of death. The patient was extubated and then expired.
3)Lactic acidosis: Patient presents with anion gap metabolic
acidosis. He has component of renal insufficiency as well as
bleeding into the liver with worseing liver function also likely
contributing. Bicarbonate is also low. He also has portal vein
thrombus which may be causing some ischemia to the liver. His
lactate after hydration improved but then increased on day of
death, likely due to end organ damage.
4)Acute renal failure: Patient presents with Cr~1.8 on
admission; elevated from baseline of 0.8. No history of
hepatorenal syndrome. Most likely prerenal etiology in light of
underlying bleeding and poor PO intake. His Cr increased
significantly to 2.1 on day of expiration, likely due to
significant blood loss and poor perfusion.
5)HCC: Patient was diagnosed earlier this year. He is not a
candidate for any further treatment. He was treated with
Sorafenib which was stopped recently. Likely causing current
presentation.
6)Hemophilia: Patient has history of self administering himself
Factor 8 when necessary. He was given Factor 8 in the ED.
Hematology was consulted in the ED and followed patient closely.
His factor 8 level was followed closely and he was given Factor
8 200 units to keep level >50%.
7)HIV: Patient is on anti-retrovirals as an outpatient. Given
current clinical scenario his regimen was held.
Medications on Admission:
Abacavir 300mg PO BID
Lopinavir-Ritonavir 400-100mg PO BID
Rifaximin 400mg PO TID
Tenofovir Disoproxil Fumarate 300mg Po daily
Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO 5X/DAY
Hydromorphone 4-8mg PO Q6H PRN
Omeprazole 20mg PO daily
Selenium Oral
Spironolactone 50mg PO daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Liver hepatoma
Hepatocellular carcinoma
Hepatitis C
Discharge Condition:
Patient expired on [**6-3**] at 12:12pm.
Discharge Instructions:
Patient expired on [**6-3**] at 12:12pm.
Followup Instructions:
Patient expired on [**6-3**] at 12:12pm.
|
[
"2762",
"5849"
] |
Admission Date: [**2175-2-21**] Discharge Date: [**2175-2-23**]
Date of Birth: [**2134-3-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
respiratory distress after clonazepam and clonidine overdose
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation.
Extubation.
History of Present Illness:
History of Present Illness:
40M brought in after alledged ingestion of clonidine and
suboxone admitted to the MICU in setting of AMS, respiratory
depression.
Per report EMS called and found patient lethargic. At that time
patient relayed to EMS that he took clonidine and suboxone.
They initially gave him 2mg intranasal narcan, no response.
On arrival to the ED, initial VS: 97.9 57 100/60 18 100%
Non-Rebreather. Patient received 4 additional mg of narcan in
the but had no response. Patient intubated for airway control.
Calcium gluconate 2g in case was CCB. Magnesium for prolonge
QTc. Atropine received 0.5 when brady'd to 30. EKG Sinus
bradycardia at 51, nl axis, QRS 92, QTC 445, no acute st
changes. Labs notable for lack of AG, tylenol/asa pending.
Toxicology consulted who recommended serial FS, as well as
following up pending tox screen. Head CT neg
Of note, ED noted likely aspiration event when he was being
suctioned/ET tube was being advanced father.
Past Medical History:
Narcotics abuse
Heroin abuser (previously on methadone)
Social History:
presumed narcotic abuser given suboxone use, but unable to
assess at this time [**1-26**] sedation
Family History:
NC
Physical Exam:
Admission Physical Exam:
Vitals: T: 36.4 BP: 118/50 P: 49 R: 16 O2:100% intubated
General: intubated, sedated, not arousable to speech, sternal
rub
HEENT: Sclera anicteric, ETT in place, MMM, oropharynx clear,
Pupils pinpoint, reactive
Neck: supple, JVP not elevated, no LAD
CV: regular rhythm, bradycardic, 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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, possible track marks present on LUE
Neuro: withdraws all extremities from pain
Discharge Physical:
Vitals: T: 98.3 BP: 113/77 P: 68 R: 16 O2:100%RA
General: well-appearing, appropriate, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRLA, no
miosis
Neck: supple, JVP not elevated, no LAD
CV: RRR, 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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3, 5/5 strength in all extremities
Pertinent Results:
Imaging:
CXR [**2175-2-21**]:
ReportIMPRESSION: ET tube 7 cm from the carina and can be
advanced several
Preliminary Reportcentimeters, enteric tube tip in the distal
esophagus and should be advanced
Preliminary Reportat least 15 cm.
CXR [**2175-2-22**]:
FINDINGS: In comparison with the study of [**2-21**], the tip of the
endotracheal tube now measures approximately 2.5 cm above the
carina. Nasogastric tube is in the stomach, though the side hole
may well be above the esophagogastric junction. The tube should
be pushed forward several cm.
No evidence of acute cardiopulmonary disease.
CT head w/o [**2175-2-21**]:
IMPRESSION: No acute intracranial process.
Admission Labs:
[**2175-2-21**] 01:39PM BLOOD WBC-7.2 RBC-3.87* Hgb-11.8* Hct-33.2*
MCV-86 MCH-30.5 MCHC-35.6* RDW-13.3 Plt Ct-247
[**2175-2-21**] 01:39PM BLOOD Neuts-70.1* Lymphs-25.7 Monos-3.2 Eos-0.5
Baso-0.5
[**2175-2-21**] 01:39PM BLOOD Glucose-225* UreaN-18 Creat-1.0 Na-134
K-4.4 Cl-97 HCO3-26 AnGap-15
[**2175-2-21**] 01:39PM BLOOD Lipase-13
[**2175-2-21**] 01:39PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2175-2-21**] 01:43PM BLOOD Lactate-1.9
[**2175-2-21**]: urine tox bnzodzpPOS barbitrPOS opiatesNEG cocaineNEG
amphetmNEG mthdoneNEG
Discharge labs:
[**2175-2-22**] 04:00AM BLOOD WBC-8.4 RBC-3.85* Hgb-11.6* Hct-33.1*
MCV-86 MCH-30.2 MCHC-35.2* RDW-13.3 Plt Ct-203
[**2175-2-22**] 04:01PM BLOOD Glucose-86 UreaN-12 Creat-0.8 Na-141
K-3.7 Cl-107 HCO3-28 AnGap-10
Brief Hospital Course:
Mr. [**Known lastname 13170**] is a 40 y/o M who was admitted to the ICU initially
for bradycardia, hypotension, solmnolence and concern for
ingestion. Patient was intubated in the ED for airway management
in the setting of depressed mental status.
# Ingestion/bradycardia/hypotension: After patient recovered,
reported that he intentionally ingested Clonidine and Klonopin,
about 8-10 tablets each. Pt initially presented with somnolence,
and received narcan but had no response. Patient intubated for
airway control in the ED. Pt was also given Calcium gluconate 2g
in case was CCB ingestion. He had bradycardia and received
Atropine 0.5. Repeat Labs notable for lack of AG, tylenol/asa
negative. Toxicology consulted who recommended serial FS, as
well as following up pending tox screen. Head CT negative. Pt
was placed on Dopamine gtt and remained intubated overnight. His
bradycardia improved, and dopamine was weaned off. Pt was
extubated in the AM of HD#1, and psychiatry evaluated the
patient. Pt was not thought to be suicide risk, and the sitter
was discontinued. He was transferred to the medical floors for
further monitoring. onidine overdose manifests with central
nervous system depression/lethargy, bradycardia, hypotension,
respiratory depression, and small pupil size, all of which are
present on admission. On the floor, patient was monitored
overnight, continued to be hemodynamically stable.
# Respiratory depression: Secondary to ingestion as above.
Likely due to BZD overdose. He intubated in the ED for airway
protection. He was extubated on HD#1 without event. On the
floor, his O2 sat high 90s on room air without resp distress.
# Bradycardia- Bradycardia likely [**1-26**] clonidine overdose.
Bradycardia initially did not respond to atropine, so he was
supported on dopamine drip, which was weaned by [**1-/2092**] AM.
Overnight, his HR in the high 50s while sleep, HR 60-70s on
discharge.
# H/o IV Heroine abuse- Patient was on methadone but discharged
from clinic due to selling. SW saw patient and provided
information on [**Hospital 12695**] clinic, which patient is considering.
Per patient, had recent HIV test, which was reportedly negative.
Medications on Admission:
None prescribed
(patient has been taking left over clonidine and Klonipin and
may be buying on the street)
discharged from methadone clinic in [**12/2174**]
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Clonazepam, clonidine overdose
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 13170**],
It was a pleasure participating in your care at [**Hospital1 18**]. You were
admitted after you overdosed on clonidine and clonazepam. As a
result of taking the pills, your breathing and heart rate were
slow, and you were drowsy. You were intubated briefly and kept
on the breathing machine. We also gave you medicine to increase
your heart rate. These problems resolved by the day before
discharge.
Followup Instructions:
You were provided information on for [**Hospital **] clinic- please
follow up
Please also follow up with your new Psychiatrist at [**Hospital1 2177**] as
recommended or restablish care with PCP at [**Hospital1 2177**]
Completed by:[**2175-2-23**]
|
[
"51881",
"42789"
] |
Admission Date: [**2107-5-11**] Discharge Date: [**2107-5-17**]
Service: CARDIOTHORACIC
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2107-5-11**]
Aortic valve replacement 21-mm [**Last Name (un) 3843**]-[**Doctor Last Name **] Magna
pericardial valve
History of Present Illness:
89 year old female with known aortic stenosis which has been
followed by serial echocardiograms. She has become progressively
dyspneic with exertion. Her last echocardiogram showed severe
aortic valve stenosis with a critical peak velocity 3.75 and
peak
gradient 56 mmHg. As she is otherwise healthy, it has been
recommended that she proceed with surgical replacement of her
aortic valve. She has been somewhat reluctant, but now wishes to
proceed.
Past Medical History:
Aortic Stenosis, s/p AVR [**2107-5-11**]
Past Medical History:
1. Aortic stenosis (critical peak velocity 3.75, peak gradient
56 mmHg, echo 07/[**2106**]).
2. Inferior left ventricular hypokinesis -- (echo, [**7-/2106**])
3. Nonobstructive coronary artery disease (40% mid LAD stenosis,
cath 10/[**2106**]).
4. Hypertension.
5. Hyperlipidemia.
6. Peripheral neuropathy.
7. eczema
8. Left and right rotator cuff injury.
9. Spinal stenosis/osteoarthritis
10. bilat. LE varicosities
11. vertigo
12. diverticulosis
13. skin CA
[**10**]. hemorrhoids
Past Surgical History:
R THR
tonsillectomy
cholecystectomy
TAH
Social History:
Lives with: She is widowed and lives in a single family home
by herself. There are no stairs in her house.
Occupation: Retired
Tobacco: Never
ETOH: Denies
Family History:
Parents are both deceased. Father (90; colon
cancer); mother (84 years; unknown). She has two sisters who
passed away in their 70s and 80s. She has three sons (one
disabled after an aneurysm at age 14, others healthy).
Physical Exam:
Pulse: 84 Resp: 16 O2 sat:
B/P Right: Left: 152/70
Height: 5'2" Weight: 140#
General:NAD
Skin: Dry [x] intact [x]; many moles/seborrheic keratoses over
entire trunk/back, occ. eczema patches
HEENT: PERRLA [x] EOMI [x]no JVD
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]; R clavicular scar (unknown
source to pt)
[**Name (NI) 3495**]: RRR [x] Irregular [] Murmur 3/6 SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema-none; RLE scar
from skin CA [**Doctor First Name **]
Varicosities: BLE +
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right:2+ Left:2+
Carotid Bruit murmur radiates to B carotids
Pertinent Results:
[**2107-5-17**] 04:28AM BLOOD WBC-7.9 RBC-3.93* Hgb-12.4 Hct-36.3
MCV-92 MCH-31.7 MCHC-34.3 RDW-15.7* Plt Ct-194
[**2107-5-16**] 04:30AM BLOOD WBC-8.5 RBC-3.69* Hgb-11.7* Hct-33.9*
MCV-92 MCH-31.6 MCHC-34.4 RDW-15.7* Plt Ct-183
[**2107-5-17**] 04:28AM BLOOD Glucose-119* UreaN-16 Creat-0.6 Na-137
K-4.0 Cl-95* HCO3-34* AnGap-12
[**2107-5-16**] 04:30AM BLOOD UreaN-16 Creat-0.5 Na-143 K-3.8 Cl-99
Intra-op TEE [**2107-5-11**]
Conclusions
Prebypass
No atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified
in person of the results on [**2107-5-11**] at 1015am.
Post bypass
Patient is A paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Bioprosthetic
valve seen in the aortic position. It appears well seated and
the leaflets move well. Aorta is intact post decannulation. Mild
mitral regurgitation persists.
Brief Hospital Course:
The patient was brought to the operating room on [**2107-5-11**] where
the patient underwent Aortic Valve Replacement (tissue) with Dr.
[**Last Name (STitle) **]. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued. She did develop
a small pneumothorax on the right which was followed by CXR and
improving. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 6 the patient was ambulating, yet
deconditioned, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged to Newbridge
on the [**Doctor Last Name **] in good condition with appropriate follow up
instructions.
Medications on Admission:
Medications - Prescription
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 (One) Tablet(s) by mouth once a day
INDAPAMIDE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
(One) Tablet(s) by mouth once a day
LOSARTAN - (Prescribed by Other Provider) - 50 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
Medications - OTC
ACETAMINOPHEN [ARTHRITIS PAIN RELIEVER] - (OTC) - 650 mg Tablet
Extended Release - 2 (Two) Tablet(s) by mouth twice a day
ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) -
1,000 mg Tablet - 1 (One) Tablet(s) by mouth once a day
ASPIRIN [BABY ASPIRIN] - (OTC) - 81 mg Tablet, Chewable - 2
(Two) Tablet(s) by mouth once a day
B COMPLEX VITAMINS - (OTC) - Tablet - 1 (One) Tablet(s) by
mouth once a day
CALCIUM CARBONATE [TUMS] - (OTC) - 300 mg (750 mg) Tablet,
Chewable - 1 (One) Tablet(s) by mouth at bedtime
CALCIUM CARBONATE-VIT D3-MIN [CALCIUM-VITAMIN D] - (OTC) - 600
mg-400 unit Tablet - 1 (One) Tablet(s) by mouth twice a day
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) -
Tablet
- 1 (One) Tablet(s) by mouth once a day
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO DAILY (Daily).
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. indapamide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200mg [**Hospital1 **] x 1 week, then 200mg daily until further
instructed.
12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/temp.
15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
16. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 1 weeks.
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 1 weeks.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Aortic Stenosis, s/p AVR [**2107-5-11**]
Past Medical History:
1. Aortic stenosis (critical peak velocity 3.75, peak gradient
56 mmHg, echo 07/[**2106**]).
2. Inferior left ventricular hypokinesis -- (echo, [**7-/2106**])
3. Nonobstructive coronary artery disease (40% mid LAD
stenosis,
cath 10/[**2106**]).
4. Hypertension.
5. Hyperlipidemia.
6. Peripheral neuropathy.
7. eczema
8. Left and right rotator cuff injury.
9. Spinal stenosis/osteoarthritis
10. bilat. LE varicosities
11. vertigo
12. diverticulosis
13. skin CA
[**10**]. hemorrhoids
Past Surgical History:
R THR
tonsillectomy
cholecystectomy
TAH
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
1+ LE edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
You are scheduled for the following appointments:
Surgeon Dr. [**Last Name (STitle) **] [**2107-6-2**], 1:30pm, [**Telephone/Fax (1) 170**]
Cardiologist Dr. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2107-6-16**] 11:00
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 142**] in [**4-5**] 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:[**2107-5-17**]
|
[
"4241",
"41401",
"4019",
"2724"
] |
Admission Date: [**2178-3-18**] Discharge Date: [**2178-3-25**]
Date of Birth: [**2105-12-9**] Sex: F
Service: MEDICINE
Allergies:
Iodine Containing Agents Classifier
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
DDD pacer placement ([**2178-3-18**])
History of Present Illness:
72 yo F with CAD s/p PTCA, DM, HTN, COPD on 2 L home O2, OSA on
BiPAP, and obesity who presents with acute onset of substernal
CP radiating to her back and left arm associated with SOB. Pain
did not resolve with SL NTG and she went to [**Hospital **] Hospital.
Pt given ASA in the ambulance. Received an additional SL NTG at
[**Hospital **] Hosp which decreased her pain to [**3-21**]. At OSH creat
elevated at 2.0. First set of cardiac enzymes were negative.
Her ECG showed bradycardia, likely afib with a juctional escape,
rate 40. She was recently admitted to [**Hospital1 18**] in [**12-15**] for chest
pain and underwent stress test (nonconclusive given her habitus)
and was d/c'ed home with mild medication adjustments. Of note,
she has a h/o a junctional rhythm requiring a temporary pacer
[**10-15**]. Etiology at that time thought to be renal
failure/hyperkalemia and B-B toxicity. A permanent pacemaker
was considered, however, the patient began pacing on her own.
.
In our ED K noted to be 5.8. Pt received Glucagon 4 mg, Insulin
10 Units, D50, Cal Gluc 1 gm, Combivent neb, alb neb, lasix 40
IV, and Solumedrol 125. Pt is currently chest pain free.
Reports SOB at baseline. HR in the low 40's with SBP in the low
100's.
Past Medical History:
1. DM (most recent HbA1C 7.7)
2. HTN
3. Hyperlipidemia
4. CHF - EF > 55%, RV dilation
5. OSA- uses BiPAP 21/17
6. COPD - on home O2 2 liters (PFTs [**2173**] - FEV 1.08 (64%), FVC
1.24 (53%),FEV/FVC: 122%)
7. OA - unable to ambulate at baseline, uses wheelchair
8. Chronic back pain
9. Spinal Stenosis
10. s/p cholecystectomy
[**82**]. s/p hysterectomy
12. CAD s/p LAD PTCA [**7-15**]
13. PAF s/p 6wk coumadin therapy
Social History:
Denies tobacco, EtOH, or drug use.
Family History:
Mother - CAD, DM, died age 80
Father - CAD, died age 89
Physical Exam:
VS: HR 42, BP 105/60, RR 18, O2 sat 97% RA
GEN: obese female, NAD
HEENT: Dry MM
Neck: unable to appreciate JVD
Chest: decreased air movement, exp wheezes, bibasilar crackles
CV: regular, bradycardic, no murmurs
Abd: soft, obese, NT/ND,
Ext: [**3-14**]+ pitting edema
Neuro: A&Ox3
Pertinent Results:
[**2178-3-18**] 01:20AM CK-MB-2 cTropnT-0.02* proBNP-6008*
[**2178-3-18**] 01:22AM GLUCOSE-132* NA+-140 K+-5.8* CL--109 TCO2-21
[**2178-3-18**] 01:20AM UREA N-27* CREAT-1.9*
[**2178-3-18**] 01:20AM WBC-6.8 RBC-3.50* HGB-8.7* HCT-28.6* MCV-82
MCH-25.0* MCHC-30.6* RDW-16.2*
CXR [**2178-3-18**]: blunting of costophrenic angles. pulm vasc
congestion. no infiltrate
.
ECG: RBBB and L ant fascicular block with sinus arrest,
ventricular rate 40 bpm, no ST-T changes
Brief Hospital Course:
Upon admission, Ms. [**Known lastname **] ECG showed a RBBB with L anterior
fascicular block with sinus arrest and a ventricular rate of
approximately 40 bpm. Due to the instability of this rhythm, EP
was consulted and she was taken for implantable DDD pacemaker
placement on [**2178-3-18**]. Due to her underlying pulmonary disease,
she was intubated for the procedure and remained intubated
post-procedure. She was easily weaned off the vent and
extubated on the morning of [**2178-3-19**]. Her beta-blocker was held
due to her conduction abnormalities and she was started on
diltiazem in its place and this was titrated up; per EP, beta
blockade can be resumed as an outpatient as she tolerates. She
will complete a 5-day course of peri-procedure antibiotics and
will follow up in device clinic in approximately one week. After
the pacer was placed she was noted to be intermittantly in
atrial flutter. She was started on coumadin for anticoagulation
(without heparin bridge) and will likely have cardioversion in a
few weeks with Dr. [**Last Name (STitle) **].
Additionally she noted bilateral knee pain consistent with
osteoarthritic pain that she has had in the past documented back
to the [**2151**]'s, previously evaluated for knee replacement in [**2170**]
but determined to be a poor surgical candidate given her
comorbidities. This was thought secondary to recent increased
mobilization with physical therapy and controlled with tylenol
and occaisional oxycodone.
Medications on Admission:
1. Advair 250-50 mcg [**Hospital1 **]
2. Albuterol prn
3. Amitriptyline 50mg
4. Aspirin 325mg
5. Atorvastatin 80mg
6. Clopidogrel 75mg
7. Furosemide 40mg
8. Ipratropium qid
9. Ferrous Sulfate 325mg [**Hospital1 **]
10. Gabapentin 600mg tid
11. Potassium & Sodium Phosphates 278-164-250mg [**Hospital1 **]
12. SL NTG prn
13. Clotrimazole 1 % Cream [**Hospital1 **]
14. Nystatin 100,000 unit/g Ointment [**Hospital1 **]
15. Pantoprazole 40mg
16. KCL 40meq
17. Docusate [**Hospital1 **]
18. Oxycodone 5mg prn
19. Toprol XL 50mg
20. Senna [**Hospital1 **]
21. Bisacodyl prn
22. Magnesium Hydroxide prn
23. Acetaminophen 1g qid
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation four times a day.
7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
(20) units Subcutaneous once a day: in am.
10. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen
(15) units Subcutaneous at bedtime.
11. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
12. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Three Hundred (300)
mg PO once a day.
13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
14. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
Charlwell
Discharge Diagnosis:
Sinus arrest with symptomatic bradycardia.
.
Morbid obesity, obstructive sleep apnea, chronic obstructive
pulmonary disease, diabetes mellitus, hypertension, congestive
heart failure, spinal stenosis, coronary artery disease, atrial
fibrilation.
Discharge Condition:
Good.
Discharge Instructions:
Please take all medications as prescribed, please keep all
follow-up appointments. Please notify your primary care doctor,
Dr. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 1300**] or your cardiologist,
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], ([**Telephone/Fax (1) 5455**] if you experience worsening
chest pain, shortness of breath, nausea, vomiting, wheezing,
dizziness, light headedness, increased swelling in your legs, or
any symptoms that concern you.
.
Weigh yourself every morning, call your doctor if weight > 3
lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: Please limit your fluid intake to 1500mL
(1.5L) of fluid daily
Followup Instructions:
Please follow-up in device clinic to be sure your pacer is
working properly on [**2178-3-26**] at 10:00am in radiology
([**Telephone/Fax (1) 327**]) for imaging, followed by your appointment in
device clinic ([**Telephone/Fax (1) 59**]) at 11:30am
.
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2178-4-8**] at
11:45am. Please call if questions: ([**Telephone/Fax (1) 5455**].
.
Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2178-3-26**] at
1:20pm. It is very important that you have your INR checked at
this visit so your dose of coumadin can be adjusted. Please call
if questions: ([**Telephone/Fax (1) 5455**].
|
[
"42789",
"5849",
"2767",
"496",
"5859",
"4280",
"42731",
"41401",
"V4582",
"2724",
"32723",
"25000",
"40390"
] |
Admission Date: [**2151-4-15**] Discharge Date: [**2151-4-24**]
Date of Birth: [**2111-7-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Palpitations
Major Surgical or Invasive Procedure:
ICD placement
History of Present Illness:
39 yo M presenting with chest heaviess. PMH of Ebstein's anomaly
who is s/p tricuspid valve reconstuction and ASD repair in [**2136**].
Has severe TR and resultant right heart failure. He is [**State 531**]
Heart Failure Class III and has DOE with climbing one flight of
stairs. He recently saw Dr. [**First Name (STitle) 437**] on [**2151-4-12**] for consideration of
heart transplantation. Patient was most recently admitted to
[**Hospital1 18**] 3 weeks ago after experiencing heart palpitations and had
VT. At that time he was treated with IV amiodarone and
cardioverted. He was started on po amio and d/c'ed with plan for
an ICD.
.
Yesterday he states he started having chest heaviness at rest
similar to the symptoms he had prior to his last admission.
States he felt palpitations but did not take his pulse. Also
reports feeling dizzy at that time but no pre-syncope or
syncope. These symptoms last approzimately 2 hours and had
resolved by the time he got to the ED. Had some mild SOB at this
time as well. Denies diaphoresis, N/V, abdominal pain or head
ache. Denies PND or orthopnea. States he has baseline [**Location (un) **] R>L.
States this [**Location (un) **] has actually improved significantly since his
last admission. Of note, he reports a 30-40 lbs weight loss in
the last 5 weeks - has changed his diet since his admission and
has stopped eating sugar. No fever, chills or night sweats. No
symptoms of claudication. States his taste has changed since
starting amiodarone as well.
.
ROS: As above, otherwise negative.
Past Medical History:
1. Ebstein anomaly, s/p tricuspid valve reconstruction
- moderate to severe tricuspid regurgitation
- right heart failure, RVEF 25% in [**6-17**]
2. ASD, s/p primary closure [**3-/2136**]
3. Left heart failure with evidence of noncompaction of LV, with
LVEF 28% in [**6-17**]
4. Hyperlipidemia
5. Hypertension
6. Obstructive sleep apnea
7. Obesity
8. DVT
9. Superficial phlebitis
10. endocarditis w/ septic emboli to brain prior to Cardiac
surgery.
Social History:
Married with 3 children. Former cigarette smoker, quit 10 years
ago, smokes an occasional cigar, drinks 1 drink/week. No illicit
drugs. Has recently lost 15 lbs with healthier eating habits.
Works at [**Hospital1 18**] as repair man.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father's family history is unknown, mother is
alive in her 60's.
Physical Exam:
On Presentation:
VS: T 97.6 BP 122/70 HR 68 RR 18 O2 98% on RA
GENERAL: NAD, AOX3, obese male
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 14 cm
CARDIAC: distant heart sounds, normal S1 and S2, 4/6 SEM at LLSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND, obese. No HSM or tenderness.
EXTREMITIES: 1+ edema L, 2+ edema R (long standing). No palpable
cord, no calf tenderness, negative [**Last Name (un) 5813**] sign.
SKIN: mild LE venous stasis changes. No ulcers, scars, or
xanthomas.
PULSES:
Right: Carotid 2+ DP 2+
Left: Carotid 2+ DP 2+
Pertinent Results:
TEE [**2151-4-22**]: Limited images were obtained by transesophageal
echocardiogram to view the positioning of a right ventricular
pacemaker lead in the electrophysiology laboratory. Ebstein's
anomaly was present with apically displaced sail-like tricuspid
leaflets. A tricuspid annuloplasty ring is present at the AV
groove. Atrialized right ventricle is dilated with a hypokinetic
true right ventricle at the apex. The right ventricular
pacemaker lead was guided through the tricuspid valve into the
true right ventricular apex.
RELEVANT LABS:
- CHEM 7: GLUCOSE-105 UREA N-17 CREAT-1.2 SODIUM-138
POTASSIUM-3.5 CHLORIDE-100 TOTAL CO2-26 ANION GAP-16
- CBC: WBC-6.5 HGB-13.0* HCT-39.8*#
- Coags: PT-18.1* PTT-32.7 INR(PT)-1.7*
- HCV Ab: negative
Brief Hospital Course:
39 yo M presenting with palpitations, dizziness and chest
heaviness with PMH of Ebstein's anomoly s/p tricuspid valve
recontsruction and ASD repair with known NYHF calss III CHF and
recent admission for palpitations and VT s/p cardioversion. Had
ICD placed without complication. Discharged in stable contition
home with cardiology, EP and BACH team follow up appointments.
# Palpitations: Had prior to admission, none while in patient.
Has Ebstein's anomoly. Patient with hx VT, EP study unable to
reproduce but had short runs of NSVT, but nothing was ablated
given could no induce VT. At that time, morphology was LBBB
wtih inferior axis and V1/V2 transition point. Focus per EP
study was likely RVOT. Patient was on amiodarone drip fpr 2
days which was then d/c'ed in preparation for ICD placement
which was done without complication. Continued metoprolol 25 mg
tid. Discharged in stable condition with follow up as above.
# Chest pressure: Had on admission, but none after. Has no known
coronary artery disease. Cardiac biomakers negative were
negative x3. Symptoms were likely related to palpitations.
# Ebstein's Anomoly: Followed by the BACH team at [**Hospital1 **],
contact is Dr. [**Last Name (STitle) 2413**]. Has follow up with them in [**Month (only) 547**].
Likely plan is surgery after optimizing patient's physical
health - weight loss specifically. Patient aware.
# CHF: EF 40%, class III symptoms. Euvolemic throughout hospital
stay, had baseline lower extremity edema right greater than left
which is baseline. Patient has had LENIs at prior admission
with no DVT. Has elevated JVP thought to be [**3-15**] to 4+ tricuspid
regurgitation. Increased lasix to 40mg qd and increased
lisinopril to 5mg qd.
# Elevated INR: Has been chronically elevated 1.5-1.7,
non-responsive to po vitamin K x2 during this hospitalization.
Likely secondary to heart failure, possibly cirrhosis. LFT's
normal Hep C negative, mixing study negative. Recommend out
patient follow up with hepatologist and liver ultrasound.
# PPx: received heparin
Medications on Admission:
Aspirin 325 mg daily
Amiodarone 200 mg t.i.d.
Lipitor 20 mg daily
Colchicine 0.6 mg daily
Lasix 40 mg daily
Lisinopril 2.5 mg daily
metoprolol 25 mg b.i.d.
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours.
Disp:*60 Tablet(s)* Refills:*2*
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
8. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO
every 4-6 hours as needed for pain.
Disp:*15 Tablet(s)* Refills:*0*
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours: Take every 8 hours for 3 days then as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
- Ebstein anomaly, s/p tricuspid valve reconstruction with
moderate to severe tricuspid regurgitation
- Right heart failure, RVEF 25% in [**6-17**]
- ASD, s/p primary closure [**3-/2136**]
- Left heart failure with evidence of noncompaction of LV, with
LVEF 28% in [**6-17**]
- Hyperlipidemia
- Hypertension
- Obstructive sleep apnea - on CPAP at home
- Obesity
- DVT
- Superficial phlebitis
- History of bacterial endocarditis w/ septic emboli to brain
prior to Cardiac surgery
Discharge Condition:
Vitals stable. Ambulating without difficulty or pain.
Discharge Instructions:
You were admitted with heart palpitations and an abnormal heart
rhythm. Because this rhythm is potentially dangerous, you had an
intracardiac defibrillator (ICD) implanted. This is in case
your heart goes in to an abnormal rhythm and needs to be
shocked. You tolerated this procdure without difficulty. You
were also evaluated by the [**Hospital1 **] adult congenital surgery
team and they will consider surgery on you in the future. You
should make an appointment to see Dr. [**Last Name (STitle) 2413**] on [**2151-5-24**] at 3pm.
Your amiodarone was stopped and you should discontinue this
medication at home.
Additionally, you should take Levofloxacin 500mg once a day for
the next 5 days to prevent infection at your ICD site. You can
also Tylenol #3 [**2-12**] pills every 6 hours for pain. Take
ibuprofen 400mg every 8 hours - take for 3 days and then as
needed.
Finally, your Lasix was increased to 40mg TWICE a day and your
Lisinopril was increased to 5mg once a day.
No other medication changes were made and you should continue
all your other home medications as directed.
As we spoke about, further weight loss will help you when you go
for surgery and you should continue the healthy eating habits
you've recently started.
Because you have heart failure, you should weigh yourself every
morning and call your doctor if your weight increases by 3
pounds or more. You should also follow a low salt diet.
Some of your liver tests indicated that there may be damage to
your liver from your long standing heart failure. You should
follow up with your primary care doctor who can recommend a
liver specialist.
If your ICD fires you should come to the emergency room
immediately.
If you have heart paliptations, chest pain, pain, redness or
swelling at the ICD implantation site, shortness of breath,
abdominal pain, increased lower leg swelling, high fever, nausea
or vomiting, light headedness or dizziness, or any other
concerning symptom, please seek medical care immediately.
It was a pleasure meeting and participating in your care.
Followup Instructions:
DEVICE CLINIC:
Phone:[**Telephone/Fax (1) 62**] on [**2151-4-29**] at 10:00pm
CARDIOLOGY:
- [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2151-6-2**]
12:20
- [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2151-7-7**] 9:20
[**Hospital1 **]:
Dr. [**Last Name (STitle) 2413**] [**2151-5-24**] at 3:00pm
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], you can reach him at
[**Telephone/Fax (1) 250**]. He will also be able to help you find a liver
specialist.
|
[
"4280",
"42789",
"32723",
"2724",
"4019"
] |
Admission Date: [**2196-1-24**] Discharge Date: [**2196-2-1**]
Date of Birth: [**2139-5-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
Abdominal pain, increasing abdominal girth, weakness, confusion
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
56yoM with hx of EtOH cirrhosis, EtOH abuse, and hx of recent
GIB presenting with abdominal pain, mental status change and
diarrhea. Describes having 1 week of increasing stomach girth.
Started feeling weak last night and then today felt as though he
could not walk. Denies falls. In addition, has had 1 week of
sporadic diffuse abdominal pain that comes and goes, is worse
when he is lying down, and he cannot identify triggers. It has
not been worsening over the week. Also endorses slight back
pain. Has had very frequent, but formed stools in spite of not
having recently taken Lactulose (d/c'd by Dr [**Last Name (STitle) **] per pt's
report because he could not tolerate the frequency of the BM's).
Has been taking Rifaximin. His partner became concerned and
called an ambulance today when the weakness and inability to
walk continued, and he also became confused. Denies fever, says
he is "always cold," denies night sweats. No cough, SOB, or CP.
No nausea or vomiting, no blood in stools or BRBPR.
Recently discharged from [**Hospital1 18**] ([**2196-1-7**]) after being treated for
hepatic encephalopathy, EtOH intoxication, and GIB. He had an
EGD, which was unremarkable for an active bleeding source, but
he was found to have portal gastropathy, no varices (though has
been noted to have varices on prior EGD reports). The patient's
Hct remained stable during that admission, and he did not have
any blood transfusions. He also had a RUQ U/S and CT abdomen to
assess for portal vein thrombosis, but these were also negative.
Denies prior episodes of SBP. Said the last time he was tapped
was [**2187**] when he was diagnosed with ascites. Dry weight is
175lbs, has gained 10lbs over the past week. Has not eaten
today, but was able to eat yesterday without N/V. Last EtOH
drink was prior to last admission (over 1 month ago). Has been
taking all medications as directed.
.
In the ED, VS were 97.8, 108/69, 108, 20, 100% RA. He was given
Ceftriaxone 2gm IV, Albumin 100g, 1L NS, and 30cc lactulose.
.
On the floor, endorses mild diffuse abdominal pain and says he
is currently feeling confused. Still having loose stools. No
SOB.
Past Medical History:
EtOH cirrhosis, followed by liver here (Dr. [**Last Name (STitle) **]
EtOH abuse - no hx of seizures or DTs
H/o GIB [**1-4**] PUD, portal gastropathy. No known varices on most
recent EGD.
Prior episode of encephalopathy
Hypertension
Hypercholesterolemia
Social History:
Patient is currently employed as a concierge. He lives with his
partner in [**Name (NI) 86**]. History of heavy etoh use ([**1-5**] vodka
drinks/night), now has not had alcohol since end of [**Month (only) 404**].
Tobacco- quit 8 years ago, prev. smoked [**12-4**] ppd for many years.
Denies IVDU or illicit drug use.
Family History:
Mother: heart disease, 3 strokes, uterine cancer.
Father: heart disease, died of heart attack in his 40's,
diabetes. He has eight siblings; one brother with heart
disease.
Physical Exam:
VS: T 96.9 HR 106 BP 122/70 RR 16 98%RA
GEN: appears of stated age, no distress, though moves slowly due
to "stiffness." + fetor hepaticus.
HEENT: NCAT, EOMI, PERRL, sclera icteric, OP dry but without
lesions.
NECK: Supple, no lymphadenopathy, no JVD, no carotid bruits.
CV: regular, 2/6 systolic murmur best heard at LLSB.
CHEST: bilateral crackles, L>R, equal breath sounds throughout
ABD: distended, diffuse discomfort to palpation, dullness to
percussion throughout.
RECTAL: guaiac negative, no masses.
EXT: 2+ pitting edema bilaterally in LE from feet to upper
thighs, + asterixis.
SKIN: spider angiomas on chest, jaundice, caput medusa on
abdomen.
NEURO: Awake, alert, oriented to person, and place. Delay in
answering date with error and then corrects himself. Impaired
attention (does days of week forwards but not backwards).
CNII-XII grossly in tact. [**4-5**] muscle strength in UE/LE b/l,
sensation to LT intact, toes down-going bilaterally.
Pertinent Results:
ADMISSION LABS:
CHEMISTRIES:
[**2196-1-24**] 02:10PM GLUCOSE-116* UREA N-39* CREAT-1.4* SODIUM-134
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-23 ANION GAP-20
WBC:
[**2196-1-24**] 02:10PM WBC-16.9* RBC-3.09* HGB-10.1* HCT-29.9*
MCV-97 MCH-32.5* MCHC-33.6 RDW-16.2*
[**2196-1-24**] 02:10PM NEUTS-91.7* LYMPHS-5.6* MONOS-2.3 EOS-0.4
BASOS-0.1
TOX SCREEN:
[**2196-1-24**] 02:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
AMMONIA LEVEL:
[**2196-1-24**] 02:10PM AMMONIA-79*
LFTs
[**2196-1-24**] 02:10PM ALT(SGPT)-60* AST(SGOT)-75* LD(LDH)-175 ALK
PHOS-312* TOT BILI-16.5* ALBUMIN-2.4*
COAGS:
[**2196-1-24**] 03:30PM PT-18.6* PTT-39.5* INR(PT)-1.7*
PANCREATIC ENZYMES:
[**2196-1-24**] 02:10PM LIPASE-84*
ASCITES FLUID:
[**2196-1-24**] 04:50PM ASCITES TOT PROT-0.6 GLUCOSE-0 LD(LDH)-277
ALBUMIN-<1.0
[**2196-1-24**] 04:50PM ASCITES WBC-[**Numeric Identifier 106537**]* RBC-3975* POLYS-95*
LYMPHS-0 MONOS-0 MACROPHAG-5*
[**2196-1-27**] 02:50PM ASCITES WBC-4700* RBC-800* Polys-0 Lymphs-0
Monos-0
[**2196-1-29**] 11:20AM ASCITES WBC-[**Numeric Identifier 106538**]* RBC-475* Polys-84* Lymphs-0
Monos-0 Macroph-16*
--------
--------
MICROBIOLOGY:
[**2196-1-24**] 9:45 pm BLOOD CULTURE
**FINAL REPORT [**2196-1-27**]**
Blood Culture, Routine (Final [**2196-1-27**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final [**2196-1-25**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name9 (NamePattern2) 106539**] [**Doctor Last Name **] [**Numeric Identifier 106540**] [**2196-1-25**] 11:55AM.
Aerobic Bottle Gram Stain (Final [**2196-1-25**]): GRAM NEGATIVE
ROD(S).
------
[**2196-1-27**] 2:50 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final [**2196-1-28**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 74280**] [**2196-1-28**] 8:00AM.
-------
[**2196-1-29**] 11:20 am PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final [**2196-1-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**Doctor Last Name **] BLACK 1430 [**2196-1-29**].
FLUID CULTURE (Preliminary):
ESCHERICHIA COLI. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
PIPERACILLIN---------- 32 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
FUNGAL CULTURE (Preliminary):
--------
IMAGING STUDIES:
ABD U/S [**2196-1-25**]:
IMPRESSION:
1. Echogenic, nodular liver which is compatible with reported
history of
cirrhosis.
2. Cholelithiasis without evidence of cholecystitis.
3. Ascitic fluid contains low-level internal debris.
-------
CT ABD/PELVIS [**2196-1-25**]
IMPRESSION:
1. Large-volume ascites. No evidence for abdominal or pelvic
hemorrhage.
2. Extensive peri-bronchovascular opacity at the lung bases
would be
consistent with infection. Small left greater than right pleural
effusions.
3. Cholelithiasis.
4. Cirrhosis with portal hypertension, though noncontrast
evaluation is
limited.
5. Diffuse anasarca.
-------
CXR [**2196-1-29**]:
In comparison with the study of [**12-26**], there is persistent and
possibly increasing opacification at the left base consistent
with pneumonia
and pleural effusion. Increased prominence of interstitial
markings that are
not sharply defined is consistent with increasing pulmonary
venous pressure,
consistent with overhydration.
Brief Hospital Course:
This is a 56 year old male with a history of decompensated EtOH
cirrhosis recently treated with a steroid course for acute
hepatitis secondary to alcohol abuse who presented with
abdominal pain, diarrhea, and altered mental status. He was
found to have spontaneous bacterial peritonitis with ESBL
E.Coli, bacteremia with ESBL E.Coli, possible pneumonia, and
acute renal failure. He later developed hepatic encephalopathy.
He was treated aggressively with antibiotics, fluids, albumin,
lactulose, and octreotide/midodrine (for possible hepatorenal
syndrome). Repeat paracenteses revealed worsening of the
infection. Tube feeds were given for nutrition. He was hypoxic
and oxygen was initiated. Despite these measures, the patient's
condition deteriorated and upon discussion with his family
(brother [**Name (NI) 106541**] health care proxy, and [**Name2 (NI) 1063**] [**Name (NI) **]), he was
made DNR/DNI, and eventually comfort measures only. He expired
on [**2196-2-1**] at 8:07AM.
Medications on Admission:
1. Rifaximin 200 mg Tablet - Two Tablets PO TID
2. Furosemide 40 mg PO DAILY
3. Pantoprazole 40 mg PO Q12H
4. Spironolactone 50 mg Tablet PO QD
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY
6. Thiamine HCl 100 mg Tablet PO DAILY
7. Folic Acid 1 mg Tablet PO DAILY
8. Prednisone 10 mg Tablet - Three (3) Tablet PO DAILY
9. Calcium Carbonate 500 mg PO TID (3 times a day).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two PO
DAILY
11. Insulin Glargine 100 unit/mL Cartridge Sig: 6 Units
Subcutaneous at bedtime.
12. Insulin Syringe [**12-4**] mL 29 x [**12-4**] Syringe Sig: One (1)
syringe Miscellaneous at bedtime for 30 days.
13. Lancets,Ultra Thin Misc Sig
14. One Touch Ultra 2 Kit [**Hospital1 **]
15. One Touch II Test [**Hospital1 **]
Discharge Medications:
none, expired
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Spontaneous bacterial peritonitis with ESBL E.Coli
2. Sepsis with ESBL E.Coli
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2196-2-1**]
|
[
"5849",
"486",
"99592",
"2859",
"2875"
] |
Admission Date: [**2146-6-27**] Discharge Date: [**2146-7-5**]
Date of Birth: [**2062-9-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
fever, obstructive cholestasis, and acute renal failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83-year-old man with PMHx of CVA and resultant "locked in"
syndrome, recurrent aspiration pneumonia and UTIs who presented
with fever, tachypnea, abd distension and suspected aspiration
event. Of note, pt is aphasic at baseline and unable to provide
history. Per OMR, he had a new PEG tube placed on [**2146-6-23**] at
[**Hospital1 18**].
Past Medical History:
CVA with "locked in" syndrome
H/o PE on coumadin
Dementia
Depression
Recurrent UTI
s/p G-tube placement for recurrent aspiration
Recurrent skin ulcer
Atypical psychosis
Thoracic aortic aneurysm
h/o Recurrent UTIs including proteus
Social History:
Pt lives in [**Hospital3 **], aphasic at baseline and dependant
for all ADLs
Family History:
non-contributory
Physical Exam:
Vitals: T: 95.7 BP: 118 P: 90 R: 23 Sats 100% on NRB
General: eyes open, grimaces to exam, no response to verbal stim
[**Hospital3 4459**]: Sclera anicteric, eyes follow examiner
Neck: supple, unable to assess JVP
Lungs: audible upper airway secretions with rhonchi, L sided
wheezes, abd breathing
CV: RRR, unable to appreciate murmurs through upper airway
sounds
Abdomen: soft, non-distended, bowel sounds audible, no grimaces
to deep palpation,
GU: foley in place
Ext: warm, 1+ pulses, no cyanosis or edema.
Pertinent Results:
Labs at admission [**2146-6-27**]:
WBC-31.8*# RBC-4.40* Hgb-12.4* Hct-36.8* MCV-84 MCH-28.1
MCHC-33.7 RDW-15.6* Plt Ct-194
Neuts-74* Bands-9* Lymphs-11* Monos-6 Eos-0 Baso-0 Atyps-0
Metas-0 Myelos-0
Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-NORMAL
Microcy-1+ [**Name (NI) 2850**]
PT-38.1* PTT-53.2* INR(PT)-4.0*
Fibrino-736*# D-Dimer-As of [**10-26**]
Glucose-146* UreaN-45* Creat-2.4*# Na-131* K-3.9 Cl-93* HCO3-24
AnGap-18
ALT-19 AST-33 CK(CPK)-250* AlkPhos-63 TotBili-1.7* DirBili-0.8*
IndBili-0.9
Lipase-17
CK-MB-6 cTropnT-0.05*
Albumin-3.4 Calcium-7.8* Phos-2.8 Mg-2.8*
D-Dimer-962*
Acetone-NEGATIVE
Vanco-4.8*
Lactate-3.1*
.
Labs at transfer [**2146-6-29**]:
WBC-22.3* RBC-3.44* Hgb-9.5* Hct-28.3* MCV-82 MCH-27.6 MCHC-33.6
RDW-16.6* Plt Ct-160
Neuts-94.3* Lymphs-1.3* Monos-3.2 Eos-0.1 Baso-1.1
PT-41.1* PTT-54.6* INR(PT)-4.3*
Glucose-123* UreaN-37* Creat-1.5* Na-142 K-3.5 Cl-110* HCO3-22
AnGap-14
ALT-24 AST-43* LD(LDH)-177 AlkPhos-50 TotBili-0.9
CK-MB-9 cTropnT-0.01
Albumin-2.6* Calcium-8.6 Phos-2.1* Mg-2.3
Vanco-4.8*
.
UA [**2146-6-27**]: RBC-[**1-27**]* WBC-[**10-14**]* Bacteri-MANY Yeast-NONE Epi-0-2
.
Micro:
.
Blood cx [**2146-6-27**]: STAPH AUREUS COAG +
Blood cx [**Date range (1) 27298**]: no growth to date
C.diff negative x2
UCx - negative
.
IMAGING:
.
CT [**Last Name (un) **]/pelvis [**2146-6-27**]: 1. Distended gallbladder containing
gallstones and pericholecystic fluid, cholecystitis is not
excluded. 2. Signifcant fecal loading, correlate for clinical
evidence of fecal impaction. 3. Bibasilar areas of atelectasis
and/or consolidation with small right pleural effusion. 4.
Incompletely assessed region of intermediate density in the left
kidney, if clinically warranted, could be further evaluated with
MRI.
5. Non obstructive renal calculi. 6. Dilated aorta at the
diaphragmatic hiatus is stable in size, but not fully evaluated
given lack of intravenous contrast.
.
RUQ U/S [**2146-6-27**]: Very limited ultrasound evaluation of the
gallbladder demonstrating multiple stones and minimal wall
thickening but trace pericholecystic fluid.
.
HIDA [**2146-6-28**]: Acute cholecystitis
.
CXR [**2146-6-29**]: compared to [**2146-6-28**], Progressive consolidation at the
right lung base could be due to either worsening pneumonia or
atelectasis. Atelectasis at the base of the left lung is less
severe but stable. Cardiac silhouette is hard to assess, because
of adjacent pleural and parenchymal abnormalities. Pleural
effusion is small, if any. The head and mandible obscure the
lung apices particularly the left. No pneumothorax is evident
along the imaged portions of pleural surfaces.
.
ECHO [**2146-6-29**]: Poor technical quality. LV function is probably
normal, a focal wall motion abnormality cannot be fully
excluded. The RV is not well seen. No cardiac source of embolism
or evidence of endocarditis identified. No significant valvular
abnormality seen. Compared with the prior study (images
reviewed) of [**2144-12-3**], the findings are similar. A cardiac
source of embolus cannot be definitively excluded.
.
EKG: sinus tachycardia without acute ST-T wave changes
Brief Hospital Course:
83-year-old man with history of CVA, recurrent aspiration and
UTIs who presented with fever, tachypnea and suspected
aspiration now with abdominal CT concerning for cholecystitis.
.
In the ED, initial VS were: T 101.2 BP 79/42 HR 109 RR 32 Sats
87% on RA which came up to 100% on a NRB. Pt received a total
of 4L IVF, [**Year (4 digits) 9847**] 400mg IV, metronidazole 500mg IV, cefepime 2
grams and vanc 1 gram. He had a left femoral CVL placed and CXR
revealed low lung volumes with possible right lower lobe
infiltrate. He had a distended abd with mildly abnormal LFTs
and thus, he underwent a CT abdomen with results above. Surgery
recommended RUQ ultrasound which was not interpretable. Patient
was admitted to the ICU for further management.
# Fever/Leukocytosis: Etiology was initially unclear as pt was
at risk for infection from multiple possible sources. Given
loose stools and impressive leukocytosis C. diff was ordered,
which was negative x2. H/o recurrent aspiration PNA with
infiltrates and hypoxia suggested a possible component of
aspiration PNA or pneumonitis. Initial UA positive for UTI but
UCx demonstrated no growth. Additional concern for
cholecystitis although Tbili only mildly elevated and alk phos
was normal. Pt was treated empirically with vanc, pip-tazo, and
metronidazole. Pt underwent HIDA which demonstrated acute
cholecystitis. Pt was not surgical candidate given multiple
co-morbidities. After stabilization of patient, he was
transferred out of the ICU. Blood culture was positive for MRSA.
Metronidazole was discontinued and patient was kept on
vancomycin and pip-tazo. Plan is to keep pt on vancomycin for
three weeks with last day on [**2146-7-18**] and on pip-tazo with last
day [**2146-7-11**].
.
# Hypoxia: Pt with h/o recurrent aspiration, now with bilateral
lower lobe infiltrates. Possible aspiration in the Nursing home
prior to transfer to ED. Pt was covered empirically with
vanc/pip-taz. He was given albuterol/atrovent nebs for wheezing
and received chest PT. Diruesis was not done given pt's
hypotension on admission. By discharge, patient's O2 sat was in
the high 90s on room air.
.
# ARF: Cr 2.4 on admission, likely due to dehydration and
hypoperfusion. Pt with h/o recurrent UTI and stones though no
clear evidence of obstruction of CT [**Last Name (un) 103**]. Pt was treated for
presumed UTI (given h/o proteus/pseudomonas UTI) with pip-tazo.
He was given IV fluids with goal UOP>30cc/hr with improvement in
his ARF. By discharge, Cr has trended down to 0.8.
# s/p PE on coumadin: INR supratherapeutic at 5.0. Warfarin was
held and restarted when INR trended down to 3.1. Warfarin was
restarted on [**2146-7-5**] at home dose of 5mg po daily, and INR will
need to be monitored closely for a goal INR of [**12-28**].
.
# s/p CVA: pt with "locked in" syndrome. Diazepam was initially
held for hypotension. Once his BP stabilized, his diazepam was
restarted at nursing home dose.
.
# FEN: Pt was initially made NPO given possible aspiration.
After stabilization, tube feeds were restarted.
.
# Foot ulcer: Pt was found to have a pressure ulcer at the first
MTP joint on his left foot with exposed bone, concerning for
osteomyelitis. Podiatry was consulted. However, given pt's
comorbodities and non-palpaple distal pedis pulses, he was not
thought to be a good candidate for debridement. The ulcer was
managed medically with the above antibiotic regimen.
.
# Access: Femoral CVL was removed and tip sent for culture and
replaced with 18 gauge PIV and a PICC line was placed.
Medications on Admission:
Senna 8.6 mg Cap
Prilosec OTC 20 mg Tab daily
Acetaminophen 325 mg Tab 2 Tablet(s) twice a day via jtube
Potassium Chloride SR 20 mEq via G-tube once daily
Baclofen 10 mg Tab 1 Tablet(s) QID via g-tube
Coumadin 1 mg Tab
Teargen 1.4 % Eye Drops [**11-26**] gtts. ou four times a day
Metoprolol SR 12.5 mg 24 hr twice a day give via j-tube
Discharge Medications:
1. Diazepam 2 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
2. Baclofen 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QID (4 times a
day).
3. Famotidine 20 mg IV Q24H
4. 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.
5. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
6. Vancomycin 1,000 mg Recon Soln [**Month/Day (2) **]: One (1) Intravenous
every twelve (12) hours for 13 days: Please continue through
[**2146-7-18**].
7. Zosyn 4.5 gram Recon Soln [**Month/Day/Year **]: One (1) Intravenous every
eight (8) hours for 6 days: Please continue through [**2146-7-11**].
8. Warfarin 5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO once a day:
Please monitor INR.
9. Artificial Tear (Hypromellose) 0.5 % Drops [**Month/Day/Year **]: One (1) drops
Ophthalmic four times a day: Both eyes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary diagnoses: Acute cholecystitis, aspiration pneumonia,
MRSA bacteremia
Secondary diagnoses:
CVA with dysphagia and "locked in syndrome", dementia,
depression, aspiration pneumonia , constipation, recurrent skin
ulcer, atypical psychosis, pulmonary embolism, thoracic aortic
aneurysm , recurrent urinary tract infections
Discharge Condition:
Stable
Discharge Instructions:
You presented to [**Hospital1 18**] on [**2146-6-27**] with a fever and low blood
pressure. Work-up revealed that you most likely had an
aspiration pneumonia, MRSA bacteremia and acute cholecystitis.
You were treated with antibiotics. Your fever and blood pressure
improved.
You are still on two antibiotics--vancomycin and
piperacillin/tazobactam--which you need to continue for your
pneumonia and bacteremia.
Please continue vancomycin for 21 more days and
piperacillin-tazobactam for 6 more days.
Please call your doctor or return to the ER for fevers, chills,
chest pain, shortness of breath, or any other concerning
symptom.
Followup Instructions:
Completed by:[**2146-7-5**]
|
[
"5070",
"5849",
"5990",
"42731"
] |
Admission Date: [**2162-5-26**] Discharge Date: [**2162-6-7**]
Date of Birth: [**2123-2-19**] Sex: F
Service: SURGERY
Allergies:
Remicade / Prednisone / Vancomycin
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Exploratory laparotomy, drainage of intraperitoneal intraloop
abscess, and small bowel resection.
History of Present Illness:
Ms. [**Known lastname **] is a 39-year-old female with Crohn's disease which was
first diagnosed 3 years ago, and she reports that it has never
been fully controlled. She awoke yesterday morning with
abdominal pain and subsequently presented to her local ED ([**Location (un) **],
[**State 1727**]) for evaluation. There, a CT scan of the abdomen revealed
evidence of a likely bowel microperforation, and she was
transferred to [**Hospital1 18**] for further care. She has been on TPN
since [**10-15**], and has been off of all medications for Crohn's
disease for approximately a month (has taken steroids, pentasa,
and methotrexate in the past). She denies having been on
steroids for "months". She had been feeling well until earlier
yesterday. Her abdominal pain is diffuse and non-radiating, not
improved by anything, and felt worse while going over bumps
during the ambulance transfer. She had nausea and vomiting
early yesterday afternoon, but currently denies either of those
symptoms. Denies any subjective fevers. Last bowel movement
was yesterday, and
she cannot recall if she has passed flatus recently.
Past Medical History:
Past Medical History:
1. Severe Crohn's disease of small bowel/colon (dx [**2156**])
2. Severe malnutrition
3. Iron deficiency anemia- s/p IV Fe infusions
4. Osteoporosis- thought [**1-9**] steroids
5. Pelvic organ prolapse
6. Periumbilical hernia
7. GERD
Past Surgical History: Denies
Social History:
Married, lives with husband and 2 children. Former 5th grade
teacher. No alcohol, tobacco, or IVDA.
Family History:
Daughter with VSD. Mother with history of breast CA. Father with
psoriasis. Two younger brothers are healthy.
Physical Exam:
Physical exam on Admission:
T 96.8 HR 130 BP 127/81 RR 16 SaO2 97% RA
Alert & oriented x 3, visibly uncomfortable
Dry mucous membranes
Regular rhythm, tachycardic
Lungs are clear bilaterally
Abdomen is firm, distended, and diffusely tender with guarding.
There is no rebound tenderness and no discomfort with
movement. There is a reducible umbilical hernia. No masses.
Rectal exam is deferred
Extremities are warm, palpable pedal pulses, no edema.
Cranial nerves II-XII intact grossly.
Pertinent Results:
[**5-26**] CT scan of abdomen from OSH: revealed evidence of a likely
bowel microperforation
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 62361**],[**Known firstname **] [**2123-2-19**] 39 Female [**-7/2343**]
[**Numeric Identifier 62362**]
Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cofc
SPECIMEN SUBMITTED: small bowel.
Procedure date Tissue received Report Date Diagnosed
by
[**2162-5-26**] [**2162-5-26**] [**2162-5-31**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7001**]/axg
Previous biopsies: [**-5/3949**] SIGMOID COLON, RECTUM, PROXIMAL
(JEJUNUM) & DUODENUM PART.
[**-4/4454**] Consult slides referred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].
DIAGNOSIS:
Small bowel, segmental resection:
1. Small intestine with chronic active enteritis demonstrating:
a. Foci of ulceration, focally transmural necrosis and
associated perforation with abscess formation and extensive
serositis.
b. Focally prominent lymphoid aggregates, transmural.
c. No granulomas or dysplasia seen.
d. Resection margins free of active enteritis.
2. Uninvolved mucosa with focally, mildly increased
intraepithelial lymphocytes; see note.
Note: The finding of increased intraepithelial lymphocytes,
while non-specific, raises the possibility of concomitant celiac
disease, a drug effect, or other immune-mediated injury.
Correlation with clinical and serological findings is
recommended.
Clinical: Perforated small bowel.
Gross: The specimen is received fresh labeled with the
patient's name "[**Known lastname **], [**Known firstname **]" and additionally labeled "small
bowel". The specimen consists of a portion of unoriented
segment of bowel that measures 36 cm in length x 4.5 cm in
diameter. The specimen is stapled at both ends. One stapled
margin measures 3 cm and the other measures 4 cm. Located 11 cm
away from the 4 cm stapled margin is a single suture. This area
is inked black on the serosal surface. The remainder of the
serosa is hemorrhagic and granular. The specimen is opened to
reveal a lumen filled with fluid and fecal matter. The mucosa is
cobblestoned, focally ulcerated with two separate ulcers, and
hemorrhagic at the area of the stitch. The ulcerated areas
measure up to 4.5 cm. The specimen is represented as follows:
A=4 cm staple margin, B=3 cm staple margin, C=representative
section of ulcerated mucosa, D-E=representative sections of
grossly unremarkable mucosa, F=representative section of
possible lymph node and mesentery.
[**2162-5-26**] 03:49AM WBC-8.0# RBC-4.98 HGB-13.6# HCT-42.5# MCV-85
MCH-27.3 MCHC-32.1 RDW-16.3*
[**2162-5-26**] 03:49AM NEUTS-83* BANDS-13* LYMPHS-1* MONOS-1* EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-0
[**2162-5-26**] 03:49AM GLUCOSE-178* UREA N-16 CREAT-0.7 SODIUM-138
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-13
[**2162-5-26**] 07:26AM LACTATE-4.8*
[**2162-6-6**] 04:02AM BLOOD WBC-7.1 RBC-2.79* Hgb-8.2* Hct-24.4*
MCV-88 MCH-29.2 MCHC-33.4 RDW-15.2 Plt Ct-481*
[**2162-6-7**] 04:38AM BLOOD Glucose-97 UreaN-14 Creat-0.7 Na-141
K-4.6 Cl-108 HCO3-24 AnGap-14
[**2162-6-7**] 04:38AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.0
[**2162-6-6**] 04:02AM BLOOD calTIBC-191* Ferritn-210* TRF-147*
[**2162-5-27**] 02:16PM BLOOD Lactate-1.2
[**2162-6-6**] 04:02AM BLOOD Albumin-2.5* Iron-15*
Brief Hospital Course:
39-year-old female with severe Crohn's disease and now with what
appears to be a contained microperforation in the area of the
distal ileum. She was afebrile and hemodynamically stable,
though with persistent tachycardia even after resuscitation.
She had a normal WBC but with a bandemia. Due to the clinical
picture it was decided to take her to the OR for exploratory
laparotomy, drainage of intra loop abscess and small bowel
resection.
1. Neuro: Immediately post-op she was on a propofol gtt and a
fentanyl gtt which was switched to a Dilaudid PCA after she was
extubated on POD 1. When she was tolerating clear liquid she
was switched to PO Dilaudid. Her pain is well controlled on PO
Dilaudid. She also has anxiety at baseline and was given Ativan
prn. Her PCP is going to work on a regimen as an outpatient.
2. Cardiovascular: Patient has been tachycardiac since
admission. It was sinus tachycardia. HR ranged up to 140s while
she was in the ICU immediately post-op. She was always
hemodynamically stable and tachycardia did not improve even with
PRBCs. Talking to her PCP she is always tachycardiac in the
office and it has never been treated previously so her baseline
is HR of 100-110. Her heart rate now ranges at her baseline.
3. Respiratory: Immediately after the OR she was intubated but
on POD 1 she was extubated and has been weaned off the oxygen.
No issues.
4. GI: She was continued on TPN during this hospitalization.
She had an NGT and was NPO until POD 8. On POD 8 her NGT was
removed when she started having flatus and she was started on
sips. POD 9 she was started on clear liquid diet which she
tolerated without nausea or vomiting. On POD 9 she started
having numerous bowel movements which were sent for c.diff.
C.diff was negative times two. On POD 10 she was started on low
residue diet. She is in control of her diet and her diarrhea
has since improved to her baseline.
5. Renal: no issues. she is voiding on her own. creatinine
stable
6. Heme: immediately post-op her HCT was 19. She received a
total of 4 units of PRBCS during this hospitalization and her
HCT has been stable at approximately 25.
7. ID: since she had perforation of her abdomen she was started
on broad spectrum antibiotics. She spiked a temp on POD 9 and
cultures were sent which at this time are preliminary negative.
She will go home on her Cipro and Flagyl. Her temp max for 24
hours was 100.0 at time of discharge.
8. Endo: she is on a regular insulin sliding scale for her TPN.
9. prophylaxis: heparin subcutaneous, venodyne boots, and she is
ambulating.
10. Disp: home with services. Continuing TPN.
Medications on Admission:
ALENDRONATE-VITAMIN D3 [FOSAMAX PLUS D] - (Prescribed by Other
Provider) - 70 mg-2,800 unit Tablet - 1 Tablet(s) by mouth
weekly pill
CIPROFLOXACIN [CIPRO] - (Not Taking as Prescribed: Not taking
for 3 1/2 weeks.) - 500 mg Tablet - 1 Tablet(s) by mouth twice a
day
FOLIC ACID - (Not Taking as Prescribed: Not taking for 3 1/2
weeks.) - 1 mg Tablet - 2 Tablet(s) by mouth once a day
MESALAMINE [PENTASA] - (Not Taking as Prescribed: Not taking
for
3 1/2 weeks.) - 500 mg Capsule, Sustained Release - [**1-10**]
Capsule(s) by mouth three times a day take as 3/2/3 capsules
three divided doses(total 8/day)
METHOTREXATE SODIUM - (Dose adjustment - no new Rx) (Not Taking
as Prescribed: Not taking for 3 1/2 weeks.) - 25 mg/mL Solution
-
17.5 weekly shot Will hold for now and see how she is doing
METRONIDAZOLE - (Not Taking as Prescribed: Not taking for 3 1/2
weeks.) - 375 mg Capsule - 1 Capsule(s) by mouth twice a day
OXYCODONE - (Prescribed by Other Provider) (Not Taking as
Prescribed: Not taking for 3 1/2 weeks.) - 5 mg Tablet -
Tablet(s) by mouth as needed
PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) (Not
Taking as Prescribed: Not taking for 3 1/2 weeks.) - 40 mg
Tablet, Delayed Release (E.C.) - Tablet(s) by mouth once a day
SODIUM-K+-MAG-CA-CHLOR-ACETATE [TPN ELECTROLYTES] - (Prescribed
by Other Provider; Not listed) - Dosage uncertain
VALACYCLOVIR [VALTREX] - (Prescribed by Other Provider) - 1,000
mg Tablet - as needed Dosage uncertain
Medications - OTC
CALCIUM - (Prescribed by Other Provider) (Not Taking as
Prescribed: Not taking for 3 1/2 weeks.) - 500 mg Tablet -
Tablet(s) by mouth three times a day
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) (Not Taking as Prescribed: Not taking for 3 [**12-9**]
weeks.)
- 400 unit Tablet - Tablet(s) by mouth twice a day
GLUTAMINE - (OTC) - Powder - 10grams three times a day
MULTIVITAMIN - (Prescribed by Other Provider) (Not Taking as
Prescribed: Not taking for 3 1/2 weeks.) - Tablet - 1
Tablet(s)
by mouth once a day
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
(Not Taking as Prescribed: Not taking for 3 1/2 weeks.) - 1,000
mg Capsule - 1 Capsule(s) by mouth twice a day
PROBIOTICS - (OTC) - - taking 50,000,000 3 strains in the
preparation
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED). unit
[**Unit Number **]. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*60 Tablet(s)* Refills:*2*
4. Mesalamine 500 mg Capsule, Sustained Release Sig: not taking
as prescribed Capsule, Sustained Release PO three times a day:
she takes 3/2/3 tablets during the course of the day.
5. Metronidazole 375 mg Capsule Sig: One (1) Capsule PO twice a
day.
6. Sodium Chloride 0.9 % 0.9 % Piggyback Sig: One (1) mL
Intravenous every twelve (12) hours as needed for PICC line
flush.
7. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Five (5)
ML Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Home With Service
Facility:
SOUTHERN [**State **] VNA
Discharge Diagnosis:
Crohn's disease with perforation
Discharge Condition:
Stable
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Activity: No heavy lifting of items [**9-22**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications. You should take a
stool softener, Colace 100 mg twice daily as needed for
constipation. You will be given pain medication which may make
you drowsy. No driving while taking pain medicine.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2162-6-22**] 10:15
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2162-8-10**] 11:20
Completed by:[**2162-6-7**]
|
[
"42789"
] |
Admission Date: [**2128-7-15**] Discharge Date: [**2128-8-4**]
Date of Birth: [**2077-9-13**] Sex: M
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 50-year-old
gentleman with end-stage liver disease secondary to hepatitis
C who presented to [**Hospital1 69**] for a
liver transplant.
Prior to his transplant, the patient had encephalopathy as
well as a significant history of gastrointestinal bleeds. An
echocardiogram revealed an ejection fraction of 65%, and
there was no cardiac history. The patient was status post
transjugular intrahepatic portosystemic shunt. The patient
was scheduled to undergo a liver-related liver transplant
from his cousin on [**2128-7-15**].
PAST MEDICAL HISTORY:
1. Hypertension.
2. Dyspnea on exertion.
3. End-stage liver disease (secondary to hepatitis C).
PAST SURGICAL HISTORY:
1. Transjugular intrahepatic portosystemic shunt.
2. Tonsillectomy.
MEDICATIONS ON ADMISSION: Colace, acetaminophen, lactulose,
Welchol, vitamin E, vitamin D, calcium, Mycelex,
spironolactone, nadolol, and ursodiol.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is married with three children.
History of a minimal amount of cocaine use 25 years ago and a
history of intravenous drug abuse in the distant past. He no
longer smokes.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, temperature was 98.3, blood pressure was 116/40,
heart rate was 60, respiratory rate was 18, and oxygen
saturation was 100% on room air. In general, the patient was
jaundiced and well-developed. Head, eyes, ears, nose, and
throat examination revealed normocephalic and atraumatic.
Extraocular movements were intact. Pupils were equally round
and reactive to light. The sclerae were icteric. The
oropharynx was clear. The mucous membranes were moist. The
neck was supple. No lymphadenopathy. The lungs were clear
to auscultation bilaterally. Heart was regular in rate and
rhythm. The abdomen was mildly distended. Bowel sounds were
present. The abdomen was soft and nontender. Extremity
examination revealed no tenderness. No edema. Full range of
motion. Neurologic examination a nonfocal.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed hematocrit was 26.5, white blood cell count was 6.5,
and platelets were 92. Sodium was 141, potassium was 4,
blood urea nitrogen was 17, and creatinine was 0.9.
Phosphate was 4.4. AST was 335, ALT was 210, alkaline
phosphatase was 73, and total bilirubin was 6.5. INR was
1.3.
HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was brought to
the operating room on [**2128-7-15**] for a liver-related liver
transplant from his cousin.
The operation went without any complications, and the patient
was brought to the Cardiothoracic Intensive Care Unit
intubated and sedated for monitoring of cardiovascular and
pulmonary status overnight. The patient was transfused
several units for a low hematocrit.
On postoperative day one, the patient underwent a Duplex
ultrasound of the liver which revealed normal blood flow and
no biliary obstruction. The patient was started on total
parenteral nutrition for nutritional support. The patient
was eventually weaned off the ventilator and extubated.
Eventually, the patient's nitroglycerin drip was turned off.
On postoperative day two, the patient developed some chest
pressure which seemed to be associated with being given
intravenous CellCept. The patient was mildly bradycardic,
but was still maintaining good hemodynamics. His creatinine
was maintained.
Cardiology was consulted. Troponin levels were drawn and
were elevated. An echocardiogram of the heart indicated
inferior wall motion abnormalities with 2 to 3+ mitral
regurgitation. It was decided not to take the patient to the
Catheterization Laboratory secondary to increased risk of
bleeding. The patient was on the usual prophylactic
medications. The patient was diuresed and weaned off
nitroglycerin. The patient was started on an ACE inhibitor
and beta blocker.
The patient was making good urine output throughout. The
patient was transferred from the Cardiothoracic Intensive
Care Unit to the floor on [**2128-7-23**]. Up until that point,
the patient had been tolerating solid oral intake.
However, by postoperative day ten, the patient started to
develop some nausea and bouts of emesis. A KUB revealed some
air/fluid levels, but gas was present in the colon to the
rectum. A nasogastric tube was placed which relieved his
distention. They were coffee-brown in color, so an
esophagogastroduodenoscopy was performed which revealed some
mild gastritis.
The patient had a computed tomography scan of the abdomen
which revealed normal hepatic flow; however, there was
dilated loops of small bowel with a question of an ischemic
process. The patient then underwent an upper
gastrointestinal swallow which indicated a mechanical partial
small-bowel obstruction with dilation of both limbs of
Roux-en-Y proximal to jejunostomy with decompressed small
bowel afterwards; likely due to an adhesion.
The patient was continued on the nasogastric tube until
distention was relieved and nasogastric tube output was
minimal, and we awaited bowel function and ileus to resolved.
The patient eventually was able to tolerate a regular diet,
and his liver function tests trended downward.
The patient underwent a tracheostomy tube cholangiogram
through both biliary drains on postoperative day eighteen.
The biliary anastomosis was found to be patent, and there was
prompt antegrade flow contrast injected into the efferent
loop. Both biliary drains were subsequently capped.
Before discharge, the patient had a repeat echocardiogram
which still revealed an unchanged inferior wall motion
abnormality; however, there was significant improvement with
only mild mitral regurgitation.
The patient had a slight bump in his creatinine secondary to
an increased level of cyclosporin which was subsequently
decreased. However, the patient continued to maintain
excellent graft function.
On postoperative day twenty, the patient was discharged home
with appropriate follow-up appointments with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. At that point, the patient
was on a combination of immunosuppressants which included
CellCept, prednisone, and Neoral.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE:
1. Valcyte 450 mg p.o. once per day
2. Prednisone 20 mg p.o. once per day.
3. Hydralazine 50-mg tablets 0.5 tablet p.o. q.6h.
4. Metoprolol 50-mg tablets one tablet p.o. twice per day.
5. Ursodiol 300-mg capsule one capsule p.o. twice per day.
6. Captopril 50-mg tablets one tablet p.o. three times per
day.
7. Pantoprazole 40-mg tablets one tablet p.o. once per day.
8. Bactrim-SS one tablet p.o. once per day.
9. Fluconazole 200-mg tablets two tablets p.o. every day.
10. CellCept [**Pager number **]-mg tablets two tablets p.o. twice per day.
11. Percocet one to two tablets p.o. q.4-6h. as needed (for
pain).
12. Docusate sodium 100-mg capsules one capsule p.o. twice
per day.
13. Neoral 125 mg p.o. twice per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in
the Transplant Center (telephone number [**Telephone/Fax (1) 673**]) on [**2128-8-11**] at 10:45 a.m.
2. The patient was to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] at
the [**Last Name (un) 2577**] Building Transplant Center on [**2128-8-18**] at
11:10
3. The patient was to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at the
[**Last Name (un) 2577**] Building Liver Center (telephone number [**Telephone/Fax (1) 2422**])
on [**2128-8-24**] at 10:15 a.m.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Name8 (MD) 33257**]
MEDQUIST36
D: [**2128-8-4**] 20:05
T: [**2128-8-12**] 09:37
JOB#: [**Job Number 33258**]
|
[
"9971"
] |
Admission Date: [**2136-11-29**] Discharge Date: [**2136-12-5**]
Date of Birth: [**2075-11-7**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This is a 61-year-old gentleman
with a history of shortness of breath which has increased
over the past several days prior to his admission.
He has known history of coronary artery disease and a prior
percutaneous transluminal coronary angioplasty. He is also
noted to have congestive heart failure on his initial
evaluation at [**Hospital6 3872**] and elevated troponin
levels. The patient was started on a heparin drip at [**Hospital6 33180**]. A cardiac catheterization was performed
prior to admission on [**2136-11-28**] which showed an
occluded left anterior descending proximal to his prior left
anterior descending stent, a 90 percent obtuse marginal
lesion, and an 80 percent proximal posterior descending
artery lesion. Ventriculography was not performed as the
patient had depressed left ventricular function. The patient
was transferred to [**Hospital1 69**] for
coronary artery bypass grafting.
PAST MEDICAL HISTORY:
1. Insulin-dependent diabetes mellitus.
2. Coronary artery disease; status post left anterior
descending stent.
3. Hypertension.
4. Peripheral vascular disease.
5. Congestive heart failure.
PAST SURGICAL HISTORY: Cholecystectomy and bilateral toe
amputations.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION: Lisinopril 20 mg by mouth once
daily, Lopressor 50 mg by mouth twice daily, Zocor 20 mg by
mouth once daily, aspirin 325 mg by mouth once daily, and
insulin (70/30) 35 units twice daily.
SOCIAL HISTORY: He has a 20-pack-year history of smoking but
quit in [**2107**]. He has rare use of alcohol.
PHYSICAL EXAMINATION ON ADMISSION: His blood pressure was
130/72, his heart rate was 72, his respiratory rate was 20,
and he was saturating 97 percent on 2 liters. He was in no
apparent distress. He had a systolic ejection murmur. He
had decreased breath sounds at the bases, but no rales or
rhonchi. The abdomen was obese. There were positive bowel
sounds and was soft and nondistended. His extremities had no
clubbing, cyanosis or edema. He had brawny induration and
erythema on his right lower extremity greater than on his
left lower extremity. The right third toe amputation site
with some dry eschar. He had no varicosities noted. He had
no hematoma present in his right groin which was dressed post
catheterization. He had no carotid bruits. He had 2 plus
bilateral carotid, radial, and femoral pulses. He had a 1
plus dorsalis pedis pulse on the left and a 2 plus posterior
tibial pulse on the right. No palpable dorsalis pedis pulse
on the right. He had a 2 plus posterior tibial pulse on the
right.
PERTINENT LABORATORY DATA ON ADMISSION: Preoperative
laboratories revealed white blood cell count was 6.3,
hematocrit was 31.1, and platelet count was 159,000. PT was
16.5, PTT was 37.4, and INR was 1.7. He had hematuria
present in his urine, but otherwise had a negative
urinalysis. Sodium was 118, potassium was 3.2, chloride was
89, bicarbonate was 23, anion gap was 9, blood urea nitrogen
was 16, creatinine was 1, and blood glucose was 705. Calcium
was 7.5, alkaline phosphatase was 33.6, magnesium was 1.8.
Hemoglobin A1C was 7.4 percent.
RADIOLOGY: A preoperative chest x-ray showed cardiomegaly
and small bilateral pleural effusions.
A preoperative electrocardiogram showed a sinus rhythm at 66
with first-degree atrioventricular block and a question of
left ventricular hypertrophy. Please refer to the EKG report
dated [**2136-11-29**].
SUMMARY OF HOSPITAL COURSE: The patient was referred to Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 70**]. On [**11-30**], he underwent coronary
artery bypass grafting times three with a left internal
mammary artery to the left anterior descending, a vein graft
to the posterior descending artery, sequence to the obtuse
marginal. He was transferred to the Cardiothoracic Intensive
Care Unit in stable condition on a Neo-Synephrine drip at 0.3
mcg/kg per minute and a titrated propofol drip.
On postoperative day one, he was A paced for bradycardia
overnight. He began Lasix diuresis. He was hemodynamically
stable. His blood pressure was 108/47. He was on an insulin
drip at 3 units per hour and begun on aspirin therapy.
Postoperative laboratories were as follows. White blood cell
count was 10.5, hematocrit was 26.6, and platelet count was
158,000. Potassium was 3.9, blood urea nitrogen was 17,
creatinine was 0.8, with a blood sugar of 75.
He remained in the Cardiothoracic Intensive Care Unit. He
was receiving morphine and Percocet for pain. He was
extubated successfully. He had some stridor overnight, for
which he received a cool nebulizer. Lasix diuresis was
begun.
On postoperative day two, his pacer was turned off.
Lopressor beta blockade was given. His white blood cell
count rose slightly to 12.6. His creatinine was stable at 1.
He was off all drips. His examination was unremarkable. The
incisions were clean, dry, and intact. The chest tubes were
discontinued. He was evaluated by Case Management. On
postoperative day two, he again had some stridor overnight
and was given some steroids in addition to the cool
nebulizers. His Foley was discontinued.
On [**12-3**], he was transferred out to the floor to begin
working with Physical Therapy and the nurses to increase his
activity level. He was encouraged to continue to ambulate
and to use his incentive spirometer. He was also seen by the
[**Last Name (un) **] Service in consultation for management of his blood
sugars, and these recommendations were appreciated by the
Cardiac Surgery team. He also had a full evaluation by
Physical Therapy, and he was doing extremely well with his
postoperative ambulation.
His Lopressor was increased to 25 mg twice daily on
postoperative day four. He was also started again on his
statin therapy and restarted on Plavix. His examination was
unremarkable. He cleared a level V on postoperative day five
and was deemed safe to be discharged home with VNA services.
Discharge laboratories were as follows. White blood cell
count was 11.3, hematocrit was 28.2, and platelet count was
234,000. Sodium was 136, potassium was 4, chloride was 108,
bicarbonate was 27, blood urea nitrogen was 34, creatinine
was 1, and blood glucose was 94. He was alert and oriented
with a nonfocal examination. The lungs were clear
bilaterally. His heart was regular in rate and rhythm. His
incisions were clean, dry, and intact. He had positive bowel
sounds. He had 1 plus peripheral edema in his legs.
DISCHARGE DISPOSITION: He was discharged to home with VNA
services on [**2136-12-5**].
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times three.
2. Status post left anterior descending stent.
3. Insulin-dependent diabetes mellitus.
4. Hypertension.
5. Peripheral vascular disease.
6. Congestive heart failure.
MEDICATIONS ON DISCHARGE:
1. Potassium chloride 20 mEq by mouth twice daily (times
seven days).
2. Colace 100 mg by mouth twice daily (times one month).
3. Protonix 40 mg by mouth once daily.
4. Enteric coated aspirin 81 mg by mouth once daily.
5. Lasix 40 mg by mouth twice daily (times seven days).
6. Insulin (70/30) 20 units subcutaneously twice daily.
7. Percocet 5/325 one to two tablets by mouth q.4.h. as
needed (for pain).
8. Plavix 75 mg by mouth once daily.
9. Vitamin C 500 mg by mouth twice daily.
10. Ferrous sulfate 325-mg tablets by mouth once daily.
11. Zocor 20 mg by mouth once daily.
12. Lisinopril 20 mg by mouth once daily.
13. Metoprolol 25 mg by mouth twice daily.
DISCHARGE INSTRUCTIONS:
1. The patient was instructed to make an appointment with Dr.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 70**] (his surgeon) for postoperative followup
in the office in six weeks.
2. The patient was also instructed to follow up with Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **] in one to two weeks and to follow up with his
cardiologist (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 32255**]) in one to two weeks
postoperatively.
DISCHARGE STATUS: The patient was discharged to home on
[**2136-12-5**].
CONDITION ON DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2137-1-14**] 12:07:29
T: [**2137-1-14**] 20:02:02
Job#: [**Job Number 59932**]
|
[
"41401",
"4280",
"2449",
"4019"
] |
Admission Date: [**2148-5-17**] Discharge Date: [**2148-5-18**]
Date of Birth: [**2103-2-22**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Lisinopril
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Throat swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
45 yo [**Location 7979**] speaking F with PMH of HNT, PCOS,
hypothyroidism who presents with neck and throat swelling. She
says that she started taking lisinopril 2 days ago. Yesterday
she began to feel some swelling in her throat which went away.
Today she woke up and felt as though her throat was closing and
she couldn't swallow even her saliva. She denies pain in her
throat but feels as though it is tight. Denies SOB or chest
pain. No vomiting, constipation, diarrhea. No cough. No fevers,
chills, night sweats. No sick contacts. Denies having had this
sensation before.
In the ED, her vitals initially were T 98.2, BP 159/89, HR 78,
RR 20, O2sat 100% RA. Given the history, she was thought to have
angioedema from the ACEI and was given diphenhydramine,
famotidine, and methylprednisolone 125mg IV x1. ENT consult was
obtained and CT neck was ordered.
Currently, she says she feels a little bit better but still
feels as though her throat is tight. She has mild nausea but no
vomiting. No cough, no SOB, no CP.
Past Medical History:
PCOS
insulin resistance in an old note in OMR
HTN
hypothyroidism
allergies- skin itching she describes it as
Social History:
has two children. Gave birth to the last one last [**2147-9-11**].
Denies tobacco history or present use. Drinks rare alcohol a
couple of times a year. Denies other drug use. Not currently
working.
Family History:
NC
Physical Exam:
T 98, BP 122/78, HR 57, O2sat 100% 2L NC
General: flat affect, obese female in NAD
HEENT: NC, AT, anicteric sclera, non-injected conjunctiva,
PERRL, EOMI
MMM, very enlarged uvula but midline. OP edema but no erythema
noted. No anterior or posterior cervical or supraclavicular LAD.
Asymmetric swelling of right inframandibular area- non-tender.
Thyroid non-tender. No nodules palpated.
CV: bradycardic, RR. 1/6 systolic murmur heard at USB
Lungs: CTAB no w/r/r. No stridor noted.
Abdomen: +BS, soft, NTND
Ext: no e/c/c. DP 2+ symmetric, radial 2+ symmetric
Neuro: alert and oriented. CN III-XII in tact with the edema
noted above in the OP. Strength full throughout.
Pertinent Results:
[**2148-5-18**] 04:36AM BLOOD WBC-9.1 RBC-5.21 Hgb-14.3 Hct-42.2
MCV-81* MCH-27.4 MCHC-33.8 RDW-13.3 Plt Ct-282
[**2148-5-17**] 08:25AM BLOOD WBC-7.8 RBC-5.41* Hgb-15.0 Hct-44.0
MCV-81* MCH-27.8 MCHC-34.2 RDW-13.7 Plt Ct-255
[**2148-5-17**] 08:25AM BLOOD Neuts-75.5* Lymphs-20.0 Monos-3.2 Eos-1.0
Baso-0.3
[**2148-5-18**] 04:36AM BLOOD Plt Ct-282
[**2148-5-17**] 08:25AM BLOOD Plt Ct-255
[**2148-5-17**] 08:25AM BLOOD Glucose-94 UreaN-9 Creat-0.8 Na-140 K-4.5
Cl-102 HCO3-28 AnGap-15
[**2148-5-18**] 04:36AM BLOOD Calcium-9.5 Phos-4.0# Mg-2.1
CT SCAN OF NECK:
HISTORY: 45-year-old female with neck swelling and dysphagia.
Please
evaluate for anterior edema versus infection or abscess.
COMPARISON: None available.
TECHNIQUE: Axial imaging was performed from the skull base to
the carina
following the uneventful administration of IV contrast.
CT NECK WITH IV CONTRAST: At the level of the hypopharynx, there
is
pharyngeal edema, with faint rim enhancement and a rounded focus
of fluid
(2:25). At the level of the tonsil, there is peritonsillar
cellulitis with
frank abscess formation and a 9 x 5 mm fluid collection (2:27).
There is
extension of edema into the retropharyngeal/prevertebral space.
There is also right parapharyngeal fat stranding with no frank
extension into the right parapharyngeal space. Swelling extends
inferiorly along the lateral wall of the hypopharynx along the
false cords. The vallecula and piriform sinuses on the right are
obliterated. There is no airway compromise. No necrotic lymph
nodes are identified.
The vessels are patent and unremarkable in appearance. The lung
apices
demonstrate no nodule or unexpected opacities. The visualized
skull base and paranasal sinuses are unremarkable.
IMPRESSION:
1. Right peritonsillar cellulitis with frank abscess formation
and extension into the retropharyngeal and prevertebral spaces.
2. Right perapharyngeal fat stranding with no frank extension
into the right parapharyngeal space.
3. No evidence of airway compromise.
These findings were posted to the ED dashboard at approximately
2:45 p.m. on [**2148-5-17**] and discussed shortly after with Dr.
[**Last Name (STitle) **] (ENT).
Brief Hospital Course:
45 yo F with PMH of HTN, hypothyroidism, PCOS who presents with
likely angioedema s/p starting lisinopril.
Angioedema: Likely secondary to lisinopril. Patient without
stridor or respiratory distress. Satting 100% on room air. No
trouble managing her own secretions. Seen by ENT who noted
improvement after initiating steroids. CT neck read as tonsillar
cellulitis and abscess. However not consistent with clinical
picture as patient afebrile with normal wbc count. Per ENT scope
no evidence of abscess. Aspiration unable to withdraw pus. Diet
was advanced and patient was discharged home on medrol dose pack
as well as 2 days of zantac and benadryl. Patient was directed
to return to the hospital if she develops difficulty swallowing,
itching in her throat or fevers, chills and throat pain.
HTN: Normotensive on home regimen.
hypothyroidism: continued levothyroxine
Medications on Admission:
hydroxizine 25mg q6 prn- she uses it once daily
levothyroxine 25mcg daily
lisinopril 10mg daily
Discharge Medications:
1. Zantac 150 mg Capsule Sig: One (1) Capsule PO twice a day for
2 days.
Disp:*4 Capsule(s)* Refills:*0*
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Benadryl 25 mg Capsule Sig: Two (2) Capsule PO four times a
day for 2 days.
Disp:*16 Capsule(s)* Refills:*0*
4. Medrol (Pak) 4 mg Tablets, Dose Pack Sig: as directed
Tablets, Dose Pack PO once a day: 1 medrol dose pack.
Disp:*1 Dose Pack* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Ace inhibitor induced angioedema
Secondary: hypothyroidism
Hypertension
Discharge Condition:
Good; no respiratory distress, VSS, able to take PO without
difficulty.
Discharge Instructions:
You were admitted to the hospital because you developed throat
swelling from your new medication, lisinopril. We started you on
medications to decrease the swelling including steroids. You
should take this medication as directed. Please complete the
full course as your throat may become swollen again if you stop.
If you develop any itching, tingling, hoarse voice or trouble
swallowing, please return to the emergency department
immediately. Please contact your doctor if you develop any
fevers or chills.
Followup Instructions:
Follow up with your regularly scheduled appointments.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11713**], OD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2148-6-12**] 10:00
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"4019",
"2449"
] |
Admission Date: [**2118-10-4**] Discharge Date: [**2118-10-6**]
Date of Birth: [**2043-3-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Percocet / Restoril / Zoloft / simvastatin / Requip / Lasix /
Hydromorphone
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Bilateral SDH/EDH
Major Surgical or Invasive Procedure:
Hemodialysis [**2118-10-5**]
History of Present Illness:
This is a 75 year old man with a history of renal cell carcinoma
s/p left nephrectomy, on dialysis who presented to his PCP [**Name Initial (PRE) **]
2 weeks ago for one week of headache that started gradually. He
describes this is as a [**2117-1-29**] dull head pain that can be
bifrontal or holocephalic, not associated with visual
disturbances, nausea/vomitting, asymmetric weakness/numbness,
dizziness/vertigo
or difficulties sleeping at night. The patient reports that he
has had limited relief with a large aspirin, OTC tylenol or
aleve. At the same time, he prefers to avoid all pain
medications and states that he once took percocet and felt very
ill and would prefer no percocet like agents.
When he presented to his PCP two weeks ago and had a NCHCT done
which was normal. His headache persisted, and his PCP ordered [**Name Initial (PRE) **]
brain MRI to be done this
morning which revealed bilateral SDH and one EDH with concern
for midline shift. He was asked to present to the LGH ED who
transferred him here for a neurosurgical evaluation.
Past Medical History:
- Left sided RCC s/p nephrectomy
- DMII
- ESRD on HD
- Diverticulitis
- History of pericarditis
Social History:
He has a 20 pack year smoking history, occasional drinks, no
drugs. Worked as an airforce engineer, quit 17 years ago.
Family History:
Negative for neurological illness
Physical Exam:
On admission:
Physical Exam:
Vitals: 98,8, 85, 155/57, 12, 100%
General: Well appearing man, awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**11-29**] at 5 minutes.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1.5 mm and brisk. VFF to confrontation.
III, IV and VI: EOM are intact and full, no nystagmus
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughou
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 0 1
R 2 2 2 0 1
Plantar response: Down
-Coordination: No intention tremor, no dysmetria on FTN testing
-Gait: Not tested
Upon Discharge:[**2118-10-6**]
He is neurologically intact.
Pertinent Results:
CXR [**2118-10-4**]
No acute cardiopulmonary abnormality
CT Head [**2118-10-4**]:
Allowing for differences in distribution, there is no
significant
change in bilateral extra-axial collections likely representing
acute-on-chronic subdural hematomas with small amount of
subdural hemorrhage layering along the tentorium.
CT head [**2118-10-5**]:
1.No significant change in the bilateral extra-axial
collections, likely
representing acute-on-chronic subdural hematomas, with no change
in degree of mass effect.
2. Minimal subdural blood layering along the left leaflet of the
tentorium, also unchanged, with no new hemorrhage.
[**2118-10-6**] 04:35AM BLOOD WBC-8.0 RBC-3.41* Hgb-11.1* Hct-34.0*
MCV-100* MCH-32.5* MCHC-32.5 RDW-14.1 Plt Ct-167
[**2118-10-6**] 04:35AM BLOOD Glucose-86 UreaN-28* Creat-4.1*# Na-134
K-4.0 Cl-97 HCO3-27 AnGap-14
[**2118-10-6**] 04:35AM BLOOD Albumin-4.3 Calcium-9.8 Phos-3.5 Mg-2.3
[**2118-10-6**] 04:35AM BLOOD Phenyto-5.7*
Brief Hospital Course:
This is a 75 year old man who was admitted to Neurosurgery in
the ICU for close monitoring. He remained stable overnight and
on [**10-5**] had a repeat Head CT which showed no interval change. He
went to the dialysis unit and suffered form a frontal headache
while in treatment. He was medicated with APAP. He was seen by
Neurosurgery and he was neurologically intact and VS were
stable.
He was transferred to the floor. On [**10-6**] he was seen by
physical and occupational therapy who cleared him for home with
outpatient PT. He was told to resume ASA in one week and
dialysis as previously scheduled. Heparin infusion should be
avoided.
Medications on Admission:
ASA 81mg daily
Epo weekly
Renagel (dose?)
Iron pills
MVI
Chondroitin supplements
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for headaches, T>38.3C: MAX 4g/day.
2. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
3. Outpatient Physical Therapy
RE; Bilateral SDH
Pleave eval gait and safety
Discharge Disposition:
Home
Discharge Diagnosis:
Bilateral Subdural Hematomas
Renal Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
Please continue Dialysis as you are normally scheduled. You
should not have a heparin infusion during dialysis until after
your follow up appointment with Dr. [**Last Name (STitle) 739**]
?????? Take Tylenol for pain control. We did not prescribe you any
narcotics as you expressed a desire to avoid them.
?????? 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, Advil, or Ibuprofen
etc.
?????? You may resume taking Aspirin in one week.
You have been prescribed Dilantin for prevention of seizures.
You should have a Dilantin and albumin level drawn with your PCP
each week. Please call [**Telephone/Fax (1) 1669**] with the results. A
corrected Dialntin level goal is between [**9-15**].
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:
Please follow-up with Dr [**Last Name (STitle) 739**] in 4 weeks with a Head CT
w/o contrast. Please call Paresa at [**Telephone/Fax (1) 1272**] to make this
appointment.
Please bring the CT head done on [**9-20**] on a CD to your
appointment.
Please follow up with you PCP in the next week to follow up on
your admission and for lab work (mentioned above).
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2118-10-6**]
|
[
"3051"
] |
Admission Date: [**2185-7-5**] Discharge Date: [**2185-7-16**]
Date of Birth: [**2127-11-2**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Hyponatremia.
Major Surgical or Invasive Procedure:
PICC line placement (removed by patient).
Right internal jugular vein hemodialysis line placement (removed
by ICU team).
History of Present Illness:
57 yo male with history of ESLD [**3-2**] HCV cirrhosis, c/b portal
hypertension with resistant ascites, hepatic encephalopathy, and
recurrent hyponatremia with multiple recent admissions for
refractory hyponatremia and volume overload. On [**6-15**], he was
admitted with hyponatremia at which point tolvaptan was
increased from 30mg to 60mg and diuretics were held. Diuretics
were reinstituted prior to discharge on [**6-18**] once sodium was
125. On [**6-24**], he was readmitted for weight and hyponatremia.
Tolvapatan was continued but diuretics were held during
admission and at discharge.
He was most recently discharged on [**2185-7-2**] after an admission for
volume overload where he was found to have diastolic heart
failure as a contributing factor. He was started on torsemide
given its equal parenteral bioavailability as the patient is
known to not follow his sodium restriction at home.
The patient had routine labs drawn and was found to be
hyponatremic to 125. The patient states that he was contact[**Name (NI) **] by
[**Name (NI) 1022**] [**Name (NI) **] and told to come into the clinic, however the
patient instead called 911 and went to the [**Hospital3 **] emergency
room where he apparently had a sodium of 105. His sodium on
recheck here was 127. He is alert and oriented but incorrect in
many of his facts during interview.
In the ED, he was found to have acute kidney injury with
creatinine of 1.4, so he was given a single dose of albumin and
sent to the floor.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
-HCV (genotype 1) cirrhosis complicated by hyponatremia,
ascites, and hepatic encephalopathy
-obesity
-hypertension
-Insulin-dependent diabetes
-CVA with no residual deficits
-dyslipidemia
-neuropathy
-osteoarthritis of the knees
-spinal stenosis w/ disk herniation and disc fragments in the
canal resulting in permanent diability and foot drop
-right lower extremity nerve impingement.
-PAD
-h/o hypomagnesemia
-COPD
-anxiety
-h/o kidney stones
-Past heavy ETOH use, quit [**2177**]
-s/p right wrist tendon repair after a plate-glass injury [**2154**]
Social History:
Lives at home with his children and wife who is his primary
caretaker. Relationship with wife is contentious given his
noncompliance to fluid or sodium restriction. History of
cocaine and marijuana use as well as previous heavy drinking
(prior to [**2177**]). He still smokes half a pack per day, which is
less than previously. On disability for spinal stenosis and
chronic back pain.
Family History:
Positive for HTN and CAD as well as CVAs. No family history of
liver disease.
Physical Exam:
Upon admission:
VS: 96 142/81 102 20 98% on RA
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: MMM, scleral icterus, mild conjunctival pallor.
NECK: Supple, no cervical LAD.
HEART: RRR, soft S1, systolic murmur radiating to carotids.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Protuberent abdomen, flank dullness. Unable to assess
HSM.
EXTREMITIES: WWP, 1+ bilateral LE edema, 2+ peripheral pulses.
SKIN: No rashes or lesions.
NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact
Pertinent Results:
LABS UPON ADMISSION:
[**2185-7-5**] 03:30PM BLOOD WBC-7.6# RBC-2.88* Hgb-9.3* Hct-27.2*
MCV-95 MCH-32.4* MCHC-34.2 RDW-20.7* Plt Ct-117*#
[**2185-7-5**] 03:30PM BLOOD Neuts-76.2* Lymphs-14.3* Monos-6.1
Eos-2.9 Baso-0.5
[**2185-7-5**] 03:30PM BLOOD PT-23.3* PTT-46.4* INR(PT)-2.2*
[**2185-7-5**] 03:30PM BLOOD Glucose-110* UreaN-21* Creat-1.4* Na-127*
K-4.1 Cl-88* HCO3-23 AnGap-20
[**2185-7-5**] 03:30PM BLOOD AST-120* AlkPhos-125 TotBili-10.4*
[**2185-7-5**] 03:30PM BLOOD Albumin-3.2*
[**2185-7-6**] 05:35AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.3
[**2185-7-6**] 05:35AM BLOOD Osmolal-262*
[**2185-7-5**] 03:30PM BLOOD AFP-2.4
[**2185-7-5**] 03:30PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2185-7-5**] 04:08PM BLOOD Glucose-107* Lactate-5.1* Na-125* K-4.0
Cl-86* calHCO3-25
[**2185-7-5**] 04:08PM BLOOD Hgb-9.1* calcHCT-27
[**2185-7-5**] 04:08PM BLOOD freeCa-1.00*
LABS PRIOR TO DISCHARGE:
MICRO:
[**2185-7-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2185-7-12**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2185-7-11**] URINE URINE CULTURE-FINAL
[**2185-7-11**] MRSA SCREEN MRSA SCREEN-PENDING
[**2185-7-11**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2185-7-10**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2185-7-5**] IMMUNOLOGY HCV VIRAL LOAD-FINAL
[**2185-7-5**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2185-7-5**] BLOOD CULTURE Blood Culture, Routine-FINAL
IMAGING:
[**2185-7-5**] RUQ ultrasound: 1. Limited evaluation of the left lobe of
the liver. Cirrhosis with mild splenomegaly and small volume
ascites. 2. Patent portal venous system. 3. Cholelithiasis.
[**2185-7-5**] CXR: There is mild enlargement of the cardiac silhouette
which is unchanged. There has been no interval change in the
appearance of mild indistinctness of the pulmonary vascular
markings suggestive of minimal pulmonary vascular congestion. No
focal consolidation,
pleural effusion or pneumothorax is present. The mediastinal and
hilar contours are stable. Mild degenerative changes are present
in the thoracic spine.
Brief Hospital Course:
57 yo male with hep C cirrhosis presented with hyponatremia,
mild confusion, and acute kidney injury, after very recent
hospitalization during which he was started on torsemide for
mild diastolic heart failure.
#Goals of care: During this admission it was clear on multiple
occasions that Mr. [**Known lastname 85273**] was not compliant with our treatment
recommendations. He was seen by nursing and other staff members
to go to the kitchen and bathroom and drink large amounts of
water, in regular violation of the free water restriction of
1800 mL/day. In addition, he admitted to lying about his urine
output by adding sink water to the urinal container. Lastly, he
removed his PICC line at a time when he was being treated with a
continuous furosemide infusion for volume overload. He said that
the PICC line "fell out when he was scratching his arm." Given
all of these concerns about compliance, and a long history of
such problems, the decision was made to remove Mr. [**Known lastname 85273**] from
the liver transplant list. A family meeting was held in which
immediate family members, including wife and his two daughters,
were present. At the meeting, we discussed transitioning Mr.
[**Known lastname 85273**] to comfort-directed care and making arrangements for
hospice care, either at home or at an inpatient facility. At the
time when these arrangements were being made, Mr. [**Known lastname 85273**] insisted
on leaving the hospital to go home. He was warned that we did
not feel he was medically ready to go home; he was at the time
still being treated with continuous furosemide infusion.
However, he was insistent on leaving the hospital against
medical advise. He was transitioned over to torsemide 30 mg once
daily. His tolvaptan was held. (His hyponatremia is more likely
the result of non-compliance with free water restriction, and it
is unlikely that tolvaptan will benefit him as long as he is
unable to comply with dietary recommendations). Spironolactone
was also held. Simvastatin is likely of little benefit for
primary prevention given his overall poor prognosis with
end-stage liver disease (MELD 28-29), and this medicine was also
held. The patient will go home with plans for visiting nursing
and transition to home hospice.
#Acute renal failure: Creatinine mildly increased from prior.
This was likely a result of decreased effective circulating
volume due to poor oncotic pressure despite total body volume
overload. He was recently started on torsemide during his last
admission and discharged on torsemide and spironolactone. Upon
admission, diuretics were held. Lower dose torsemide was
restarted once his creatinine normalized.
#Volume overload: Likely a combination of mild diastolic heart
failure and cirrhosis in a patient who is non-compliant with
sodium restriction. Albumin is low at 3.2. A low salt diet was
ordered, although patient was noncompliant with this
recommendation. Diuretics were initially held and then resumed
given the degree of his volume overload. A TSH was normal.
MICU Course: Mr. [**Known lastname 85273**] was transferred to the MICU on [**2185-7-11**]
for a higher level of nursing attention and for initiaion of
CVVH. Ultrafiltration was started for volume overload via a
right IJ HD line. Tolvaptan was discontinued. He did not
tolerate ultrafiltration due to agitation, despite haldol 5mg
iv. A lasix gtt was initiated. He had transient hypotension in
the setting of initiating ultrafiltration, requiring levophed
briefly. Nephrology was following and the decision was made to
continue the lasix drip. Patient diuresed well with the lasix
drip over 48 hours, net negative 4-5 L. He was also temporarily
placed on low dose dopamine for diuresis, which was
discontinued.. Encephalopathy started to clear with liquid
lactulose. Transferred to [**Hospital Ward Name **] 10. Lasix drip discontinued due
to staffing concerns. Patient given Lasix 40mg IV x1.
Subsequently, he triggered as he became asymptomatically
hypotensive to 80/40 with SOB requiring 2L nasal cannula. He
was given two doses of albumin 25g and his blood pressures
improved. Patient was ultimately discharged on torsemide 30 mg
once daily.
#Hyponatremia: The patient's hyponatremia was at baseline prior
to admission. However, his fluid status continues to be
difficult to manage and his diuretic regimen may need further
optimization. He was continued on tolvaptan 60mg daily with an
1800cc fluid restriction. Tolvaptan was held at time of
discharge due to changing goals of care.
#Hyperbilirubinemia: Currently the patient has no signs of a
portal vein thrombosis or SBP that would cause the patient's
liver disease to decompensate. RUQ ultrasound was unrevealing,
and tbili trended back to baseline. HCV VL much lower than last
check. AFP lower than prior. No fevers or white count, with
all cultures negative to date.
#Hepatic encephalopathy: Most likely secondary to noncompliance
with lactulose. Lactulose was uptitrated and rifaximin was
continued.
# Elevated lactate: possibly due to impaired clearance of
lactate by liver, however this is higher than normal for the
patient. This may be a result of intravscular depletion from
diuretics.
Medications on Admission:
clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day
doxepin 25 mg Capsule Sig: One (1) Capsule PO HS
ergocalciferol (vitamin D2) 50,000 unit PO 1X/WEEK (WE).
insulin glargine 100 unit/mL Solution Sig: Twenty Nine (29)
units SC qhs
ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-30**] inh
qid
lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID
metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day
ondansetron 4 mg Tablet, Rapid Dissolve Sig: One Q8H as needed
for nausea.
oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
prn pain
pantoprazole 40 mg Tablet, Delayed Release po q24h
rifaximin 550 mg Tablet Sig: One (1) Tablet PO DAILY
simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
tolvaptan 30 mg Tablet Sig: Two (2) Tablet PO DAILY
ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID
ferrous sulfate 300 mg (60 mg iron) PO DAILY (Daily).
magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO tid
multivitamin Tablet Sig: One (1) Tablet PO DAILY
simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, qid prn
gas pain.
camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical tid
prn pruritis
hydroxyzine HCl 25 mg Tablet Sig: 1-2 Tablets PO QHS prn
pruritis.
torsemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
2. doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (WE).
4. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-30**]
Puffs Inhalation Q6H (every 6 hours) as needed for dyspnea.
5. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
13. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO QHS
(once a day (at bedtime)) as needed for itching.
14. lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO every
four (4) hours as needed for encephalopathy.
15. insulin glargine 100 unit/mL Cartridge Sig: Twenty Nine (29)
units Subcutaneous at bedtime.
16. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
17. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for dry skin.
18. metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day.
19. torsemide 20 mg Tablet Sig: 1.5 Tablets PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **]Hospice
Discharge Diagnosis:
Primary Diagnoses: Hyponatremia, Acute kidney injury secondary
to hypovolemia
Secondary Diagnoses: Cirrhosis seconday to hepatitis C and EtOH
Insulin-dependent diabetes, Obesity, Hypertension, Dyslipidemia,
Chronic obstructive pulmonary disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Weight at discharge:
Discharge Instructions:
You were admitted to the hospital for evaluation of some
abnormal laboratory tests:
1. Low sodium levels.
2. Acute kidney injury.
During the admission, your diuretic medicines, torsemide and
spironolactone, were stopped. You were treated with a medicine
similar to torsemide but given intravenously, and your symptoms
improved. We would like you to continue to take torsemide. The
dose will be 30 mg daily.
We asked that you stay in the hospital so that you could
continue intravenous medicines to help remove fluid from the
body. However, you have insisted on returning home. Please know
that you are leaving the hospital against our medical advice,
since we believe that you would benefit from further medical
treatment while in the hospital.
We spoke to you at length about following our diet
recommendations. The diet recommendations are:
1. Maintaining a low-sodium diet (<2 grams total daily).
2. Limiting fluid intake to less than 1500 cc/day.
The following changes have been made to your medication regimen:
HOLD simvastatin
HOLD tolvaptan
HOLD spironolactone
Followup Instructions:
Please attend the following appointments:
Department: TRANSPLANT CENTER
When: WEDNESDAY [**2185-7-20**] at 11:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: TRANSPLANT CENTER
When: WEDNESDAY [**2185-7-20**] at 12:30 PM [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2185-8-2**] at 3:00 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2185-7-18**]
|
[
"5849",
"2761",
"496",
"25000",
"4280",
"V5867",
"4019",
"3051"
] |
Admission Date: [**2163-9-7**] Discharge Date: [**2163-9-14**]
Date of Birth: [**2079-5-29**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin / Benazepril
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
a.fib with RVR in the setting of cholestatis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 1169**] is a 84 year-old male with a.fib on coumadin who was
brought from an OSH to [**Hospital1 18**] for an ERCP today for cholangitis
secondary to a CBD stone who developed atrial fibrillation with
RVR prior to ERCP and was sent to the ED. He was admitted on
[**9-2**] to the OSH and was found to have a CBD stone. He was
treated for cholangitis with levofloxacin and flagyl. Blood
cultures grew out klebsiella pneumoniae. Today he transferred
here for ERCP, but developed a.fib with RVR in 150's, so the
ERCP was aborted and he was send to the ED.
.
In the ED, initial vs were: T 98 P 140 BP R 97 % O2 sat.
Patient was given 1 gm IV vanc, zosyn, 10 mg IV diltiazem x 3,
and fentanyl. His HR remained in the 150's-160's, so a dilt gtt
was started. Surgery was consulted and felt that there was no
surgical intervention indicated. Plan is for ERCP the day after
admission once his atrial fibrillation is controlled.
.
Currently he denies pain, but does admit to dizziness. He is
unable to consistently answer questions.
.
Review of systems: Unable to obtain.
Past Medical History:
Cholangitis, being treated at [**Hospital 6136**] Hospital
Atrial fibrillation on coumadin
Alzheimer's dementia
Hypertension
Diabetes
Depression
Dyslipidemia
Ataxia
Peripheral vascular disease
Social History:
He lives in a nursing home. Per OSH records, has a remote
alcohol history. He is wheelchair bound.
Family History:
Unable to obtain.
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Elderly male lying in bed in NAD.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Breathing comfortably, CTAB.
CV: Tachycardic and irregular.
Abdomen: +BS, soft, mildly distended, tenderness in his RUQ with
no rebound or guarding.
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert, not oriented to person, place, or time. Somewhat
dysarthric speech. Follows commands sporadically.
Pertinent Results:
Admission Labs: [**2163-9-7**]
PT-18.5* PTT-32.3 INR(PT)-1.7*
GLUCOSE-341* UREA N-38* Cr-1.4* Na-147* K-3.6 CL-114* CO2-22
ANION GAP-15
ALT(SGPT)-33 AST(SGOT)-17 LD(LDH)-147 CK(CPK)-161 ALK PHOS-150*
BILI-0.9
CK-MB-4 cTropnT-0.01
ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-2.0* MAGNESIUM-1.9
TSH-1.6
WBC-10.9 RBC-4.24* HGB-12.4* HCT-38.2* MCV-90 PLT COUNT-163
LACTATE-2.1*
PT-17.6* PTT-27.1 INR(PT)-1.6*
Follow-up Labs:
[**2163-9-12**] 07:20AM WBC-10.7 RBC-3.99* Hgb-11.5* Hct-35.6* MCV-89
Plt Ct-197
[**2163-9-12**] 07:20AM Glc-138* UreaN-15 Creat-1.0 Na-144 K-3.8
Cl-112* HCO3-24
[**2163-9-14**] 10:55AM Creat-1.2 Na-136 K-5.4* Cl-107
[**2163-9-10**] 07:45AM ALT-20 AST-19 LD(LDH)-206 AlkPhos-122
TotBili-0.9
Right Upper Extremity U/S: No evidence of deep venous thrombosis
of the right upper extremity.
RUQ U/S ([**2163-9-12**]): 1. Collapsed gallbladder, containing sludge
and gallstones. 2. Redemonstration of hepatic dome mass, better
evaluated on recent CT.
Abdominal CT:
1. Heterogeneous and hyperdense well-circumscribed liver lesion
(seg
VIII)which is concerning for atypical hemangioma versus
malignancy. Recommend further evaluation with MRI and possible
biopsy.
2. Moderate bilateral pleural effusions, bibasilar compressive
atelectasis, LLL consolidation concerning for infection or
aspiration.
3. Decompressed gallbladder with prominent CBD within normal
limits for the patient's age. No hyperdense obstructing calculus
or lesion identified on the current study.
4. Extensive vascular disease with chronic-appearing occlusion
of the left
common iliac artery and branches with distal reconstitution at
left CFA. Right common iliac aneurysm measuring 2.8 cm. Marked
narrowing of the distal abdominal aortic lumen due to atheroma.
5. Diverticulosis without diverticulitis.
6. 4 mm left lower lobe pulmonary nodule. Attention on f/u
studies
recommended.
Brief Hospital Course:
Mr. [**Known lastname 1169**] is a 84 year-old male with a.fib on coumadin who was
brought from an OSH to [**Hospital1 18**] for an ERCP today for cholangitis
secondary to a CBD stone who developed atrial fibrillation with
RVR prior to ERCP and was sent to the ED.
# A.fib with RVR: The patient has a history of atrial
fibrillation and is on coumadin and atenolol 25 mg daily as an
outpatient. He developed RVR in the setting of possible
cholangitis and klebsiella bacteremia. There were no ischemic
changes on his EKG, and he arrived from the ED on a dilt gtt,
without great effect, as the HR was still in the 130s-140s. The
patient was then started on an amiodarione gtt, which helped to
bring his rate into the 80-90s. Upon his discharge from the ICU,
the patient was on an oral dose of Amiodarione 200 mg PO/NG
DAILY. While on the medical floor his heart rates again
increased to the 100-110's, and his blood pressure improved
sufficiently that he was able to be started on Metoprolol 25mg
PO q8 in addition to Amiodarone. This was further increased to
50mg PO q8 on [**2163-9-14**] for improved blood pressure and heart
rate control (SBP=140-150's and HR=90-100's prior to change).
Provided the patient's heart rate and blood pressure remain
stable x 24 hours would recommend transitioning to Toprol XL as
patient's heart rate tends to increase prior to each dose of
Metoprolol and he would benefit from a longer acting medication.
# Cholangitis/Klebsiella bacteremia: Patient was transferred
here for ERCP due to CBD stone and persistent abdominal pain. He
was unable to undergo ERCP due to the episode of A.fib.
Initially the patient had been started on Flagyl/Levofloxacin in
the OSH, but Zosyn was started in the ED. The patient was
discharged from the ICU on Ciprofloxacin 400 mg IV Q12H in order
to specifically cover his Klebsiella, which was sensitive to
Cipro. He completed his course of antibiotics on [**2163-9-13**].
In terms of the patienet's cholangitis, CT scan performed here
on [**9-7**] showed a decompressed gallbladder with prominent CBD
within normal limits for the
patient's age. No hyperdense obstructing calculus or lesion was
identified. Additionally, the patient's ALT, AST, and Alk Phos
were all WNL at the time of his discharge. The ERCP team at
[**Hospital1 18**] saw the patient while he was in the ICU and recommended a
repeat RUQ U/S to ensure that the patient truly required ERCP on
this admission. That RUQ U/S confirmed the findings on CT, and
ERCP was deferred.
# Hypernatremia: Likely due to decreased po intake over his
hospitalization. We gave the patient maintence fluids with
normal saline, LR, and D51/2NS to ultimately improve his Na from
147 to 144. He was able to maintain a normal sodium with PO
intake alone for >72 hours prior to discharge.
# Diabetes: Patient is on amaryl, januvia, and metformin as an
outpatient. We covered the patient with SSI during his
hospitalization and resumed his home medications at discharge.
# Alzheimer's dementia:
We held the Namenda and exelon while the patient was actuely
ill; these were re-started at discharge.
# Hypertension: Patient was on home doses of Amlodipine 2.5 mg
daily, aldactone 25 mg daily, and Atenolol 25 mg daily. His
Atenolol was replaced with Metoprolol for easier titration as
discussed above, and his Amlodipine was held to allow blood
pressure room for higher dose of Metoprolol.
# Edema: Patient noted to have scrotal and RUE edema, likely
secondary to volume repletion. RUE U/S was negative for clot.
Would recommend frequent repositioning, out of bed as able, and
scrotal elevation.
Medications on Admission:
(per nuring home records)
Tylenol 1 gram po bid
Amlodipine 2.5 mg po daily
Atenolol 25 mg po daily
Colace 100 mg po bid
Amaryl 4 mg po daily
Januvia 50 mg qam
Multivitamin daily
Aldactone 25 mg po daily
Exelon 6 mg po bid
Metformin 500 mg po bid
Namenda 10 mg po bid
Coumadin
Discharge Medications:
1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours): [**Month (only) 116**] discontinue when pain resolves.
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Please check LFT's and TSH upon arrival to nursing home
as a baseline.
4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours): If blood pressure and heart rate stable x 24
hours please transition to Toprol XL 150mg.
7. Amaryl 4 mg Tablet Sig: One (1) Tablet PO once a day.
8. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
9. Exelon 6 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Namenda 10 mg Tablet Sig: One (1) Tablet PO twice a day.
11. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
The [**Last Name (un) **]
Discharge Diagnosis:
Cholangitis
Atrial Fibrillation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with cholangitis and were treated with
antibiotics. Your hospital course was complicated by rapid heart
rates, and a new medication for that was started.
Followup Instructions:
Please follow-up with your PCP as needed
|
[
"42731",
"5849",
"2760",
"4019",
"25000",
"2724",
"311"
] |
Admission Date: [**2135-6-1**] Discharge Date: [**2135-6-2**]
Date of Birth: [**2080-11-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Reglan / Protonix
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
hypotension, sepsis
Major Surgical or Invasive Procedure:
.
History of Present Illness:
Mr. [**Known lastname 10936**] is a 54yo M w/hx ESRD with failed tx on PD, DM-I, CAD,
CHF with EF ~15% who presents to the ED with hypotension. He
"thinks" that he took too much off with PD at home today but
cannot quantify exact amount. He states he usually takes off
1500ml but knows it was a lot higher than this number.
.
Of note, he was recently admitted [**Date range (2) 19491**] for cellulitis
and abscess of the R thigh which was I&D'd on [**5-18**]. He was
treated initially with Vanc/Unasyn, then changed to Unasyn when
cultures came back with MSSA. He was discharged on Augmentin
for a further 10 day course to end [**2135-6-2**].
.
In the ER, initial vitals were T98.6F, HR 74, BP 70/37, RR 17
and oxygen sat 99% RA. Blood pressures dropped to 56 systolic
and he was given 2L NS and systolics came up to 70s-80, so he
was placed on peripheral dopamine. He was given vanc/zosyn in
the ED for broad coverage, with particular concern for
cellulitis spread / abscesses in legs. Renal was consulted and
will plan to follow patient as inpatient. His PD fluid was sent
for culture and cytology. Cell count from the PD fluid showed
50 WBCs and 9% polys. ECG showed ST depressions anterolaterally
which are similar to prior ECGs. He had a central line placed
for access to continue monitoring hemodynamics and for easy
pressor use.
.
On evaluation in the MICU, patient was very lethargic and
attention waxed and waned during exam. He seemed to be in no
acute distress or pain. Arrived with right IJ in place and was
on dopamine pressor with blood pressures stable at 118/67.
Past Medical History:
# Insulin dependent diabetes type I - complications of
neuropathy, retinopathy, gastroparesis (somewhat responsive to
erthromycin)
# Renal transplant, [**2119**], now on PD since [**5-27**] - followed by Dr
[**First Name (STitle) 805**]
# CAD - 3VD, DES to OM [**3-26**], following MI (deferred placing
multiple stents d/t excessive dye load in setting of renal
insufficiency). Recent NSTEMI during ICU stay from admission
3/[**2135**].
# Systolic CHF: LVEF 10-15%, akinesis of the inferior,
inferoseptal, and inferolateral walls and severe hypokinesis of
the other segments, RV dilation/failure, moderately elevated PA
pressures, 2+ MR.
# History of C. diff ([**2-27**])
# Polycythemia [**Doctor First Name **]
# PVD
# HTN
# h/o Osteomyelitis of R 5th metatarsal in [**2128**]
# s/p L toe amputation after ICU stay for sepsis/osteomyelitis
(MSSA) [**1-26**]
# Eosinophilic gastritis
# Stoke in [**2123**] with right hand weakness, resolved on its own.
Social History:
Mr. [**Known lastname 10936**] lives with his wife and 2 children who are in early
20s. . He is a retired auto mechanic. Denies any tobacco use.
Rare alcohol use , no illicit drug use.
Family History:
One sister has a congenital [**Last Name 4006**] problem. Mother and another
sister with bipolar disorder on lithium.
Physical Exam:
Vitals: Temp 96F, HR 110, BP 118/67, RR 22, saturation 100% NC
2L
General: alert and oriented x2, NAD, mildly lethargic
[**Last Name 4459**]: EOMI, PERRL, OP clear
Neck: supple, Right IJ clean/dry/in tact, JVP 6-7cm
Pulm: mild bibasilar crackles, no wheezes
CVS: S1/S2 regular, RRR, no other murmurs/rubs
Abdomen: nontender, nondistended, PD site appears clean,
normoactive bowel sounds
Extremities: 2+ pedal pulses, trace edema, 2-3cm round ulcerated
lesions over both heels, scraped knees bilaterally
Neuro: CNs [**4-1**] grossly in tact, sensation light touch in tact,
moving 4 extremities
Derm: skin
Pertinent Results:
EKG - rate 74, NSR, qwaves [**Last Name (LF) 1105**], [**First Name3 (LF) **] depressions in V2-V6, similar
to prior EKGs
LABS
[**2135-6-1**] 07:10PM BLOOD WBC-6.4# RBC-3.75* Hgb-10.3* Hct-33.3*
MCV-89 MCH-27.4 MCHC-30.8* RDW-19.9* Plt Ct-128*
[**2135-6-2**] 01:49PM BLOOD WBC-14.2*# RBC-3.64* Hgb-9.9* Hct-31.9*
MCV-88 MCH-27.2 MCHC-31.1 RDW-20.4* Plt Ct-107*
[**2135-6-2**] 11:49AM BLOOD PT-15.0* PTT-34.6 INR(PT)-1.3*
[**2135-6-2**] 01:49PM BLOOD Plt Ct-107*
[**2135-6-1**] 07:10PM BLOOD Glucose-225* UreaN-44* Creat-9.9* Na-130*
K-3.9 Cl-92* HCO3-22 AnGap-20
[**2135-6-2**] 01:49PM BLOOD Glucose-154* UreaN-45* Creat-8.8* Na-140
K-4.5 Cl-95* HCO3-25 AnGap-25*
[**2135-6-1**] 07:10PM BLOOD ALT-11 AST-20 LD(LDH)-289* CK(CPK)-35*
AlkPhos-85 TotBili-0.2
[**2135-6-2**] 01:49PM BLOOD CK(CPK)-194
[**2135-6-2**] 11:49AM BLOOD CK-MB-17* MB Indx-8.5*
[**2135-6-2**] 01:59PM BLOOD Type-[**Last Name (un) **] pO2-62* pCO2-47* pH-7.24*
calTCO2-21 Base XS--7
[**2135-6-2**] 01:59PM BLOOD Glucose-135* Lactate-9.0* Na-135 K-3.8
Cl-98*
Brief Hospital Course:
Mr. [**Known lastname 10936**] is a 54 yo M w/hx of ESRD (s/p failed renal transplant
on PD), DM1, CAD, CHF (EF 10%) who was initially admitted to
MICU with hypotension consistent with shock. Differential
included hypovolemia from excessive fluid removal during PD vs.
septic shock from infection. Baseline blood pressures were
90s-100s. Sources of infection include bacteremia from skin
infection given recent abscess/cellulitis vs. abdominal source
given ascites and PD catheter in place, although PD fluid is
negative for infection on cell counts. He also had severe
cardiac disease with baseline EF 10% at high risk for ACS and
arrhythmias or cardiogenic shock. He was admitted overnight,
maintained on broad spectrum antibiotics and pressors (dopamine
which was being weaned down) with improved mental status with
lethargy and stable hemodynamics when he had acute event as
described below.
At 1:35pm, called to room with acute bradycardia down to HR 40s
down from 90s. Patient not breathing, so oral airway placed, and
then intubated at bedside. Given 1mg atropine x 2, found to be
pulseless and code blue called. Compressions started and cardiac
arrest code run per ACLS guidelines for intermittent pulseless
vtach and PEA arrest including 4 shocks, epi x 3, amio boluses x
2 and gtt, vasopressin, 4mg IV mag, 2 rounds bicarb, insulin
10units, 1 amp D50. Unable to regain pulse and after 30 minutes
of coding, time of death called at 2pm. Unclear cause of death:
highest on differential was ACS vs PE vs cardiac tamponade in a
patient with poor cardiac function and reserve at baseline.
Other causes including hypoxia, electrolyte disturbances,
hypoglycemia, were treated during code.
Medications on Admission:
Trazodone 25mg PO qHS PRN insomnia
Sevelamer 2400mg PO TID w/[**Known lastname 16429**]
Augmentin 500-125 PO qday x 10 days
Simvastatin 40mg PO qHS
Prednisone 5mg PO qday
Aspirin 81mg PO qday
Plavix 75mg PO qHS
Vitamin D3 400IU PO qday
Cinacalcet 30mg PO qday
MVI 1 tab PO qday
Oxycodone 5mg PO q4H
Lantus 5 units SC qHS
Lanthanum 1,000mg PO TID
Hydroxyzine 10mg PO BID
Discharge Medications:
Patient passed away of cardiac arrest
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient passed away of cardiac arrest
Discharge Condition:
Patient passed away of cardiac arrest
Discharge Instructions:
Patient passed away of cardiac arrest
Followup Instructions:
Patient passed away of cardiac arrest
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"0389",
"78552",
"40391",
"99592",
"4280",
"41401",
"V4582",
"V5867"
] |
Admission Date: [**2146-1-18**] Discharge Date: [**2146-1-27**]
Date of Birth: [**2114-6-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Tegretol / Vicodin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2146-1-21**] Aortic valve replacement (21mm St. [**Male First Name (un) 923**] mechanical),
mitral valve replacement( [**Street Address(2) 44058**]. [**Male First Name (un) 923**] mechanical), tricuspid
valve repair (32mm [**Company 1543**] Contour 3D ring), and patent
foreman ovale closure)
History of Present Illness:
31 year old female with history of MSSA endocarditis in [**9-23**],
seizures, depression, hepatitis C p/w fever. Fevr started 2 days
ago, highest temp has been 103 at home, and also low back pain.
In addition she has felt palpitations at night along with
shortness of breath. Yesterday symptoms got works with nausea
and vomiting, vomited x 5 which was nonbloody and yellow. Mostly
she has been eating soup and water, as she has had difficulty
eating solid foods. She feels that her back pain is worsening as
well from her chronic low back pain.
.
Initially pt presented to [**Hospital6 3105**] on [**2146-1-8**].
blood cultures were drawn, which are pending. She was started on
vancomycin and gentamicin given concern for endocarditis.
Daptomycin was started in place of vancomycin for concern for
VRE on [**1-9**] as [**5-17**] blood cx pwere positive for likely
enterococcus also per chart pt had an adverse reaction to
vancomycin. CXR was concerning for infiltrate as well thought to
be [**3-17**] septic emboli. TEE was done and concern for vegetations
on mitral and aortic valves on [**1-10**], also noted ot have 2+ AI
and 2+ MR. MRI of spine showed no e/o osteomyelitis. Abx changed
to gentamicin and ampicillin following [**5-17**] blood cx returned
with enterococcus faecalis. ID team was consulted regarding
these recommendations. TTE done on [**1-15**] showed vegetations on AV
and on MV, c/w TEE results on [**1-10**]. CXR was done on [**1-15**] which
showed RLL infiltrate, cefepime was started but discontinued
after CT chest showed no PNA and bilateral pleural effusions
concerning for CHF thought to be [**3-17**] endocarditis. BNP was 508.
Pt transferred to [**Hospital1 18**] for evaluation by cardiac surgery for
surgical eval of valvular disease.
.
Currently, pt complaining of mild back pain and abdominal pain,
c/w pain that she had at OSH resolving with percocet. No
shortness of breath, nausea, or other complaints.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope. Referred for
surgical evaluation.
Past Medical History:
MSSA endocarditis in [**9-23**]
seizures x 3 years
depression
hepatitis C
anemia
IVDU
Social History:
Tobacco history: denies
ETOH: denies
Illicit drugs: endorses heroin use, last use 3 months ago
Herbal Medications: denies
lives alone, no sick contacts
Family History:
adopted, family hx unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
53 kg 61"
VS: 98.5 96/44 111 18 95% RA
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. No xanthalesma.
NECK: Supple with JVP of 15 cm.
CARDIAC: RRR, II/VI systoilic and diastolic murmurs heard
throughout, 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 abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits. PICC line in place in
L arm
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
LABS:
[**2146-1-25**] 03:52AM BLOOD WBC-8.2 RBC-3.33* Hgb-9.1* Hct-28.4*
MCV-85 MCH-27.3 MCHC-32.1 RDW-16.8* Plt Ct-276#
[**2146-1-24**] 04:49AM BLOOD WBC-9.9# RBC-3.10* Hgb-8.6* Hct-26.0*
MCV-84 MCH-27.8 MCHC-33.1 RDW-17.0* Plt Ct-178
[**2146-1-23**] 03:56AM BLOOD WBC-21.4* RBC-3.60* Hgb-9.8* Hct-29.5*
MCV-82 MCH-27.3 MCHC-33.3 RDW-16.9* Plt Ct-238
[**2146-1-25**] 03:52AM BLOOD PT-22.4* PTT-37.0* INR(PT)-2.1*
[**2146-1-24**] 04:49AM BLOOD PT-15.0* INR(PT)-1.4*
[**2146-1-23**] 03:56AM BLOOD PT-14.1* PTT-26.8 INR(PT)-1.3*
[**2146-1-22**] 01:35AM BLOOD PT-13.4* PTT-31.2 INR(PT)-1.2*
[**2146-1-25**] 03:52AM BLOOD Glucose-96 UreaN-18 Creat-0.6 Na-141
K-4.5 Cl-105 HCO3-29 AnGap-12
[**2146-1-24**] 04:49AM BLOOD Glucose-103* UreaN-16 Creat-0.6 Na-139
K-3.4 Cl-99 HCO3-33* AnGap-10
[**2146-1-23**] 03:56AM BLOOD Glucose-117* UreaN-12 Creat-0.7 Na-135
K-4.9 Cl-97 HCO3-28 AnGap-15
[**2146-1-22**] 01:35AM BLOOD Glucose-91 UreaN-10 Creat-0.6 Na-131*
K-5.1 Cl-99 HCO3-26 AnGap-11
[**2146-1-19**] 04:28AM BLOOD WBC-8.9 RBC-3.79* Hgb-9.5* Hct-30.6*
MCV-81* MCH-25.0* MCHC-31.0 RDW-14.5 Plt Ct-398
[**2146-1-19**] 04:28AM BLOOD PT-11.2 PTT-34.0 INR(PT)-1.0
[**2146-1-19**] 04:28AM BLOOD Glucose-90 UreaN-12 Creat-0.7 Na-140
K-4.7 Cl-103 HCO3-29 AnGap-13
[**2146-1-20**] 06:11AM BLOOD ALT-8 AST-13 LD(LDH)-191 AlkPhos-59
TotBili-0.3
[**2146-1-19**] 04:28AM BLOOD Calcium-9.0 Phos-4.8* Mg-2.3
[**2146-1-19**] 04:28AM BLOOD %HbA1c-5.3 eAG-105
[**2146-1-19**] 03:41PM BLOOD Genta-0.8*
[**2146-1-27**] 05:43AM BLOOD Hct-29.1*
[**2146-1-27**] 05:43AM BLOOD PT-33.8* INR(PT)-3.3*
[**2146-1-27**] 05:43AM BLOOD UreaN-13 Creat-0.5 Na-135 K-4.4 Cl-101
ABD ULTRASOUND ([**1-19**]):
FINDINGS: There is a large right and left pleural effusion
identified.
The hepatic architecture is unremarkable. No focal liver
abnormality is
identified. No biliary dilatation is seen and the common duct
measures 0.6
cm. The portal vein is patent with hepatopetal flow. The
gallbladder is
normal. The pancreas is unremarkable. The spleen is borderline
in size
measuring 12.1 cm. No hydronephrosis is seen. The right kidney
measures 11.8 cm and the left kidney measures 12.6 cm. The aorta
is of normal caliber throughout. The visualized portion of the
IVC is unremarkable. No ascites is seen in the abdomen.
IMPRESSION:
1. No findings to suggest a hepatic abscess.
2. Bilateral pleural effusions.
3. No ascites.
TEE [**2146-1-21**]:Conclusions (prelim)
PRE-BYPASS: 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. A patent foramen ovale is
present. A right-to-left shunt across the interatrial septum is
seen at rest. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is moderately
depressed (LVEF= XX %). The right ventricular cavity is mildly
dilated with mild global free wall hypokinesis. The ascending,
transverse and descending thoracic aorta are normal in diameter
and free of atherosclerotic plaque to XX cm from the incisors.
There is a large vegetation on the aortic valve. No aortic valve
abscess is seen. Severe (4+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is a
moderate-sized vegetation on the mitral valve. Severe (4+)
mitral regurgitation is seen. Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion.
POST CPB#1
1. Improved left and right ventricular systolci function with
background inotropic support (Epinephrine)
2. Bileaflet maechanical valves seen in mitral aortic position.
Well seated and stable with good lealflet excursion with mild
valvular regurgitation jets (Washing jets)
3. Minimal gradients across the prosthetic valves in aortic and
mitral position.
4. Progressive worsening of trisuspid regurgitation (central)
after separation from CPB with associated systolic reversal of
hepatic venous flow. No lealfelt avulsion/restriction
visualized, but necessitated re-institution of CPB.
POST CPB#2
1, Annuloplqasty ring seen in the tricuspid position. Good
leaflet excursion and mnimal gradient, with trace trisuspid
regurgitation.
2. No ther change.
Echo [**1-26**]
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Mild
regional LV systolic dysfunction. No resting LVOT gradient.
RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV
systolic function. Abnormal septal motion/position.
AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). AVR well
seated, normal leaflet/disc motion and transvalvular gradients.
[The amount of AR is normal for this AVR.]
MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR).
TRICUSPID VALVE: Tricuspid valve annuloplasty ring. Moderate
[2+] TR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with septal hypokinesis.
The right ventricular cavity is mildly dilated with borderline
normal free wall function. There is abnormal septal
motion/position. A bileaflet aortic valve prosthesis is present.
The aortic valve prosthesis appears well seated, with normal
leaflet/disc motion and transvalvular gradients. [The amount of
regurgitation present is normal for this prosthetic aortic
valve.] A bileaflet mitral valve prosthesis is present. A
tricuspid valve annuloplasty ring is present. Moderate [2+]
tricuspid regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: No significant pericardial effusion. Normal LV
cavity size with hypokinesis of the septum. The movement of the
septum appears abnormal - probably due to a combination of
hypokinesis and post-pericardiotomy. The right ventricle is
borderline dilated and borderline hypodynamic. Mitral and aortic
mechanical prosthesis are functioning normall. There is moderate
tricuspid regurgitation
Compared with the prior study (images reviewed) of [**2146-1-20**],
the patient is post-op with AVR, MVR and a tricuspid ring.
Ventricular function has improved, the amount of pericardial
fluid has decreased.
Brief Hospital Course:
She was admitted with enterococcus endocarditis sensitive to
ampicillin and gentamicin. Power PICC was in place. Her
antibiotics started [**1-9**] and first negative blood cultures were
on [**1-11**]. She had some dyspnea on exertion, and was requiring
2L-3 O2. RUQ U/S demonstrates b/l pleural effusions (no
abscesses). Echo demonstrated severe 4+ aortic valve
regurgitation, aortic veg and 3+ MR. [**First Name (Titles) **] [**Last Name (Titles) 1834**] surgery with
Dr. [**Last Name (STitle) 914**] on [**1-21**] and was transferred to the CVICU in stable
condition on epinephrine and propofol drips. She was extubated
the following morning and epinephrine weaned off. She was
transferred to the floor on POD #2 to began to work with
physical therapy to increase strength and mobility. Coumadin was
started for mechanical valves and was bridged with Heparin until
she was anticoagulated for INR goal 3.0-3.5. The infectious
disease team was consulted and recommended 6 weeks of Ampicillin
and Gentamicin from [**2146-1-22**] for enterococcus. Chest tubes and
pacing wires removed per protocol. She continued to progress
well. Gentamicin peak and trough were checked to assure proper
dosing. By POD 6 she was ambulating with assistance, her
incisions were healing well and she was tolerating a full oral
diet. It was felt that she was safe for transfer to [**Hospital1 **]
state hospital for continued antibiotics.
Medications on Admission:
HOME MEDICATIONS:
depakote 250 mg daily
zoloft 50 mg daily
lexapro 20 mg daily
.
MEDICATIONS ON TRANSFER:
depakote 250 mg daily
acetaminophen 325 mg prn
percocet Q4H PRN
lactobacillis
lovenox 40 mg daily
ferrous sulfate 325 mg daily
clotrimazole 1% cream
gentamicin 70 mg/1.75 mL every 8 hrs
ampicillin 2 gm Q4H
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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
4. divalproex 250 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO DAILY (Daily).
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. 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.
7. Outpatient Lab Work
Labs q [**Hospital1 766**] CBC with Diff, LFT, BUN, Cr, Gent peak and gent
trough, PT/INR
Labs qwed PT/INR
Labs qfriday PT/INR BUN, Cr gent peak and gent trough
Lab results to [**Hospital **] clinic phone ([**Telephone/Fax (1) 4170**]
Office Fax:([**Telephone/Fax (1) 1353**]
8. warfarin 1 mg Tablet Sig: goal INR 3-3.5 Tablets PO once a
day: to check INR [**1-28**] in am for further dosing - had received
between 2-6 mg see coumadin form .
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
10. ampicillin sodium 2 gram Recon Soln Sig: Two (2) Recon Soln
Injection Q4H (every 4 hours): 2 gram q4h for 6 weeks [**1-22**] thru
[**3-5**] follow up in [**Hospital **] clinic prior to completion .
11. gentamicin 40 mg/mL Solution Sig: Fifty (50) mg Injection
Q8H (every 8 hours): 50 mg q8h next trough and peak on [**Hospital **]
[**1-31**]
for 6 weeks [**1-22**] thru [**3-5**] follow up in [**Hospital **] clinic prior to
completion .
12. Lexapro 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
MSSA endocarditis complicated by enterococcal endocarditis
s/p AVR/MVR/TV repair/PFO closure
aortic valve regurgitation
mitral valve regurgitation
seizures
Hepatitis C
IVDU
depression
anemia
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Edema none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) 914**] [**Name (STitle) 766**] [**3-7**] at 1:00 pm, [**Hospital Ward Name **] Bldg, [**Hospital Unit Name **] [**Telephone/Fax (1) 170**]
Cardiologist:Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3646**] [**2-18**] at 11:30 AM 1-[**Telephone/Fax (1) 21903**]
Infectious disease with Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 457**] - please call to
schedule for appointment in 4 weeks
Labs Weekly - CBC with diff, LFT - results to [**Hospital **] clinic
Labs Biweekly BUN, Cr, gent peak and trough - results to [**Hospital **]
clinic
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **] in [**5-18**] 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 mechanical aortic and
mitral valves
Goal INR 3-3.5
First draw Friday [**1-28**]
Please check [**Month/Year (2) **], wednesday, and friday for 2 weeks then
twice a week if INR and dosing stable
Rehab physician to manage coumadin until discharge from rehab
**please arrange for coumadin/INR f/u prior to discharge from
rehab*
Completed by:[**2146-1-27**]
|
[
"311",
"4280",
"2859"
] |
Admission Date: [**2114-4-6**] Discharge Date: [**2114-5-4**]
Date of Birth: [**2039-7-15**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17683**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
s/p ex-lap
parastomal hernia repair
fascial dehiscence
History of Present Illness:
74yo female p/w abdominal pain and decreased stoma output. This
began [**2114-4-5**]. Pt noticed increasing pain and became concerned
Past Medical History:
Breast cancer
HTN
NIDDM
colostomy [**3-15**] GIB
appendectomy
fibroid resection
Social History:
n/a
Family History:
n/a
Physical Exam:
nad
ctab
rrr
soft/tender, diminshed bowel sounds
cva tenderness
Pertinent Results:
[**2114-4-6**] 07:20PM BLOOD WBC-10.9 RBC-4.30# Hgb-12.7# Hct-38.1
MCV-89 MCH-29.5 MCHC-33.4 RDW-13.5 Plt Ct-274#
[**2114-4-9**] 08:19AM BLOOD WBC-8.5 RBC-3.91* Hgb-11.5* Hct-34.2*
MCV-87 MCH-29.4 MCHC-33.6 RDW-13.4 Plt Ct-227
[**2114-4-13**] 01:00PM BLOOD WBC-5.9 RBC-3.78* Hgb-11.2* Hct-34.3*
MCV-91 MCH-29.6 MCHC-32.6 RDW-13.2 Plt Ct-287
[**2114-4-18**] 10:29PM BLOOD WBC-21.7* RBC-3.18* Hgb-9.4* Hct-28.9*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.1 Plt Ct-290
[**2114-4-30**] 06:10AM BLOOD WBC-10.4 RBC-2.72* Hgb-8.0* Hct-24.9*
MCV-92 MCH-29.4 MCHC-32.1 RDW-14.0 Plt Ct-448*
[**2114-5-3**] 04:30AM BLOOD WBC-6.4 RBC-2.81* Hgb-8.3* Hct-25.5*
MCV-91 MCH-29.7 MCHC-32.7 RDW-14.0 Plt Ct-458*
[**2114-4-6**] 07:20PM BLOOD PT-12.3 PTT-22.6 INR(PT)-1.1
[**2114-5-1**] 07:28PM BLOOD PT-11.9 PTT-21.7* INR(PT)-1.0
[**2114-4-6**] 07:20PM BLOOD Glucose-173* UreaN-19 Creat-1.6* Na-141
K-4.3 Cl-104 HCO3-24 AnGap-17
[**2114-4-11**] 12:20PM BLOOD Glucose-104 UreaN-12 Creat-1.2* Na-143
K-3.8 Cl-103 HCO3-29 AnGap-15
[**2114-4-13**] 06:55AM BLOOD Glucose-115* UreaN-21* Creat-1.8* Na-142
K-5.2* Cl-100 HCO3-31 AnGap-16
[**2114-4-17**] 06:55AM BLOOD Glucose-98 UreaN-20 Creat-1.5* Na-146*
K-4.1 Cl-109* HCO3-28 AnGap-13
[**2114-4-19**] 02:47AM BLOOD Glucose-134* UreaN-29* Creat-1.8* Na-142
K-3.8 Cl-112* HCO3-21* AnGap-13
[**2114-4-24**] 02:12AM BLOOD Glucose-175* UreaN-25* Creat-1.2* Na-142
K-4.1 Cl-109* HCO3-24 AnGap-13
[**2114-5-3**] 04:30AM BLOOD Glucose-116* UreaN-4* Creat-0.9 Na-143
K-3.9 Cl-104 HCO3-32 AnGap-11
[**2114-4-6**] 07:20PM BLOOD AST-16 Amylase-135* TotBili-0.5
[**2114-5-1**] 11:11PM BLOOD ALT-7 AST-16 CK(CPK)-50 AlkPhos-77
Amylase-310*
[**2114-5-3**] 04:30AM BLOOD Amylase-200*
[**2114-4-19**] 02:47AM BLOOD Lipase-9
[**2114-4-8**] 08:05AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.9
[**2114-5-3**] 04:30AM BLOOD Calcium-8.0* Phos-4.3 Mg-1.8
[**2114-4-17**] 01:56PM BLOOD Type-ART Tidal V-600 FiO2-23 pO2-68*
pCO2-42 pH-7.40 calHCO3-27 Base XS-0 Intubat-INTUBATED
Vent-CONTROLLED
[**2114-4-19**] 12:16PM BLOOD Type-ART pO2-111* pCO2-49* pH-7.26*
calHCO3-23 Base XS--5
[**2114-4-23**] 10:11PM BLOOD Type-ART pO2-129* pCO2-44 pH-7.37
calHCO3-26 Base XS-0
[**2114-4-27**] 04:01AM BLOOD Type-ART Temp-37.2 Rates-/20 pO2-102
pCO2-47* pH-7.41 calHCO3-31* Base XS-3 Intubat-NOT INTUBA
Comment-NASAL [**Last Name (un) 154**]
[**2114-5-2**] 06:51AM BLOOD Type-ART pO2-86 pCO2-55* pH-7.35
calHCO3-32* Base XS-2
Brief Hospital Course:
On [**2114-4-6**] Ms. [**Known lastname **] was admitted to the surgery service under
the care of Dr. [**Last Name (STitle) **] with a diagnosis of a partial small
bowel obstruction secondary to a parastomal hernia. An NG tube
was placed and she was resuscitated with IF fluids. On HD 5 her
NG tube was d/c'd and over the next several days her diet was
slowly advanced. She was tolerating clears until her ostomy
output started to decrease. She developed increasing abdominal
pain and nausea. An NG tube was replaced and approximately 1600
cc of fecal material was suctioned. On hospital day 12 she was
taken to the OR for a parastomal hernia repair and anastomosis
of her ileum to her sigmoid colon. For details of the operation,
please see Dr.[**Name (NI) 22019**] operative report. Postoperatively she
remained intubated for several days in the ICU. TPN was
initiated. On POD 5 she had to return to the OR for a wound
dehiscence. Postoperatively from this second operation, Ms.
[**Known lastname **] did well. Her TPN was weaned down as tube feeds were
increased to goal via an NGT. On POD 10 from her initial
operation she was transferred to the floor and started on
clears. On POD 12 her NG tube was d/c'd and she was tolerating
fulls. By POD 13 she was tolerating a regular diet and walking
with physical therapy.On HD 26, patient found unresponsive in
bed. She was unable to move her extremities or mouth. Appeared
to have left facial droop and significant weakness on left side.
Vital signs were noted to be stable. Neurology was consulted. A
CXR, head CTA were performed and found to be negative. A EEG
showed some evidence of slow waves consistent with a post-ictal
state. On HD 27, pt noted to have significant imporvement. By HD
28, pt had returned to her baseline state. A VAC dressing was
placed at the bedside on the day of discharge for wound healing.
The pt was doing well.
Medications on Admission:
HCTZ
Glipizide
Metoprolol
Discharge Medications:
1. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
7. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q4H (every 4 hours) as needed for wheezing.
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day): titrate to [**3-16**] BM's/day. .
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
s/p partial small bowel obstruction
ex-lap
parastomal hernai repair
Discharge Condition:
good
Discharge Instructions:
Please call your doctor or the ER if you experience any of the
following: increased pain, fever >101.1, nausea, vomitting,
increasign diarrhea, chest pain, pus from your wound site or any
other concerns.
Followup Instructions:
Please follow up with Dr [**Last Name (STitle) **] in 1 week from discharge. An
appointment can be scheduled at ([**Telephone/Fax (1) 33502**]
Please remove VAC prior to follow up for wound evaluation
[**Name6 (MD) 843**] [**Name8 (MD) 844**] MD [**MD Number(1) 845**]
Completed by:[**0-0-0**]
|
[
"0389",
"5849",
"5859",
"25000"
] |
Admission Date: [**2189-3-11**] Discharge Date: [**2189-3-30**]
Date of Birth: [**2134-7-18**] Sex: M
Service: SURGERY
Allergies:
Mold Extracts
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Right atrium mass and inferior vena cava mass.
Major Surgical or Invasive Procedure:
[**2189-3-13**] Exploratory laparotomy, mobilization of the
liver, mobilization inferior vena cava, inflow occlusion.
(Dr.[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **])
The remainder of the procedure performed by Dr. [**Known firstname **]
[**Last Name (NamePattern1) 914**] from Cardiovascular Surgery included cardiopulmonary
bypass, median sternotomy and resection of the right atrial
tumor thrombus.
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 54 year old male with hepatocellular carcinoma
and a right atrial tumor thrombus extending into the inferior
vena cava and hepatic veins.
In short, Mr. [**Known lastname **] has a history of hepatitis C and alcoholic
cirrhosis who was found to have a 5 cm mass on CT scan in [**9-/2186**]
which was shown to be expanding in [**10/2187**] to 9x6 cm with
multiple pulmonary nodules. AFP levels were greater than
600,000
ng/ml. Further imaging in [**2-/2188**], however, failed to show a
mass
and AFP had then decreased to 2177 ng/ml. When hospitalized in
[**3-/2188**] for an UGI bleed he was found to have a right atrial mass
on echocardiogram, confirmed to be HCC on biopsy in [**2188-4-17**].
He was started on multiple chemotherapy regimens thereafter
which
were interchanged due to side-effects and presented in [**12/2188**]
with a pulmonary embolism. Workup showed concern for tumor
progression. He presents now for resection in a combined
procedure with hepatobiliary and cardiac surgery.
Past Medical History:
# HCC
- has a history of hepatitis C and alcoholic cirrhosis
complicated by grade II-III varices
- initial surveillance CT performed at an outside hospital in
[**9-/2186**] showed a 5-cm mass in the left liver as well as multiple
satellite lesions. AFP on [**2187-11-14**] was greater than 100,000
ng/mL.
- at [**Hospital1 18**] CT on [**2187-12-6**] showed a 9 x 6 cm enhancing mass in
the left liver as well as innumerable pulmonary nodules, the
largest measuring 9-10 mm. AFP was >600,000ng/mL. However,
further imaging showed improved in infiltrating liver process
and
AFP decreased to 2177ng/mL on [**2188-2-25**]. No lesion was
identified
by chest CT, liver CT, U/S, or MRI for biopsy.
- He was hospitalized in [**3-/2188**] with upper GI bleed, and
echocardiogram during that hospitalization diagnosed a right
atrial mass. HCC diagnosis was confirmed on the right atrial
mass biopsy on [**2188-4-24**].
- He began sorafenib [**2188-5-4**]. Dose was reduced after two
weeks
due to severe hand/foot syndrome and thrombocytopenia to 200mg
[**Hospital1 **].
- Mr. [**Known lastname **] self discontinued sorafenib [**2188-8-17**] due to
progressive leg cramps. His AFP had begun to rise.
- He began second line treatment with capecitabine [**2188-10-30**].
[**2189-3-13**] Exploratory laparotomy, mobilization of the
liver, mobilization inferior vena cava, inflow occlusion.
The remainder of the procedure performed by Dr. [**Known firstname **]
[**Last Name (NamePattern1) 914**] from Cardiovascular Surgery included cardiopulmonary
bypass
and removal of the right atrial tumor thrombus.
OTHER MEDICAL HISTORY:
Hepatitis C /ETOH cirrhosis c/b 2 cords grade 3 esophageal
varices s/p banding most recently [**4-26**].
Barrett's esophagus.
Hypertension.
GERD.
Status post right BKA after a motorcycle collision in [**2159**]
requiring eight surgeries.
History of hospitalization for pneumonia.
H/o upper GI bleed s/p hospitalization [**4-26**]
Social History:
Mr. [**Known lastname **] is divorced and has two children. He lives with his
father, mother, and brother. [**Name (NI) **] previously worked in an
automotive repair and as a driver delivering auto parts but is
currently out of work. TOBACCO: 35 years x1 pack per day. He
continues to smoke about 1.5 ppd. ALCOHOL: History of abuse,
now
about 2 beers per day. Denies history of withdrawals.
ILLICITS:
None.
Family History:
The patient's father is alive at 84. The patient's mother is
alive at 85 with dementia. He has a brother and sister and two
children without health concerns. There is no family history of
liver disease or malignancy.
Physical Exam:
97.8 89 127/86 20 100% RA
NAD, AAOx3
CTA
RRR
Abd soft, non-tender, non-distended
Right leg BKA stump, well healed with skin fold extending at mid
portion of stump and running to medial aspect of stump, no
drainage or signs of opening
No lower extremity edema
5.2>31.6<48
Pertinent Results:
[**2189-3-27**] 05:25AM BLOOD WBC-7.6 RBC-3.57* Hgb-11.1* Hct-33.3*
MCV-93 MCH-31.1 MCHC-33.3 RDW-21.9* Plt Ct-133*
[**2189-3-29**] 07:55AM BLOOD WBC-3.3* RBC-2.88* Hgb-9.6* Hct-27.5*
MCV-96 MCH-33.4* MCHC-35.0 RDW-21.7* Plt Ct-88*
[**2189-3-30**] 07:05AM BLOOD WBC-3.6* RBC-2.94* Hgb-9.7* Hct-27.7*
MCV-94 MCH-32.9* MCHC-35.0 RDW-21.5* Plt Ct-78*
[**2189-3-27**] 05:25AM BLOOD PT-26.5* INR(PT)-2.6*
[**2189-3-28**] 05:25AM BLOOD PT-22.3* INR(PT)-2.1*
[**2189-3-29**] 07:55AM BLOOD PT-24.7* PTT-34.8 INR(PT)-2.4*
[**2189-3-30**] 07:05AM BLOOD PT-26.0* PTT-35.7* INR(PT)-2.5*
[**2189-3-28**] 05:25AM BLOOD Glucose-95 UreaN-15 Creat-0.6 Na-128*
K-3.7 Cl-95* HCO3-28 AnGap-9
[**2189-3-29**] 07:55AM BLOOD Glucose-90 UreaN-12 Creat-0.6 Na-126*
K-4.0 Cl-94* HCO3-27 AnGap-9
[**2189-3-30**] 07:05AM BLOOD Glucose-86 UreaN-11 Creat-0.5 Na-128*
K-3.8 Cl-96 HCO3-23 AnGap-13
[**2189-3-26**] 05:40AM BLOOD ALT-21 AST-60* AlkPhos-159* TotBili-2.5*
[**2189-3-27**] 05:25AM BLOOD ALT-28 AST-65* AlkPhos-171* TotBili-2.2*
[**2189-3-28**] 05:25AM BLOOD ALT-27 AST-58* AlkPhos-149* TotBili-2.1*
[**2189-3-16**] 06:12AM BLOOD Lipase-30
[**2189-3-30**] 07:05AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.0
[**2189-3-11**] 07:50PM BLOOD calTIBC-558* Ferritn-39 TRF-429*
[**2189-3-28**] 1:04 pm URINE Source: CVS.
**FINAL REPORT [**2189-3-30**]**
URINE CULTURE (Final [**2189-3-30**]):
CITROBACTER FREUNDII COMPLEX. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
54 year old male with a tumor thrombus from his right atrium
into his inferior vena cava to hepatic veins, involving the
liver. He was admitted for procedural workup prior to his
operation on [**3-13**]. Arrangements for cardiac catheterization and
carotid duplex ultrasound on [**2189-3-12**] were made prior to his
operation on [**2189-3-13**]. Cardiac catheterization demonstrated the
following:
No angiographically apparent flow-limiting coronary disease.
2. Catheter-induced spasm at ostium of RCA with 60% mid-segment
3. Normal systemic arterial pressures.
4. Vagal reaction/hypotension secondary to IC NTG
administration,
resolved with IVF and atropine.
TEE was also performed noting EF of 55-65% and a large spherical
mass of 5.9 cm diameter was seen in the right atrium and a mass
was seen in the liver at the junction of the hepatic vein with
the IVC.
Carotid duplex demonstrated less than 40% stenosis in the
internal carotid arteries
bilaterally. He was preop'd and taken to the OR on [**2189-3-13**]. He
underwent exploratory laparotomy, mobilization of the liver,
mobilization of inferior vena cava, inflow occlusion. Surgeon
was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. The remainder of the procedure was
performed by Dr. [**Known firstname **] [**Last Name (NamePattern1) 914**] from Cardiovascular Surgery that
included median sternotomy, cardiopulmonary bypass and removal
of the right atrial tumor thrombus. Please refer to operative
reports for further details.
Postop, he was taken intubated with a chest tube to the CV ICU
under the care of Dr. [**Last Name (STitle) 914**]. On [**3-14**], a liver duplex was done
noting the following:
Poor evaluation of the left hepatic vein, and residual tumor in
this area
cannot be excluded.
2. Patent inferior vena cava as well as middle and right hepatic
veins.
3. Reversal flow within the left portal vein which is otherwise
patent.
4. Gallbladder sludge with minimal gallbladder wall thickening,
the latter of
which may be due to underlying chronic liver disease.
A TTE was then done noting EF of >55% and no residual right
atrial mass seen. Normal global and regional biventricular
systolic function.
Repeat liver duplex on [**3-19**] was performed again demonstrating the
following:
1. Appropriate flow is seen in the IVC and the right and middle
hepatic
veins. Again the left hepatic vein is not well visualized which
might relate
to residual tumor or occlusion as previously noted. There is no
change in the
appearance. Reverse flow again noted in the left portal vein.
2. No focal hepatic lesion and no biliary dilatation seen.
3. Sludge in the gallbladder.
Given the liver duplex findings, a CT was performed to evaluate
the hepatic vasculature. CT on [**3-20**] showed interval right atrial
and IVC tumor thrombectomy with persistent pulmonary emboli,
persistent middle and left hepatic venous occlusion, unchanged
from [**2189-3-5**] CT. No definite focal lesions were seen
in the liver. Portal, splenic and superior mesenteric veins were
patent with gastric, splenic and esophageal varices. Bibasilar
ground glass opacities were demonstrated, likely mild pulmonary
edema; however superimposed infection could not be excluded.
He was started on Heparin drip then Coumadin was initiated on
[**3-22**]. Heparin was stopped. INR became therapeutic on [**3-24**] with
inr 2.4.
Overall, he did well postop. Chest tube was removed. He was
transferred out of the ICU. For many days, he experienced high
JP ascites output for which he received Albumin and IV fluid. JP
output decreased to 1200. Diet was slowly advanced and
tolerated. He was eventually passing BMS. Pain management was
difficult as he experienced back pain as well as abdominal pain.
Oxycontin was started [**Hospital1 **] in addition to oral pain mediation
with prn Dilaudid IV for break thru. He became somewhat
confused and the OxyContin and Dilaudid were stopped. Flexeril
was not given. LFTs increased slightly then trended down. Mental
status improved.
JP was removed on [**3-23**]. The insertion site was sutured and
remained dry/intact. Abdomen increased in size a day after the
JP was removed [**3-23**]. Home diuretics were resumed. He required
potassium supplementation. The Chevron incision remained intact,
dry and without redness. The sternotomy site was also intact,
without redness or drainage.
Two days after the JP drain was removed, he started to
experience hyponatremia with sodium decreasing to 127 then as
low as 125. Abdomen appeared to have developed ascites. An
attempt was made to do a therapeutic paracentesis. A diagnostic
paracentesis was performed. Fluid was sent for gram stain, cell
count and culture. 1+ PMR were noted without organisms.
Hepatology was consulted for hyponatremia on [**3-28**]. It was felt
that the patient was dry. Diuretics were then held.
Recommendations were to restrict sodium and fluid. Albumin was
administered. Sodium trended back up to 128. On [**3-30**], abdomen
appeared larger and patient felt a little sob. Vital signs were
stable. Weight was up one kg as well. Lasix 20 mg daily and
potassium chloride 20 mEq were restarted on [**3-30**]. Hepatology did
not want sodium or fluid restricted.
PT was initially consulted noting difficulty mobilizing patient
secondary to sternal and upper abdomen (Chevron)incision. His
right leg was very edematous and needed PT to apply a "stump
shrinker". This was successful and prosthesis was applied. His
prosthesis had a belt that wrapped around his waist below the
Chevron. Due to the two incisions, sternal precautions and BKA,
ambulation was difficult. Please refer to PT notes. At time of
discharge he was easier to move but required assist due to
sternal precautions.
PT recommended rehab and a bed was sought at [**Hospital1 **]
in [**Location (un) 701**]. A bed became available on [**3-30**].
Coumadin INR goal is [**2-19**]. He will require daily PT/INRs until
goal range is stable then ~ 3x per week.
Of note, he developed foul smelling urine, ua/ucx were sent
isolating Citrobacter on [**3-28**]. This was pan sensitive to Cipro.
Cipro 500 mg [**Hospital1 **] was started on [**3-28**]. A ten day course was
planned.
Medications on Admission:
capecitabine 1500 mg [**Hospital1 **]
cyclobenzaprine 5-10 mg QHS PRN back pain
furosemide 20 mg daily
nadolol 40 mg daily
omeprazole extended release 20 mg daily
spironolactone 50 mg daily
zolpidem 10 mg QHS prn insomnia
docusate sodium 100 mg [**Hospital1 **] prn constipation
loratadine 10 mg daily
multivitamin daily
Discharge Medications:
1. Outpatient Physical Therapy
Right residual limb shrinker
DX: post Op edema
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day) as needed for pain.
9. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for hr<60, sbp<100mmHg .
10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. insulin regular human 100 unit/mL Solution Sig: follow
printed sliding scale units Injection ASDIR (AS DIRECTED).
13. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: inr
daily.
14. LABS
Daily PT/INR. Goal INR [**2-19**]
15. LABS
weekly labs, start Wed [**4-1**]: cbc, chem 10, ast, alt, alk phos,
t.bili, albumin, PT/INR
fax to [**Telephone/Fax (1) 697**] attn: [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator
16. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: started [**3-28**]. end [**4-6**]
UTI.
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. potassium chloride 10 mEq Capsule, Extended Release Sig: Two
(2) Capsule, Extended Release PO DAILY (Daily): while on Lasix.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Right atrial tumor thrombus
uti, citrobacter [**2189-3-28**]
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair. (patient has right leg prosthesis)
Sternal precautions
Discharge Instructions:
You will be transferring to [**Hospital1 **] in [**Location (un) 701**] for
rehab
Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever, chills,
confusion, nausea, vomiting, diarrhea, constipation, incisional
redness, drainage or bleeding, increased ascites, bleeding
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2189-4-9**] 10:40
([**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator for Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 17195**])
Provider: [**Known firstname 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2189-4-21**] 1:15
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1852**] (Oncologist)[**Telephone/Fax (1) 8770**] (please schedule a
follow up appointment)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2189-3-30**]
|
[
"5990",
"2761",
"41401",
"4019",
"53081",
"V5861"
] |
Admission Date: [**2164-7-26**] Discharge Date: [**2164-8-1**]
Service: MEDICINE
Allergies:
Carbamazepine / Fosamax / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 23347**]
Chief Complaint:
HTN
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] F with history of mechanial fall in [**6-/2164**] resulting in
prolonged rehabilitation that is ongoing, though patient with
increasing hypertension, dyspnea, constipation, and confusion in
last several days. Presented to the ED early on [**7-26**] (0300) with
hypertension and dyspnea. Patient reports that she awoke from
sleep with a strange feeling in her head. She and daughter agree
that she dyspnea has been persistent over entire rehab course.
Has had decreased PO intake in last week.
.
Upon presentation to the ED, vitals were: T 98, HR 68, BP
206/98, RR 14, O2Sat 98%. CXR was performed. Patient was felt to
have CHF exacerbation and was given nitro paste and furosemide
IV. KUB showed a dialted bowel loop. CT abdomen and pelvis
performed and confirmed dilated bowel loop; however, without any
additional pathology. Stool guaiac was negative. CT head was
negative. 10 hours into ED course patient's BP was still 200
systolic. Patient had been given PO HTN meds, though vomited
twice and couldn't keep meds down. Labetalol drip was started
with good effect and ICU bed request was made. EKG in ED was
sinus without acute changes and two sets of troponin were drawn
10 hours apart and were negative.
In the MICU, labetalol gtt was stopped since SBP<160. She
continued to have SBP 140-170s.Took home PO meds this morning
and vomitted up MVI but took BP meds ok. She was sleepy but
arousable. today tried po narcan to see if fentanyl patch could
be making her sleepy and fentanyl patch was decreased to
50mcg/hr TP Q72h. Cr was seen to increase slightly.
Prior to transfer to the floor, patients vitals were: T
afebrile, HR 70, BP 174 systolic, RR 97% on 2L NC.
Past Medical History:
- Diastolic CHF
- LE edema
- Iron Deficiency Anemia
- Mild/moderate dementia
- Hypercholesterolemia
- Hypertension
- Osteoporosis
- Status post CVA
- Gastroesophageal reflux disease
- Presbyesophagus
- Constipation
- Trigeminal neuralgia
- Compression fractures - T7 through 11 and T12
- Basal cell carcinoma
- Restless legs syndrome
- Parkinsonian symptoms
Social History:
She is married, and her spouse is still alive. They both reside
in an assisted care facility. She denies alcohol or tobacco
use. She has one son and one daughter.
Family History:
Non-Contributory
Physical Exam:
Physical Exam:
VS: T afebrile, HR 76, BP 161/74, RR 22, O2Sat 100% 3L NC
GEN: NAD
HEENT: PERRL, oral mucosa extremely dry
NECK: JVP elevated at approximately 10 cm
PULM: Kyphosis, diffuse crackles along posterior lung fields
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS+, thin, soft, NT, ND
RECTAL: Normal rectal tone with soft stool mixed with solid
pellets in rectal vault
EXT: bilateral 1+ pitting edema
NEURO: Hypophonia and hoarse voice, oriented to self and
clinical situation, confused about dates and chronology of
events in last week
Pertinent Results:
Labs at Admission:______________
[**2164-7-26**] 03:00AM PT-13.1 PTT-27.4 INR(PT)-1.1
[**2164-7-26**] 03:00AM WBC-9.6 RBC-4.10* HGB-11.4* HCT-34.8* MCV-85
MCH-27.9 MCHC-32.9 RDW-14.9
[**2164-7-26**] 03:00AM GLUCOSE-119* UREA N-36* CREAT-1.6* SODIUM-137
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
[**2164-7-26**] 04:45AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2164-7-26**] 03:00AM CK-MB-4 cTropnT-0.05* proBNP-4947*
[**2164-7-26**] 12:50PM cTropnT-0.04*
----Imaging:-----
***CT-Head***
FINDINGS: There is no evidence of acute hemorrhage, edema, mass
effect, or
acute large vacular territory infarction. Prominence of the
ventricles and
sulci reflects generalized atrophy and appears similar to the
prior
examination. Confluent areas of periventricular and subcortical
white matter
hypodensities most likely reflects sequela of chronic small
vessel ischemic
disease. There are calcifications of the bilateral carotid
siphons. The
visualized paranasal sinuses are clear.
IMPRESSION: No evidence of acute intracranial process.
***CT-Abdomen***
IMPRESSION:
1. Dilatation of a segment of small bowel up to 3.5 cm without
evidence of
abrupt transition point and oral contrast is seen beyond this
loop of bowel in
decompressed loops. Findings are consistewnt with partial
obstruction.
2. Small bilateral pleural effusions, left greater than right,
with simple
fluid attenuation.
3. Evidence of prior granulomatous disease in the liver and
spleen.
4. Extensive atherosclerotic calcification of the aorta.
5. Left renal cysts.
6. Multiple compression deformities, age indeterminate.
_________________________
Labs at discharge:
[**2164-7-30**] 06:10AM BLOOD WBC-7.9 RBC-3.57* Hgb-9.8* Hct-29.9*
MCV-84 MCH-27.5 MCHC-32.9 RDW-15.1 Plt Ct-265
[**2164-7-30**] 06:10AM BLOOD Glucose-89 UreaN-49* Creat-1.9* Na-139
K-4.4 Cl-104 HCO3-27 AnGap-12
[**2164-7-27**] 03:23AM BLOOD ALT-16 AST-25 LD(LDH)-365* AlkPhos-83
Amylase-84 TotBili-0.4
Brief Hospital Course:
[**Age over 90 **] yo female with hypertensive crisis likely secondary to
missing anti-hypertensive doses because of N/V. Pt was found to
have SBP>200 and had concurrent complaints of mental fuzziness
(however, baseline AD). Was started on labetalol drip because
of inability to tolerate PO. In the ICU, pt was maintained on
labetalol drip until could tolerate PO medications, and was then
restarted on home carvedilol and losartan, and because it was
thought that her nausea might be in part due to very high dose
of fentanyl, fentanyl patch dose was decreased to 50mcg. SBPs
on HD1 occasionally spiked despite home antihypertensives, so
patient was additionally started on 2.5mg amlodipine daily.
Transferred to floor with stable VS. Overnight, pt vitals
remained stable with a BP of 146-150/66-67. Her SOB improved and
cognitive functioning returned closer to baseline. She was
deemed stable for discharge to rehabilitation. She did have
diarrhea after having an aggressive bowel regimen in the ICU.
She was repleted with gentle fluids and her creatinine and dry
mouth improved. We were gentle because of her known heart
failure with an EF of about 35%. She was doing well and at her
baseline and happy to be with her husband.
Medications on Admission:
1) Aspirin 81 mg PO/NG DAILY
2) Losartan Potassium 100 mg PO/NG DAILY
3) Fentanyl Patch 75 mcg/hr TP Q72H
4) Bisacodyl 10 mg PO/PR DAILY:PRN constipation
5) Pramipexole 0.5 mg Oral [**Hospital1 **]
6) Multivitamins 1 TAB PO/NG DAILY
7) Lidocaine 5% Patch 1 PTCH TD DAILY
8) Carvedilol 25 mg PO/NG [**Hospital1 **]
9) Simvastatin 10 mg PO/NG DAILY
10) Omeprazole 40 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Pramipexole 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
6. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
8. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
11. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
-HTN
Secondary:
-Constipation
-CHF
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the [**Hospital1 **] for very high
blood pressure, difficulty breathing and overall confusion. We
treated your high blood pressure successfully and your breathing
improved as a result of these treatments. We were also
originally concerned about your constipation and evaluated you
for an obstruction but you were not obstructed based on imaging
studies and physical exam. Overnight your clinical situation
improved such that we feel comfortable sending you to a
rehabilitation facility for further monitoring and physical
therapy.
While you were here, some of your home medications were changed.
We DECREASED your Fentanyl patch to 50mcg TP Q72h. We STARTED
Amlodipine 2.5mg Daily. Please continue to take these
medications.
Please continue to take all other medications as prescribed by
your doctor.
Please attend all follow-up appointments
Followup Instructions:
Please follow up with the Physicians at the rehabilitation
facility. Tell your doctor if you have headache, nausea or feel
short of breath.
[**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]
|
[
"5849",
"4280",
"53081",
"2720"
] |
Admission Date: [**2107-12-1**] Discharge Date: [**2107-12-3**]
Date of Birth: [**2037-7-7**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
transferred to [**Hospital1 18**] with a diagnosis of sepsis
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
70 yr old male, incarcerated, who initially presented to the OSH
ED with fever, chills, lightheadedness, decreased po intake,
diarrhea, and cough x 1 day. Patient was taken to [**Hospital 13056**]
hospital were found to have fever of 102.6, WBC of 11, bandemia
37%. Patient was given Tylenol, Levaquin, and 1L NS. BP was
105/57 initially and then the patient reportedly became
hypotensive to systolic BP of 60. No reported hypotension. Also,
reportedly had an episode of an ICD firing and near syncope
prior to presentation to the OSH. The patient was started on
Amiodarone and Dopamine drips. Transferred to [**Hospital1 18**] for further
management.
Patient denied CP, but reported swears, and cough productive of
sputum.
In the ED, right IJ was placed and sepsis protocol was
initiated.
Past Medical History:
1. COPD, no h/o intubations
2. DM
3. Hyperlipidemia
4. PVD
5. CAD s/p MI in [**2101**], "silent" (last cath in [**2102**])
6. BPH
7. HTN
8. AAA s/p repair with endograft
9. S/p cholecystectomy
[**12**]. S/p laparotomy after GSW in [**2070**]
Social History:
Prisoner. Long history of smoking. Used to drink 3 drinks/day.
No IVDU or cocaine.
Family History:
Non-contributory
Physical Exam:
100.8 -> 103 102/60 111 24 98% RA
General: elderly, lying flat, NAD
HEENT: PERRL, no scleral icterus, MMM
CV: tachycardic 120's, irregular rate
Pulm: + egophany LLL, tight BS, no wheezes, no crackles
ABd: + BS, soft, tender RUQ, liver palpable 3 cm below RCM
Extr: no edema, + clubing, no palmar erythema, DP 2+ bilaterally
Neuro: CN 2-12 grossly intact, strength 5/5 throughout,
downgoing toes, no asterixis.
Pertinent Results:
[**2107-12-1**] 10:35PM BLOOD WBC-7.8 RBC-4.40* Hgb-13.7* Hct-39.5*
MCV-90 MCH-31.1 MCHC-34.7 RDW-13.6 Plt Ct-154
[**2107-12-1**] 10:35PM BLOOD Neuts-62 Bands-13* Lymphs-8* Monos-10
Eos-0 Baso-0 Atyps-6* Metas-1* Myelos-0
[**2107-12-1**] 10:35PM BLOOD PT-15.0* PTT-34.3 INR(PT)-1.4
[**2107-12-1**] 10:35PM BLOOD Glucose-131* UreaN-48* Creat-2.7* Na-141
K-3.0* Cl-103 HCO3-27 AnGap-14
[**2107-12-1**] 10:35PM BLOOD ALT-13 AST-16 LD(LDH)-180 CK(CPK)-187*
AlkPhos-33* Amylase-20 TotBili-1.9* DirBili-0.9* IndBili-1.0
[**2107-12-3**] 04:31AM BLOOD Fibrino-931*
[**2107-12-3**] 12:46PM BLOOD Lipase-11
[**2107-12-1**] 10:35PM BLOOD Albumin-3.0* Calcium-7.1* Phos-3.2
Mg-1.5*
[**2107-12-1**] 10:35PM BLOOD TSH-0.72
[**2107-12-1**] 11:06PM BLOOD Lactate-4.0*
[**2107-12-2**] 02:41AM BLOOD Lactate-4.4*
[**2107-12-2**] 03:44AM BLOOD Lactate-4.8*
[**2107-12-2**] 06:05AM BLOOD Lactate-4.5*
[**2107-12-2**] 06:49AM BLOOD Lactate-4.5*
[**2107-12-2**] 06:57AM BLOOD Lactate-4.4*
[**2107-12-2**] 02:27PM BLOOD Lactate-1.8
[**2107-12-2**] 11:03PM BLOOD Lactate-3.0*
[**2107-12-2**] 11:03PM BLOOD Lactate-3.0*
[**2107-12-3**] 04:47AM BLOOD Lactate-3.3*
[**2107-12-2**] 05:42AM BLOOD Type-ART pO2-102 pCO2-36 pH-7.36
calHCO3-21 Base XS--4
[**2107-12-2**] 02:27PM BLOOD Type-ART Temp-39.3 Rates-[**10-23**] Tidal V-600
PEEP-5 FiO2-100 pO2-206* pCO2-65* pH-7.13* calHCO3-23 Base XS--8
AADO2-453 REQ O2-76 -ASSIST/CON Intubat-INTUBATED
[**2107-12-2**] 06:57AM BLOOD Type-ART pO2-59* pCO2-37 pH-7.31*
calHCO3-20* Base XS--6
[**2107-12-1**] 10:35PM BLOOD Cortsol-138.3*
[**2107-12-2**] 03:00AM BLOOD Cortsol-151.1*
[**2107-12-2**] 03:30AM BLOOD Cortsol-163*
[**2107-12-1**] 10:35PM BLOOD CK-MB-5 cTropnT-0.12*
[**2107-12-2**] 05:38AM BLOOD CK-MB-6 cTropnT-0.09*
[**2107-12-2**] 02:15PM BLOOD CK-MB-8 cTropnT-0.21*
[**2107-12-2**] 10:24PM BLOOD CK-MB-7 cTropnT-0.20*
Microbiology:
1. Blood cultures [**2107-12-1**]: Staph aureus 3/4 bottles, methicillin
resistant
2. Urine culture [**2107-12-1**]: negative
3. Stool culture [**2107-12-2**]: negative
4. Sputum culture [**2106-12-1**]: Staph aureus, methicillin resistant
5. Blood cultures [**2107-12-3**]: no growth 4/4 bottles
5. Influenza antigen negative [**2107-12-3**]
Brief Hospital Course:
The patient was admitted to the intensive care unit. He was
continued on the MUST protocol that was initiated in the
emergency room and started on Vancomycin, Levaquin and
Ceftriaxone for broad spectrum coverage. On [**2107-12-2**], the patient
became tachypneic to 40's with decrease in oxygen saturations to
80's. ABG 59*1 37 7.31/37/55/20. He was briefly tried on NRB
and BiPAP but subsequently required intubation due to increased
work of breathing. Prior to being intubated that patient stated
"I do not want to die, but have nothing to live for. If I was
dependent on ventilator, I would want to die". Despite
aggressive fluid resuscitation and goal directed therapy, the
patient's clinical status continued to worsen. Later on [**2107-12-2**]
he became hypotensive despite fluid resuscitation. Levophed and
Vasopressin were started. The patient was also empirically
started on stress dose steroids. The patient then developed
renal failure. Xigris was started because the patient now had
met criteria for severe sepsis. His condition continued to
deteriorate. He had worsening of metabolic acidosis. Per
discussion with the patient's wife, who is his health care
proxy, patient's code status was confirmed to be do not
resuscitate but pressors and antibiotics were continued. He
continued to do poorly despite maximum doses of 4 different
pressors. After discussing the patient's poor prognosis with his
wife, the goals of care were changed to comfort and pressors
were withdrawn. The patient was pronounced dead on [**2106-12-2**] at
6:40 pm.
During this hospital admission, the patient was also found to
have a lesion suspicious for mass in the head of the pancreas as
well as dilated intra and extra hepatic biliary system on a RUQ
ultrasound which was performed to evaluate hepatomegaly and
elevated bilirubin levels.
For the patient's atrial fibrillation, the patient was continued
on amiodarone for rate control. He was briefly on Heparin drip
for a fib and also given concern for ACS EP service was
consulted and interrogated his pacer.
Medications on Admission:
Simvastatin
Lisinopril
Isosorbide
HCTZ
Doxazosin
Docusate
ASA EC
Fluticasone
Amiodarone
Albuterol
KCL
Discharge Disposition:
Expired
Discharge Diagnosis:
1. Staph aureus sepsis secondary to left lower lobe pneumonia
2. Atrial fibrillation
3. Pancreatic mass
4. Chronic obstructive pulmonary disease
Discharge Condition:
patient expired
Completed by:[**2108-2-14**]
|
[
"0389",
"486",
"5849",
"51881",
"42731",
"2762",
"4280",
"496",
"99592",
"412",
"25000"
] |
Admission Date: [**2198-10-19**] Discharge Date: [**2198-11-1**]
Date of Birth: [**2165-9-12**] Sex: F
Service: TSURG
Allergies:
Ancef
Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
esophageal carcinoma
Major Surgical or Invasive Procedure:
esophagectomy
chest tube placement
History of Present Illness:
Ms. [**Known lastname **] is a 33-year-old woman who was found to have a T3,
possible N1, distal esophageal squamous cell carcinoma. She
underwent neoadjuvant chemoradiotherapy and then was restaged
with no evidence of recurrence. She now presents for her
esophagogastrectomy.
Past Medical History:
esophageal sqaumous cell carcinoma
dysphagia
iron-deficiency anemia
GERD
history of SBO
status post ex-lap x2 for SBO
status post J-tube placement and removal x2
status post vag. hysterectomy
status post abdominoplasty
status post mammoplasty
Physical Exam:
On Discharge:
Temp 98.5, HR 97, BP 101/61, R 18, 92%RA
NAD
RRR
CTA-B; incis: no SOI
s/nt/nd; +BS; incis: no SOI
no c/c/e
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the Thoracic Surgery service under
the care of Dr. [**Last Name (STitle) 952**]. She was taken to the OR for an
esophagectomy with midle and right thoracotomy approach. She
tolerated the procedure well, please see Dr.[**Name (NI) 1816**] Operative
note for greater detail.
She was admitted to the CSRU where she had an uneventful course.
TPN was started on POD#1. By POD#2, Ms. [**Known lastname **] was transferred
to the floor. On POD #4, her epidural was discontinued.
On POD#5, her Levafloxacin and Flagyl were discontinued.
Overnight, she had a temperature spike of 101.2. Blood cultures
were drawn and negative. Physical exam showed some purulent
drainage and erythema at insertion site of the right chest tube.
She was started on Vancomycin. Ms. [**Known lastname **] remained afebrile,
and the site improved with no erythema or pus by POD #10. The
Vancomycin was discontined after 5 days.
On POD #7, Ms. [**Known lastname **] had an esophogram that revealed no
evidence of a leak. Her chest tube was pulled. She was started
on a clears diet and her diet advanced as tolerated and her TPN
was cycled at night. On POD #8 the NG was discontinued. On
POD#10, Ms. [**Known lastname 22859**] TPN was discontinued and she was
transitioned to po pain meds.
Chronic Pain Service saw Ms. [**Known lastname **] on POD #11 and made
recommendations for management of her pain and would follow her
up as an outpatient. Her diet was clarified to be liquids only
until [**2198-11-2**]; she is then to transition to pureed foods the
following week, and then soft solids the week thereafter. She
is to receive TPN at night during this period. She was
restarted on goal TPN on POD #12.
At the time of discharge on POD#13, Ms. [**Known lastname **] had adequate pain
control, was tolerating a liquid diet, tolerating her TPN, and
ambulating without difficulty.
She was discharged home with services in good condition.
Medications on Admission:
Ambien 10',
Protonix 40',
Klonipin 1 prn,
Tylenol elixir 1g q6 prn,
Roxicet elixir 5ml q4-6,
Fentanyl patch
Discharge Disposition:
Home With Service
Facility:
physicians home care
Discharge Diagnosis:
status post esophagectomy
esophageal cancer
gastro-esophageal reflux disease
dysphagia
iron-deficiency anemia
hypomagnesmia
history of small bowel obstruction
status post vaginal hysterectomy
status post abdominoplasty
status post mammoplasty
status post J-tube x2 with subsequent removal
status post ex-lap x2 for SBO
Discharge Condition:
Good
Discharge Instructions:
If you experience any chest pain, difficulty swallowing,
shortness of breath, nausea/vomiting, or fevers/chills, please
seek medical attention.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] for a follow up appointment in [**2-9**]
weeks: [**Telephone/Fax (1) 170**]
Please follow up in Pain Clinic, call [**Telephone/Fax (1) 1091**]
|
[
"5180",
"53081"
] |
Admission Date: [**2179-2-3**] Discharge Date: [**2179-2-5**]
Date of Birth: [**2109-6-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
chest pressure/pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
Ms. [**Known lastname 88403**] is 69 yo female with numerous cardiac risk factors
(HTN, HLD, smoking, +FHx) as well as AFib and SSS s/p pacemaker
who presented to [**Hospital3 1443**] ED this AM with chest
pressure. Symptoms started around 4am, when she woke up with
left-sided substernal chest pressure/tightness, non-radiating,
[**2177-2-27**] in severity. There was no associated shortness of breath,
nausea, vomiting or diaphoresis. When the pain did not go away,
she called the ambulance. In the ambulance she received NTG
SLx3, which made the pain resolve. In the ED, she was
hypertensive to >200 and started on NTG gtt for chest pain and
HTN. While on the NTG gtt, she reported L arm
discomfort/pressure and midsternal burning, which resolved with
uptitration of the drip. Initial EKG showed T wave changes in
aVL, but repeat EKG later in AM showed TWI in II,III,aVF, and
V3-V6. Labs significant for: Trop T <0.01, 0.35, 0.46 [ref range
0.01-0.04]; CK 59, 84, 87; MB 7, 7; MBI 8,8. D-dimer elevated to
0.61 so pt had V/Q scan which found low probability of PE.
Patient given ASA 325mg, Lopressor, morphine, Plavix loaded.
Prior to transfer to [**Hospital1 18**] for cath, she developed nausea which
was treated with Zofran.
.
On arrival to [**Hospital1 18**] CCU, patient is hemodynamically stable,
hypertensive to 160/100 on NTG gtt. She complains of persistent
nausea but denies chest pain, arm/jaw pain, shortness of breath,
or diaphoresis. EKG unchanged from prior. Labs show Trop T 0.39,
CK 85, MB 7.
.
Patient denies recent h/o anginal symptoms: no recent chest
pain, dyspnea on exertion, etc. She did have a similar episode
of chest pressure 2-3 years ago, for which she was worked up for
PE (CTA negative). She notes chronically decreased exercise
tolerance since getting her pacemaker 4 years ago. Per her
report, she had a nuclear stress test 3 months ago for health
maintenence purposes, which was completely normal.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
-Paroxysmal AFib (on flecainide, off coumadin)
-SSS with pacemaker
-HTN
-HLD
-Hypothyroidism
-Raynaud's syndrome
Social History:
Pt is retired lab worker. Divorced, lives alone at home. Former
smoker (1 pack/week, quit 25 years ago). Drinks ~1 bottle of
wine per week. Denies illicits.
Family History:
Mother died of CAD (age 58). Aunt with stroke. No known FHx HTN,
HLD, arrythmias, cardiomyopathies, sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: pleasant F who appears uncomfortable [**1-28**] nausea, AAOx3.
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 JVD of 3 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: 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.
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAM: unchanged from admission exam
Pertinent Results:
ADMISSION LABS:
WBC-6.5 RBC-3.55* Hgb-11.7* Hct-34.1* MCV-96 MCH-32.8* MCHC-34.2
RDW-12.1 Plt Ct-149*
PT-9.9 PTT-69.4* INR(PT)-0.9
Glucose-133* UreaN-18 Creat-0.8 Na-141 K-4.0 Cl-106 HCO3-26
AnGap-13
Calcium-8.9 Phos-3.3 Mg-2.2
ALT-37 AST-41*
.
CARDIAC ENZYMES:
[**2179-2-4**] 12:00 AM: CK (CPK) 85, MB 7, Trop T 0.39*
[**2179-2-4**] 06:07 AM: CK (CPK) 77, MB 6, Trop T 0.21*
.
ECHO ([**2179-2-4**]): 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 and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No clinically-significant valvular disease seen.
.
CHEST X-RAY ([**2179-2-4**]): Heart size is moderately enlarged.
Mediastinum is unremarkable. Lungs are essentially clear with no
pleural effusion and pneumothorax. There is no evidence of
pulmonary edema. Left-sided pacemaker is placed with two leads,
one of them terminating most likely in the right atrium and the
other one in the right ventricle. The right ventricle lead makes
a loop most likely within the posterolateral aspect
of the right atrium. No pneumothorax.
Brief Hospital Course:
# CHEST PAIN: Pt with multiple cardiac risk factors including
HTN, HLD, cigarettes and +FHx presenting with new-onset
substernal chest pressure. Symptoms improved with SL NTG and
resolved with initiation of NTG gtt + morphine bolus. Troponins
peaked at 0.46, CK 87, MB 7. Initial EKG without changes at OSH,
but repeat EKG showed TWI in II,III,aVF and V3-V6. Per OSH
records she was hypertensive to SBP>200 in the ED. Patient's
TIMI score was 5, putting her at 12% risk of death/MI at 2
weeks, and 26% risk of death/MI/urgent revascularization at 2
weeks. She was Plavix loaded and started on heparin gtt and NTG
gtt at OSH. Prior to cath, she was also treated with home
metoprolol tartrate 100mg PO BID (goal HR 60-70), atorvastatin
80mg PO daily, ASA 325mg PO daily, and Plavix 75mg PO daily, and
she was weaned off NTG gtt. She underwent cardiac cath on the
morning of [**2-4**], which showed mild CAD, LVEDP of 22, and anatomic
anomoly (bronchial arteries take off from RCA with AV
malformation). No interventions were performed. Patient did well
after cath, with no recurrence of chest pain or nausea. It was
felt that given that she had had SBP>200 at OSH, her chest pain
was most likely [**1-28**] hypertensive emergency. Therefore, on
discharge she was started on Lisinopril in addition to her home
Metoprolol for better control of blood pressure. She will also
continue her home dose of atorvastatin 40mg daily and ASA 325mg
daily. Patient agreed to purchase a BP cuff and monitor her
blood pressure regularly at home.
.
#.Nausea: patient c/o persistent nausea starting 2-3 hours prior
to arrival at [**Hospital1 18**] CCU. No evolving EKG changes or increasing
enzymes. Nausea most likely [**1-28**] morphine and NTG. Resolved with
zofran + ativan, and did not recur once NTG discontinued.
.
#.AFib: Per patient, she is no longer on Coumadin as her
cardiologist found that she only has paroxysmal afib. Her home
Flecainide was held in the setting of concern for NSTEMI; home
metoprolol and ASA were continued. Once NSTEMI had been ruled
out via cath, her home flecainide was restarted. Heart rate
well-controlled throughout hospitalization.
.
#.Sick Sinus Syndrome: patient has pacemaker, and is sinus paced
on EKG. Pacer interrogation was normal.
.
#.HTN: patient hypertensive to 160 on NTG gtt and home
metoprolol on arrival. Given that her chest pain was most likely
[**1-28**] hypertensive emergency ([**Last Name 788**] problem #1), she was discharged
on Lisinopril in addition to her home Metoprolol 100mg [**Hospital1 **].
.
#.HLD: patient on lipitor 20mg at home. She is discharged on
atorvastatin 40mg daily.
.
#.Hypothyroidism: continued home levothyroxine.
.
TRANSITION OF CARE:
1. Needs Chem 10 checked in 1 week because started Lisinopril
2. Please note RCA AVM found on cardiac cath.
Medications on Admission:
-ASA 325mg PO daily
-Simvastatin 20mg PO daily
-Metoprolol tartrate 100mg PO BID
-Flecainide 100mg PO BID
-Levothyroxine 100mcg PO daily
-Fish oil
-Vitamin C
-Calcium+D
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. metoprolol tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
3. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. flecainide 100 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Outpatient Lab Work
Please check A1C and potassium on Tuesday [**2-9**] at 2:30p
at Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 92136**] office
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Chest Pain
Hypertensive urgency
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had chest pain that did not result in a heart attack. We are
not sure why you had chest pain but it might be because of high
blood pressure. An echocardiogram showed normal heart function
and a cardiac catheterization did not show any acute blockages.
We have started a new medicine to lower your blood pressure
further which is called lisinopril. This medicine can sometimes
raise your blood potassium level so we would like you to get
your potassium checked at Dr.[**Name (NI) 92137**] office next week. A
prescription was written for this, please bring it to your appt.
.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Address: [**Street Address(2) **]
[**Hospital1 3597**] [**Numeric Identifier 20777**]
Phone: [**Telephone/Fax (3) 92138**] fax
Date/Time: please call the office on Monday for an appt
.
Name: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD
Specialty: Internal Medicine
When: Tuesday [**2-9**] at 2:30p
Address: [**Apartment Address(1) 92139**], [**Location (un) **],[**Numeric Identifier 92140**]
Phone: [**Telephone/Fax (1) 92141**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
|
[
"4019",
"41401",
"2724",
"42731",
"2449"
] |
Admission Date: [**2101-5-5**] Discharge Date: [**2101-5-10**]
Date of Birth: [**2039-12-31**] Sex: M
Service: MEDICINE
Allergies:
morphine
Attending:[**Last Name (un) 7835**]
Chief Complaint:
Altered mental status, crushing chest pain
Major Surgical or Invasive Procedure:
Central line placement
PICC line placement
Arterial line placement
Attempted lumbar puncture
History of Present Illness:
61 yo M with h/o alternative conduction disorder s/p ablation
about 10 years ago and recent viral illness presents with acute
onset altered mental status, fever, crushing chest pain,
required intubation for airway protection. History is obtained
from collaterals.
Per report from wife, patient returned home at around 10PM after
driving the Stop & Shop truck. Patient apparently reported not
feeling well and thought that perhaps he caught something from
his co-worker. [**Name (NI) **] was A&O x 3 on the day prior to admission,
but woke up around 4-5AM with shaking chill and shortness of
breath, requiring inhaler. This morning, patient was home
taking care of the dog. A maintenance person called to cancel
an appointment today and the patient stated that he was not
feeling well with overall weakness and substernal chest pain.
[**Name (NI) **] wife was informed at work, and EMS was called.
Patient was noted to be diaphoretic, tachycardic up to the 170s,
HTN up to the 200s/100s by EMS. EKG was suggestive of STE. He
was given 3 NTG without much relief. He was noted to be hypoxic
requiring supplemental oxygen. Morphine was not given b/c
anaphylaxis rxn to morphine.
Upon arrival to the ED, VS T 100.4, BP 210s/110s, HR 150s.
Patient nodded "yes" to pain, but was unable to localize. He
did not answer further questions. Neurological exam was limited
given mental status- apparently wiggled his toes but did not
squeeze hands. His UE was noted to have a coarse tremor vs.
shaking, but not rhythmic per report. Right lower lip seemed to
be drooping. He vomited 1x and had incontinence of stool x 2.
EKG showed diffused STE but cardiology thought it is less likely
STEMI. Labs were significant for WBC 7.5, H/H 14 and 42.8, Plt
140, INR 1.1, Fibrinogen 404, Crt 1.3, lipase 20, serum tox
screen negative, lactate initially 4.6--> 2.4. Initial VBG
7.39/39/39/24. He received metoprolol 5 mg IV x 2 for
tachycardia and HR improved to 130s with SBP down to 130s. He
was subsequently paralyzed, intubated with etomidate and succ
for airway protection given obtunded MS. [**Name13 (STitle) **] underwent CTA
head which did not show hemorrhage or acute infarct, there was
narrowing of left internal carotid artery. CTA chest did not
show aortic dissection, and had suboptimal quality to evaluate
for PE. CTA abd/pelvis was unremarkable by preliminary read.
Patient was then found to have SBP into the 60s, he had CVL
placed in RIJ and was started on phenylephrine. He was started
on antibiotics- 1000 vancomycin, 800 mg acyclovir, 2g CTX. He
also received 5L of IVF, 975 mg acetaminophen PR, heparin bolus.
Neurology was consulted, and recommended LP. Per report, LP
was not attempted given body habitus and that patient may need
CT guided LP. VS upon transfer T40.5C, 113/62 (on
phenylephrine), 112 HR, 97% intubated, 15 RR. Vent settings
were CMV, 50% fio2, 550 cc TV, PEEP 5 , RR 20
On arrival to the MICU, patient's VS. Temp 102.5, HR 107, BP
98/63, O2Sat 100%, RR 15
Past Medical History:
- back surgery
- Alternative conductive disorder, s/p ablation ~ 10 years ago
- OSA
- Hypothyroidism
- Hypertension
- HLD
- recent sinus infection about 1 week prior to presentation
Social History:
- truck driver
- had a prolonged drive yesterday without any break
- married with 2 daughters
- smoked, quit 30 years ago, < 1 ppd
- infrequent EtOH, once a month
- denies drug
Family History:
unknown
Physical Exam:
admission exam
Vitals: Temp 102.5, HR 107, BP 98/63, O2Sat 100%, RR 15
General: sedated, does not follow commands, intubated
HEENT: Sclera anicteric, + conjunctival edema, pupils 2 mm,
sluggish but reactive to light, + corneal reflex, intubated
Neck: unable to appreciate JVP, RIJ in place
CV: tachycardic, normal S1 and S2, no m/r/g
Resp: CTAB, no w/c/r
Abd: obese, NT, BS+
Extremities: warm, dry, 2+ DP pulses bilaterally
GU: Foley present
Neuro: unable to assess CN, strength or sensation. Unable to
elicit reflexes or babinski
.
discharge exam
Tm 100.4 (11am [**2101-5-9**]), Afebrile since, HR 60s, SBPs 130s
GENERAL: Morbidly obese male appearing fatigued but in NAD
HEENT: PERRL, EOMI, MMM
NECK: FROM, no rigidity, no meningismus, unable to appreciate
JVP given habitus
HEART: RRR, S1 S2 clear and of good quality, no MRG
LUNGS: Lungs CTA bilaterally, moving air well and symmetrically
ABDOMEN: Morbidly obese, Soft/NT/ND, no rebound/guarding.
GU: No supra-pubic tenderness
EXTREMITIES: 1+ [**Location (un) **] pitting to knee improved from prior
NEURO: Awake, A&Ox3, CNs II-XII intact, muscle strength 5/5
throughout, sensation grossly intact throughout
Pertinent Results:
admission labs:
[**2101-5-5**] 09:45AM BLOOD WBC-7.5 RBC-4.88 Hgb-14.0 Hct-42.8 MCV-88
MCH-28.8 MCHC-32.8 RDW-13.7 Plt Ct-140*
[**2101-5-5**] 09:45AM BLOOD Neuts-78* Bands-4 Lymphs-14* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2101-5-5**] 09:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2101-5-5**] 09:45AM BLOOD PT-12.2 PTT-25.1 INR(PT)-1.1
[**2101-5-5**] 09:45AM BLOOD Fibrino-404*
[**2101-5-5**] 09:45AM BLOOD Glucose-183* UreaN-17 Creat-1.3* Na-141
K-4.4 Cl-101 HCO3-22 AnGap-22*
[**2101-5-5**] 09:45AM BLOOD ALT-26 AST-29 LD(LDH)-207 AlkPhos-50
TotBili-0.6
[**2101-5-5**] 09:45AM BLOOD CK-MB-2 cTropnT-<0.01
[**2101-5-5**] 09:45AM BLOOD Albumin-4.7 Calcium-9.5 Phos-1.9* Mg-1.5*
[**2101-5-5**] 09:50AM BLOOD Type-[**Last Name (un) **] pO2-39* pCO2-39 pH-7.39
calTCO2-24 Base XS-0 Comment-GREEN TOP
[**2101-5-5**] 09:50AM BLOOD Lactate-4.6*
[**2101-5-5**] 10:01PM BLOOD freeCa-1.06*
.
troponins
[**2101-5-5**] 09:45AM BLOOD CK-MB-2 cTropnT-<0.01
[**2101-5-5**] 04:05PM BLOOD CK-MB-21* MB Indx-0.8 cTropnT-0.07*
[**2101-5-5**] 11:52PM BLOOD CK-MB-40* MB Indx-0.6 cTropnT-0.06*
[**2101-5-6**] 05:06AM BLOOD CK-MB-47* MB Indx-0.6 cTropnT-0.03*
[**2101-5-5**] 09:45AM BLOOD ALT-26 AST-29 LD(LDH)-207 AlkPhos-50
TotBili-0.6
[**2101-5-5**] 09:45AM BLOOD CK(CPK)-247
.
CK trend
[**2101-5-5**] 04:05PM BLOOD ALT-60* AST-101* CK-2473* AlkPhos-60
TotBili-0.5
[**2101-5-5**] 11:52PM BLOOD CK(CPK)-6925*
[**2101-5-6**] 05:06AM BLOOD ALT-417* AST-499* CK 7597* AlkPhos-46
TotBili-0.7
[**2101-5-6**] 05:14PM BLOOD ALT-474* AST-556* CK-8702* AlkPhos-49
TotBili-0.9
[**2101-5-7**] 12:01AM BLOOD ALT-432* AST-542* CK 8867* AlkPhos-51
TotBili-0.9
[**2101-5-7**] 05:11PM BLOOD CK(CPK)-6338*
[**2101-5-8**] 05:38AM BLOOD CK(CPK)-5183*
[**2101-5-9**] 05:39AM BLOOD CK(CPK)-2906*
[**2101-5-10**] 06:00AM BLOOD ALT-183* AST-152* CK(CPK)-1118*
.
Discharge Labs:
[**2101-5-10**] 06:00AM BLOOD WBC-7.8 RBC-3.77* Hgb-10.7* Hct-33.1*
MCV-88 MCH-28.5 MCHC-32.4 RDW-13.8 Plt Ct-136*
[**2101-5-10**] 06:00AM BLOOD PT-13.9* INR(PT)-1.3*
[**2101-5-10**] 06:00AM BLOOD Glucose-94 UreaN-16 Creat-0.7 Na-141
K-3.7 Cl-105 HCO3-28 AnGap-12
[**2101-5-10**] 06:00AM BLOOD ALT-183* AST-152* CK(CPK)-1118*
[**2101-5-9**] 05:39AM BLOOD Calcium-8.5 Phos-2.9 Mg-2.1
urine
[**2101-5-5**] 02:00PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.033
[**2101-5-5**] 02:00PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2101-5-5**] 02:00PM URINE RBC->182* WBC-56* Bacteri-FEW Yeast-NONE
Epi-0
[**2101-5-5**] 02:00PM URINE Mucous-RARE
.
micro
[**2101-5-5**] 12:20 pm BLOOD CULTURE
**FINAL REPORT [**2101-5-8**]**
Blood Culture, Routine (Final [**2101-5-8**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
URINE CULTURE (Final [**2101-5-7**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
imaging
ECG: admission
Sinus tachycardia. Baseline artifact. Left ventricular
hypertrophy. Delayed precordial R wave transition and left
anterior fascicular block. Tall peaked precordial T waves. No
previous tracing available for comparison. Clinical correlation
is suggested.
.
ECG: [**5-6**]
Sinus rhythm with slowing of the rate as compared with previous
tracing
of [**2101-5-5**]. Left anterior fascicular block. Delayed precordial R
wave
transition. Low precordial lead voltage. Compared to the
previous tracing
of [**2101-5-5**] the voltage has diminished. ST-T wave changes have
improved.
Otherwise, no diagnostic interim change.
.
CXR: IMPRESSION: Limited study due to respiratory motion and
low lung volumes. No overt pulmonary edema identified. Probably
bilateral perihilar atelectasis.
.
CXR:
Endotracheal tube tip in standard position. Nasogastric tube
can
only be visualized to the level of the mid esophageal region.
Please note
that subsequent CT of the torso demonstrates a nasogastric tube
tip to lie
within the stomach.
.
CXR
1. Right subclavian central venous line terminating at the
atriocaval
junction.
2. Bilbasilar atelectasis.
.
CTA head and neck
1. Significantly limited study with high-grade stenosis of the
left
intracranial internal carotid artery in the cavernous and
supraclinoid
segments .
2. Overall decreased caliber of left ICA compared to the right
ICA is likely developmental.
3. Patent intracranial vasculature.
4. No acute intracranial hemorrhage or large hypodense area to
suggest acute infarction.
.
CTA chest/abdomen/pelvis
1. No evidence of aortic dissection.
2. Bibasilar atelectasis with probable aspiration particularly
in the right lower lobe.
3. No evidence of acute abdominal pathology.
.
TTE
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. No mitral regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Very limited study. Grossly preserved biventricular
systolic functino. No pericardial effusion seen.
.
CXR PICC placement: IMPRESSION:
Right subclavian PICC line is present, tip overlying the
distalmost SVC. No ptx detected.
Brief Hospital Course:
61 yo M with h/o alternative conduction disorder s/p ablation
presented initially for altered mental status, found to have
gram negative bacteremia with likely DIC while in MICU now
resolved.
# GNR Sepsis/shock. On admission, patient met multiple criteria
for sepsis including tachycardia, fever, leukocytosis and known
GNR bacteremia. ARF and hematologic changes indicating end organ
damage. Unclear original source of infection initially. He had a
CXR with no consolidation. CT of head chest and abdomen was
unrevealing. He was intubated for airway protection. After
intubation, his blood pressures fell to the 60s and he was
started on phenylephrine and sent the MICU. In the MICU he was
changed to levophed. His blood cultures grew GNR in [**3-30**] bottles.
His urine culture then grew pansensitive E. coli. Due to fever
and altered mental status, there was initial concern for
meninigitis, and he was started on vancomycin, ceftazidime,
acyclovir, and ampicillin. However given clinical improvement
and lack of meningeal signs, the acyclovir and ampicillin where
discontinued the following day. With the urine culture data, his
antibiotics were narrowed to ceftriaxone. He was successfully
weaned off pressures and extubated. Patients clinically improved
and was transferred to the general medicine service. Patient was
resucitated with 12L of IVFs. Poor hygiene, urge incontinence
and holding bladder for many hours on long truck drives with
urinary stasis most likely cause of UTI. Serial blood cultures
since [**5-5**] negative since starting antibiotics. Patient was
changed to PO Ciprofloxacin prior to discharge and he remained
afebrile. Patient did have one temperature of 100.4 on [**5-9**] am
though with monitoring he remained afebrile for >24 hour prior
to discharge. He was discharged with full 2 week course of
antibiotics (ciprofloxacin) to treat UTI and GNR bacteremia.
# AMS. Acute onset in 24 hours prior to admission while feeling
systemically ill. CT head/CTA head/neck did not show acute
process although does have narrowed left ICA. There was question
of seizure while in the ED, but most likely due to rigors in the
setting of high fever. Serum and urine drug screen revealed
Benzodiazepines only, which were given by the ED. Neurology
evaluated the patient while in the ED, however given already
intubated and sedated their exam was limited. They recommended
LP and MRI, however given clinical improvement and known source
of infection (E. coli bacteremia from urine/prostate) these
studies were not performed. As infection was treated, mental
status improved. With improved mental status the patient had no
signs or symptoms of meningitis. Mental status improved to
baseline on discharge.
#Rhabdomyolysis: Patient found to have elevated CK up to the
8000 likely secondary to overwhelming sepsis. He experienced
renal insufficiency which improved with fluids. Held Crestor
during admission and instructed patient to hold on discharge
until consulting his PCP. [**Name10 (NameIs) **] should be held until CK
normalizes.
# Demand ischemia: While septic in MICU patient with elevated
Troponin to 0.06, EKG with tachycardia and diffuse STE. Likely
demand ischemia. CK MB trended up to 47 with trops flat at 0.03.
Trop <0.01 with improved MB as well with resolution of sepsis.
Patient had no other events regarding ischemia. Aspirin was
increased to 325mg daily and he was restarted on his home
beta-blocker.
# DIC: Thrombocytopenia and coagulopathy in setting of sepsis
indicates DIC. Fibrinogen elevated but likely falsely elevated
in setting of acute infection. With initiation of antimicrobials
covering pan-sensitive E.Coli his DIC picture improved.
Platelets rebounded, INR improved to 1.3 and Hct rebounded.
# Hypothyroidism: continued levothyroxine
.
# Hypertension: Patient was hypotensive requiring pressors so
anti-hypertensives held until sepsis resolved. After resolution
Metoprolol and Lisinopril were restarted which patient tolerated
well.
# Hyperlipidemia - Held statin in setting of Rhabdomyolysis as
above.
TRANSITIONAL ISSUES:
- If PCP concerned for prostatitis (recurrent urinary tract
infections, symptoms), then would prolong course of antibiotics
(4-6 weeks) and/or referral to Urology
- Holding Crestor on discharge for elevated CK/resolving
Rhabdomyolysis, this should be restarted after complete
resolution
- Dischargde on 325mg Aspirin given demand ischemia while
septic, can reduce [**Last Name (un) **] to 81mg daily per PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] needs a follow up PCP appointment [**Name9 (PRE) 110675**] discharge
- CODE: Full
- CONTACT: Wife/[**Name2 (NI) **] [**Telephone/Fax (1) 110676**] (cell), [**Telephone/Fax (1) 110677**] (home),
daughters [**Name (NI) **] and [**Name (NI) 803**]
Medications on Admission:
aspirin 81, multivitamin, Coq10 200 mg daily, crestor 40 mg
daily, ferrous sulfate 325 daily, fish oil daily, glucosamine
1500 mg daily, levoxyl 75 mcg daily, lisinopril 10 mg daily,
proair 1 puff q6 hrs prn, pulmicort 180 mcg [**Hospital1 **], toprol 50 mg
daily, tylneol pm, vitamin b12 1500 mcg daily, vitamin d3 100
units daily
Discharge Medications:
1. budesonide 180 mcg/actuation Aerosol Powdr Breath Activated
Sig: One (1) IH Inhalation twice a day.
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
3. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
8. Fish Oil Oral
9. Glucosamine 750 mg Tablet Sig: Two (2) Tablet PO once a day.
10. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 12 days.
11. Vitamin B-12 1,000 mcg Tablet Sig: 1.5 Tablets PO once a
day.
12. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. Co Q-10 200 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Active:
- E.Coli Sepsis
- Urinary Tract Infection and Bacteremia
- Demand Ischemia
- Resolved DIC
Inactive:
- Obstructive sleep apnea
- Hyperlipidemia
- Hypertension
- Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname 32458**],
It was a pleasure treating you during this hospitalization. You
were admitted to [**Hospital1 69**] because of
fever, confusion and chills. You were found to have E.Coli
bacteria in your urine and your blood which was causing your
symptoms. You were in the Medical ICU for some time where you
were given IV antibiotics and resucitated with a lot of IV
fluids. With antibiotic use your blood pressures returned to
[**Location 213**]. You were switched to oral medications and you continued
to improve.
The following changes to your medications were made:
- START ciprofloxacin 750mg twice daily until [**2101-5-23**]
- HOLD Crestor (Rosuvastatin) until intructed to restart by your
primary care physician. [**Name10 (NameIs) **] is being held because of muscle
break down and resulting kidney injury when you were very ill,
which are still resolving
- INCREASE aspirin to 325mg Daily, this was increased because of
strain on your heart during this admission. You should continue
the higher dose until instructed by your PCP
[**Name Initial (PRE) **] [**Name10 (NameIs) **] other changes were made, please continue taking your home
medications as previously prescribed.
- You should follow up with your primary care physician after
discharge from Rehabilitation center. If you develop another
urinary tract infection, you should discuss with your PCP about
seeing [**Name Initial (PRE) **] urologist.
Followup Instructions:
Be sure to follow up with your primary care physician after
discharge from Rehabilitation Center.
If you develop another urinary tract infection, you should
discuss with your PCP about seeing [**Name Initial (PRE) **] urologist.
|
[
"51881",
"78552",
"5990",
"5849",
"2762",
"99592",
"4019",
"2449",
"32723",
"2724",
"V1582"
] |
Admission Date: [**2198-3-12**] Discharge Date: [**2198-3-21**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10223**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 w/MMP presents w/respiratory distress/sepsis. (history of
asbestosis, pleural plaques, esrd), recently admitted for 48 day
course notable for CP/PNA/seizures/renal failure/MS change.
Patient at rehab with notation of recent rise in wbc, bandemia.
Over few days prior to admission increasing malaise, pale,
diarrhea for which flagyl started on [**3-12**]. At HD desaturate to
70% in respiratory distress, tachy in 140s. transferred to ER.
Code sepsis initiated with vanc/ceftriaxones, intubated. In ED
in ?SVT SBP 30s, with wire placement. Resolved with wire
removal. Zosyn/Flayl initiated by MICU team, ceftriaxone
discontinued. On transfer to MICU on 5th liter of fluid and
Levofed of 10. T103, R 140, Bp 130/64. CPAP 60%. abg
7.38/36/232, lactate 4.1. free ca 1.07. Has sacral decub, G-J
tube.
Past Medical History:
Past Medical History:
1.)asbestosis: pleural plaques; CT [**9-23**] with LUL spiculated
nodule not seen on follow up PET scan; followed with serial CT
1.5) COPD (PFT's [**9-23**] FEV1 69%, FVC 69%, DLCO 61%; obstructive
pattern)
2.)chronic renal insufficiency (creatinine 3.7 [**8-23**])
3.)hypertension
4.)cardiac w/u - Stress Echo [**2192**]- patient exercised for 4
minutes of the [**Doctor Last Name 4001**] protocol and stopped for fatigue. This
represents a limitedphysical working capacity for his age. No
arm, neck, back or chest discomforts were reported by the
patient throughout the study. There were no significant ST
segment changes at peak exercise or in recovery. The rhythm was
sinus with several isolated apbs. Appropriate
hemodynamic response to exercise. No objective or subjective
evidence of myocardial ischemia at the achieved high rate
pressure product. Echo report w/o signs of ischemia.
5.)status post colonic perforation during colonoscopy status
post colectomy
6.)rotator cuff disease
7.)left hip replacement; b/l TKR x 2
8.) atrial fibrillation in setting of colectomy surgery
9.) spinal stenosis
10) anemia, CRI
11) epididymitis, hydrocele
Social History:
Lives alone, functions independently; wife died 2 years ago2
grown sons (contact [**Telephone/Fax (1) 27845**]90 pack year tobacco hx (quit
30 yr ago); Steam Ship engineer with significan asbestos
exposure; denies EtOH
Family History:
The family history includes his father who died in his 90's of
chronic renal failure and leukemia. Brother age 80 alive with
enlarged heart and Alzheimer's disease, and sister age 75 S/P
CVA
Pertinent Results:
[**2198-3-12**] 12:45PM WBC-11.1* RBC-3.94*# HGB-12.4* HCT-38.8*#
MCV-98 MCH-31.5 MCHC-32.0 RDW-16.8*
[**2198-3-12**] 12:45PM PLT COUNT-572*#
[**2198-3-12**] 12:45PM NEUTS-93.1* BANDS-0 LYMPHS-5.0* MONOS-1.7*
EOS-0.1 BASOS-0.1
[**2198-3-12**] 12:45PM PT-13.3 PTT-54.8* INR(PT)-1.1
[**2198-3-12**] 12:45PM GLUCOSE-125* UREA N-70* CREAT-5.4*#
SODIUM-139 POTASSIUM-5.3* CHLORIDE-97 TOTAL CO2-25 ANION GAP-22
[**2198-3-12**] 12:45PM ALBUMIN-3.0*
[**2198-3-12**] 12:45PM ALT(SGPT)-19 AST(SGOT)-20 CK(CPK)-14* ALK
PHOS-185* AMYLASE-169* TOT BILI-0.3
[**2198-3-12**] 12:45PM LIPASE-49
[**2198-3-12**] 12:43PM LACTATE-4.3*
[**2198-3-12**] 12:45PM cTropnT-0.22*
[**2198-3-12**] 12:45PM CK-MB-NotDone
[**2198-3-12**] 05:12PM CORTISOL-23.1*
[**2198-3-12**] 06:10PM CORTISOL-27.4*
[**2198-3-12**] 06:16PM CORTISOL-26.3*
Brief Hospital Course:
1. Sepsis: Pt was admitted to MICU with septic shock with
associated elevated WBC, fevers likely [**2-21**] MRSA pneumonia. No
other source of infection identified. Pt was give IVF
resussitation and started on pressors (levophed) and gradually
weaned off. He was pan cultured and started on broad spectrum
antibiotics of vanco (dosed for lvel <15), flagyl, zosyn (day
7). Sputum cultures grew MRSA. Urine and blood cultures remained
negative. Pt had inappropriate response to [**Last Name (un) 104**] stim test. Was
started on hydrocort (day [**6-26**]). Sepsis resolved. Continued on
Vancomycin and Zosyn. Also emperically started on oral Flagyl
[**2-21**] loose stools, low grade fever. On D/C pt. stable on Vanco
only, dosed at HD, to be continued for one week for MRSA
pneumonia. Flagyl also to be continued for one week at the time
of discharge. Zosyn D/C'd at time of discharge.
.
2. Respiratory failure: In the setting of sepsis and pneumonia.
Pt was weaned off the ventilator and successfully extubated on
[**3-18**].
.
3. Acute on chronic renal failure: Pt has ESRD on HD. Pt
continued to be followed by renal with qod dialysis. All meds
were renally dosed and was given vanco by dose levels <15. Pt
was given phoslo for elevated phosphate and continued on epogen.
.
4. Cardiac: Cardiac enzymes cycled on admission with flat
enzymes. Pt has elevated Tn with negative CKMB in setting of
renal failure; no acute cardiac event. Unremarkable echo with EF
of 50-55% and mild focal hypokinesis. Pt was continued on ASA.
Antihypertensives were held in setting of intial hypotension. Pt
was restarted on lopressor after resolution of sepsis.
5. GI:s/p colectomy, g-j tube. G-J tube hub was noted to be
broken and was changed by IR on [**3-14**].
-cont TF via G-J tube given aspiration risk.
.
6. HEME - follow hematocrit
-cont epo
.
7. Neuro - baseline altered ms/aspiration on last discharge.
Much improved with decreased sedation and tx of sepsis
-cont to monitor mental status - waxing and [**Doctor Last Name 688**] with
sundowning. Responded well to 1 mg Haldol q hs.
.
8.Endocrine
-cont RISS - bp well controlled.
.
9.f/e/n: Maintained on TF with free water boluses.
.
10.line : L SC (placed [**3-12**];changed over wire on [**3-13**]); L A line
([**3-12**]), R dialysis catheter. L SC discontinued after being in 7
days, prior to d/c
.
11.prophylaxis -Given SC heparin, ppi.
.
12.Code: full
After coming out of the MICU, the patient did well on the floor.
He remained afebrile and blood cultures remained negative. He
was continued on empiric therapy for vancomysin and clostridium
difficile and d/c'd back to [**Hospital **] [**Hospital **] Hospital on
[**2198-3-21**].
Medications on Admission:
ASA, Heparin, Lansoprazole, Epogen, Insulin (reg.).
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
[**Month/Day/Year **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Injection TID (3 times a day).
[**Month/Day/Year **]:*90 Injection* Refills:*2*
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
[**Month/Day/Year **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Epoetin Alfa 4,000 unit/mL Solution Sig: Two (2) mL Injection
QMOWEFR (Monday -Wednesday-Friday).
[**Month/Day/Year **]:*24 mL* Refills:*2*
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
[**Hospital1 **]:*1 bottle* Refills:*2*
6. Acetaminophen 160 mg/5 mL Elixir Sig: Ten (10) mL PO Q4-6H
(every 4 to 6 hours) as needed.
[**Hospital1 **]:*QS mL* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
[**Hospital1 **]:*270 Tablet(s)* Refills:*2*
8. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Units, regular insulin Injection ASDIR (AS DIRECTED): For
BG:
151-200 give 2 units
201-250 give 4 units
251-300 give 6 units
301-350 give 8 units
351-400 give 10 U
If >401 give 12 U and [**Name8 (MD) 138**] MD.
[**Last Name (Titles) **]:*QS Units, regular insulin* Refills:*2*
9. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) mg
Injection HS (at bedtime) as needed for Agitation/Hallucination.
[**Last Name (Titles) **]:*30 mg* Refills:*0*
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
[**Last Name (Titles) **]:*21 Tablet(s)* Refills:*0*
11. Vancomycin HCl 1,000 mg Recon Soln Sig: mg, dosed at
Dialysis as appropriate per level mg Intravenous q HD for 7
days.
[**Last Name (Titles) **]:*QS mg* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Pneumonia, MRSA
Discharge Condition:
Fair
Discharge Instructions:
Followup with [**Hospital6 310**].
Followup Instructions:
With primary care doctor as needed.
|
[
"0389",
"78552",
"496",
"40391",
"5849",
"42731",
"51881",
"5070",
"99592"
] |
Admission Date: [**2179-1-30**] Discharge Date: [**2179-2-4**]
Date of Birth: [**2127-8-1**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
2 month history of headache/eye pain
Major Surgical or Invasive Procedure:
Right frontal craniotomy for tumor resection
History of Present Illness:
52 y/o male with 2 month hx. of headache and retroorbital
eye pain. The pain started gradually on the left that
progressively got worse with the pain radiating behind both
eyes.
When he moved his head suddenly, it felt like "someone was
hitting the side of his head." He took ASA and tylenol which
made it better and he denied any diploplia, nausea/vomiting,
seizures or syncope. He denies any change in his memory, but he
week, but he could not get an appointment. His mom suggested
that he go in today for which he got a CT scan showing a right
frontal mass. We were called to see this patient in the ED.
Past Medical History:
Schizophrenia (no meds), Depression
No surgeries
Social History:
Lives at home with parents. Admits to smoking
cigarettes 2 months/year for 25 years. +marajuana. He has been
on disability for 10 year
Family History:
brain tumor, Alzheimers
Physical Exam:
O: T: 98.0 BP: 121/70 HR: 54 R 18 100%O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 6mm PEERLA,EOMs. +mildly icteric.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+. Scaphoid abdomen.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-20**] 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. No pronator drift.
Power: D B T Grip
right +5 +5 +5 +5
left +5 +5 +5 +5
IP Glut Quad Ham AT [**First Name9 (NamePattern2) **] [**Last Name (un) 938**]
right +5 +5 +5 +5 +5 +5 +5 +5
left +5 +5 +5 +4 +4 +4 +4 +4
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right +2 +2 +3 +3 +3
Left +2 +2 +3 +3 +3
Toes upward going bilaterally. L>R.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin.
Pertinent Results:
[**2179-2-2**] BLOOD WBC-11.6* RBC-3.36* Hgb-11.0* Hct-30.8* MCV-92
MCH-32.8* MCHC-35.8* RDW-13.3 Plt Ct-227
[**2179-2-2**] BLOOD Glucose-100 UreaN-15 Creat-0.7 Na-143 K-3.6
Cl-107 HCO3-29 AnGap-11
[**2179-2-2**] 05:50AM BLOOD Phenyto-10.2
CT HEAD W/O CONTRAST [**2179-1-30**]:
IMPRESSION:
1. Large right medial frontal mass with severe vasogenic edema
with significant mass effect. Contrast-enhanced CT or MRI is
recommended for better assessment.
2. The mass effect causes compression of the right lateral
ventricle and third ventricle, as well as subfalcine and
beginning uncal herniation.
Post-op MR HEAD W & W/O CONTRAST [**2179-2-1**]
IMPRESSION: Status post recent right-sided frontal craniotomy
and resection of the previously noted large heterogeneous mass
within the right frontal lobe. There is residual vasogenic edema
still present with partial resolution of the midline shift.
Small amount of hemorrhage is noted surrounding the surgical
bed. Further followup is recommended within 48 hours, to assess
for any interval changes along with neurologic and clinical
correlation.
Brief Hospital Course:
Pt was admitted to neurosurgery service on [**2179-1-30**] with dx of R
fontal tumor. He underwent R frontal craniotomy for tumor
resection on [**2179-1-31**] without complication. Post-op head MRI
showed total resection of previous R frontal tumor, improved
midline shift. Pt's pre-op symptoms of HA/retroorbital pain had
also improved. He is tolerating regular diet and able to
ambulate with assistance. Neuro exam showed he is A+Ox3,
following commands, PERRLA, EOMF and VFF. No pronator drift.
Motor/sensory and DTR of extremities are unremarkable
throughout. Wound site is clean, dry and intact.
He underwent PT/OT consult during this admission, who
recommended d/c home with PT.
The pt also has a h/o schizophrenia with suicidal ideation.
In-hospital Psych consulted and recommended no need for 1:1
sitter since pt is not currently suicidal,and should follow up
with outpt psychiatric treatment.
Medications on Admission:
None
Discharge Medications:
1. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO three
times a day for 2 days: start [**Date range (1) 8942**].
Disp:*18 Tablet(s)* Refills:*0*
2. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day:
start after 3mg dose, continue until follow up in Brain tumor
clinic.
Disp:*60 Tablet(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain/fever.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day): use while taking narcotics.
Disp:*60 Capsule(s)* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Brain tumor
Discharge Condition:
Stable
Discharge Instructions:
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting > 10lb, no
straining.
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? Take your anti-seizure medicine, Keppra, as prescribed.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
Your have an appt on [**2179-2-10**] between 9am to 12am at [**Doctor First Name **], Ste 3B for suture removal.
Please make an appt with Dr [**Last Name (STitle) **] to be seen in 6 weeks at the
time of your suture removal appt.
You are also scheduled to see your Neuro-oncologist Dr [**Last Name (STitle) 724**] on
[**2179-2-15**] at 1pm. The address is [**Hospital Ward Name **], [**Hospital Ward Name 23**] bldg [**Location (un) **], neurology department.
Please make an appt to see your Psychiatrist.
Completed by:[**2179-2-4**]
|
[
"311"
] |
Admission Date: [**2179-7-31**] Discharge Date: [**2179-8-6**]
Date of Birth: [**2120-3-16**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Iodine / Talwin
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Dysarthria
Major Surgical or Invasive Procedure:
[**2179-8-3**]: Left carotid endarterectomy with Dr. [**Last Name (STitle) 1391**]
History of Present Illness:
Ms. [**Known lastname **] is a 59 year old female s/p liver [**Known lastname **] in [**Month (only) 205**]
[**2178**], DM, HTN, who presented with inability to speak. Her
husband reported that the patient woke at 430 am the day of
presentation and couldn't speak. The husband notes that it
appeared that she understood him, but could only respond with
sounds. He did not note any other abnormalities. The patient
did not appear weak. She was able to get out of bed by herself.
Ms. [**Known lastname **] notes that she could have walked out of the house to
the hospital if need be.
She was last seen well at 1 am.
The patient was noted to have diarrea a few days prior.
No commpaints of headache. There was no vomiting.
Past Medical History:
PMH: GBS cellulitis L leg 10, alcoholic hepatitis, hep C
cirrhosis, portal HTN, hepatic encephalopathy, COPD
PSH: liver tx [**2179-6-6**], hysterectomy 01, lap bx uterine fibroid
Social History:
Married, smokes. Previous heavy alcohol use,.
Stopped 1 1/2 years back. Previous cocaine use.
Family History:
non contributory
Physical Exam:
PE on admission:
General: Awake, aphasic.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, Awake. Appears to understand and will
follow commands but is aphasic.
Language is aphasic. Unable to assess repetition.Unable to
assess
prosody.
Able to follow both midline and appendicular commands. No
evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
VII: Right lower facial droop.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift .
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 5 5 5 5 5 5 5 5 5 5
R 4+ 4+ 4 4 4 5 5 5 5 5- 5
-Sensory: No deficits to light touch, No extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria or ataxia noted
through observation.
PE on discharge:
Gen: AAOx4, interactive, follows commands, indicates needs by
pointing, miming. No acute distress. Severe expressive
aphasia.
CVS: Regular, no M/R/G
Pulm: Clear bilaterally
Abd: Soft, nontender, nondistended. Well healed scar.
Ext: Right side weakness relative to left, but improved since
admission. No clubbing, cyanosis, or edema.
Pulses: Fem: palpable b/l, R: DP/PT [**Name (NI) **], L: DP
[**Name (NI) 17394**], no PT.
Neuro: Right facial droop. Right side weakness relative to
left. Extraocular movements intact. Dysarthric with severe
expressive aphasia. Able to say "None" and "and".
Brief Hospital Course:
Ms. [**Known lastname **] was admitted on [**2179-7-31**] after presenting with new
onset dysarthria. A code stroke was called and she was
immediately evaluated by the stroke team. She was admitted to
the SICU after undergoing MRA/MRI which revealed a stroke in the
distribution of the left MCA. There appeared to be shower of
emboli with no major occlusion. She was outside the window to
receive tPA and there was no neurosurgical intervention possible
per the neurology team. A carotid duplex study was performed in
workup of possible etiology, and revealed Left ICA 70-79%
stenosis. A vascular surgery consult was requested on [**8-3**] for
evaluation and possible surgical intervention.
On [**8-3**], she was seen and examined by the vascular team, who
recommended left carotid endarterectomy during the current
admission. After discussion of the risks and benefits of
surgical intervention, Ms. [**Known lastname **] and her husband agreed. She
underwent left carotid endarterectomy with internal carotid
artery shunting and cerebral oximetry on [**8-3**], and after initial
recovery in the PACU, she was transferred to the vascular
surgery service for further recovery and monitoring.
On [**8-4**], Ms. [**Known lastname **] continued to be hypertensive, requiring IV
nitroglycerin to titrate systolic blood pressure to 100-150.
She was transfused 2 units of pRBCs for post-operative anemia,
which resolved. She remained otherwise stable, and she was seen
and evaluated by the speech and swallow team, physical therapy,
occupational therapy, neurology, and the [**Known lastname **] surgery
team. She had daily labs, including tacrolimus levels, and her
medications were adjusted daily according to the liver
[**Known lastname **] protocols. Her home medications were resumed,
including oral lopressor.
On [**8-5**], Ms. [**Known lastname **] was still requiring a nitroglycerin drip to
maintain target blood pressure, but was otherwise recovering
well from her carotid surgery. Her neurologic exam continued to
improve, and she was able to use 2 new words. Her arterial line
was removed, and she was able to be out of bed to a chair. She
was started on oral hydralazine in addition to lopressor in
order to wean the nitroglycerin drip while maintaining target
SBP. She was started on aspirin and a statin per the neurology
and [**Known lastname **] teams.
On [**8-6**], Ms. [**Known lastname **] was successfully weaned from nitro at 8am,
and her blood pressure remained stable at goal throughout the
day on her home medications and oral hydralazine. Her
creatinine continued to trend down slowly at 1.6. Her Tacro
level was 13.1, and her dose was adjusted accordingly by the
[**Known lastname **] team. She was tolerating a ground/thin liquid diet,
out of bed with physical therapy, and reported good pain control
on oral pain medications. Her left neck incision staples were
removed and steri strips applied. Her foley catheter was
removed, and she voided without difficulty. She was instructed
to follow up with the [**Known lastname **] service as scheduled, the
neurology stroke clinic on [**10-6**], and the vascular
surgery clinic in 2 weeks. A packet of lab slips and requests
was prepared by the [**Month (only) **] team and provided to the
rehabilitation facility with instructions. She will require
daily physical and occupational therapy, speech therapy, and
frequent bloodwork, and has worked with case management to
choose an appropriate acute care rehabilitation facility near
her home. Ms. [**Known lastname **] and her husband understood and agreed with
the plan, and she was discharged to rehab on [**2179-8-6**] in good
condition.
Medications on Admission:
Fluconazole 400', Gabapentin 100''', Dilaudid 4 prn, Humalog
SS, Lidoderm patch, Metoprolol 50''', Myfortic 360'', Zofran
prn,
Pantoprazole 40'', Prednisone 17.5', Kayexalate prn, Bactrim SS,
Tacrolimus 4.5'', Valcyte 450 QOD
Discharge Medications:
1. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. mycophenolate sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
7. prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
8. pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for SBP > 140: Hold for systolic blood pressure
less than 110.
13. insulin regular human 100 unit/mL Solution Sig: Per sliding
scale Injection ASDIR (AS DIRECTED): See sliding scale.
14. Insulin sliding scale
Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol
71-100 mg/dL 0 Units
101-150 mg/dL 2 Units
151-200 mg/dL 4 Units
201-250 mg/dL 6 Units
251-300 mg/dL 8 Units
> 300 mg/dL 10 Units
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Left middle cerebral artery cerebrovascular accident
Left internal carotid artery stenosis
Discharge Condition:
Mental Status: Clear and coherent, severe expressive aphasia.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You may resume your usual activity level as tolerated.
You should continue physical therapy, speech therapy, and
occupational therapy daily.
Please leave your steri strips in place until they fall off on
their own.
Please keep your follow up appointments!
Avoid heavy lifting and strenuous activity until you are seen in
vascular surgery clinic.
You may shower and clean your wound with soap and water. Avoid
soaking in the tub or swimming until you are cleared by your
surgeon.
Followup Instructions:
Please call to schedule a follow up appointment with Dr.
[**Last Name (STitle) 1391**] in vascular surgery clinic in 2 weeks.
Please follow up in stroke clinic on [**10-6**] as scheduled.
Please follow up with [**Month (only) **] clinic as scheduled
*Please have [**Month (only) **] labs drawn using the lab slips provided,
qMondays and Thursdays as directed.*
|
[
"5849",
"40390",
"25000",
"496",
"3051",
"2859",
"5859"
] |
Admission Date: [**2192-1-31**] Discharge Date: [**2192-2-17**]
Date of Birth: [**2137-8-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Fevers, seizure
Major Surgical or Invasive Procedure:
Central line placement.
Lumbar puncture.
History of Present Illness:
The patient is a 54 year old male with DMII, CAD, and HTN who
presented to an OSH after a witnessed seizure. The morning of
admission, the patient was found by his wife to have a
generalized tonic-clonic seizure with urinary incontinence. The
patient received Valium by EMS and was transported to an outside
hopsital. There, a head CT was negative and the patient then
complained of [**6-5**] SSCP with ?lateral ST changes and received
SLNTG x3 and a heparin bolus. As a result, the physicians at the
outside hospital contact[**Name (NI) **] [**Hospital1 18**] for ?emergent cath and the
patient was sent directly to the cath lab. In the cath lab, the
patient was noted to be febrile to 103.8 and had a witnessed GTC
seizure, then became obtunded and was emergently intubated with
SBPs in 250s. Sedative meds caused a drop in MAPs to 40s, on and
off levophed. Neurology was consulted, dilantin loaded, and the
patient was given ceftriaxone and transferred to the MICU.
According to his wife, the patient had no sick contacts and felt
well on the day prior to admission with no mental status
changes, myalgias/arthralgias. In the MICU, he was presumed to
have pneumococcal meningitis (HSV negative) with ?temporal lobe
involvement. The patient completed a 2 week course of
ceftriaxone on [**2192-2-13**]. In addition, the patient was found to
have a MRSA aspiration pneumonia and was treated with linezolid
for a total of a 3 week course. When in the MICU, the patient
developed a perioral HSV rash and was treated with acyclovir
(last dose on [**2-13**]) and post-extubation, had new delirium and
elevated LFTS that were new since admission. He was then
transferred to the floor on [**2192-2-13**].
Past Medical History:
CAD, DM, HTN, lipids
Social History:
Lives with wife with 40 pack year smoking history.
Family History:
Noncontributory.
Physical Exam:
Tc=99.5 Tm=99.7 P=81 BP=155/84 RR=24 97% on 4 L NC
Gen - Obtunded, obese alert, able to follow simple commands,
knows name, place, not year, mild jaundice
HEENT - PERLA, anicteric, MMM, no oral/perioral lesions
Heart - RRR, no M/R/G
Lungs - Bilateral rhonchi (transmitted bronchial breath sounds)
Abd - Soft, NT, ND, + BS
Ext - RUE with convalescent, erythematous papular rash near R
hand (unclear if new), SCD bilateral LE, no edema/cyanosis.
Neuro - PERLA, wiggles bilateral toes, moves left leg
spontaneously but not the right lower extremity however does
withdraw to painful stimuli. Downgoing toes on the left with
minimal response to Babinski on right. Moves bilateral upper
extremities spontaneously and wiggles bilateral fingers.
Pertinent Results:
CHEST (PORTABLE AP) [**2192-2-12**] 6:13 AM
The lungs are clear.
LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2192-2-12**] 7:46 PM
IMPRESSION:
1. Normal appearance of the gallbladder with no evidence of
gallstones or biliary ductal dilatation.
2. Diffusely increased hepatic echogenicity, a finding
consistent with fatty infiltration. Other forms of liver disease
including significant hepatic fibrosis/cirrhosis cannot be
excluded.
3. Simple cyst along the upper pole of the right kidney.
CT HEAD W/ & W/O CONTRAST [**2192-2-11**] 9:38 AM
IMPRESSION: Pan sinusitis. No evidence of cerebral abscess or
change from [**2192-2-5**].
[**2192-1-31**] 10:33PM TYPE-ART PO2-130* PCO2-38 PH-7.36 TOTAL
CO2-22 BASE XS--3
[**2192-1-31**] 10:33PM K+-3.2*
[**2192-1-31**] 10:33PM freeCa-1.18
[**2192-1-31**] 10:22PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2192-1-31**] 10:22PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2192-1-31**] 08:54PM GLUCOSE-373* UREA N-22* CREAT-1.2 SODIUM-138
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-20* ANION GAP-20
[**2192-1-31**] 08:54PM ALT(SGPT)-31 AST(SGOT)-46* LD(LDH)-373*
CK(CPK)-846* ALK PHOS-68 TOT BILI-0.5
[**2192-1-31**] 08:54PM CK-MB-28* MB INDX-3.3 cTropnT-0.73*
[**2192-1-31**] 08:54PM ALBUMIN-3.9 CALCIUM-9.1 PHOSPHATE-1.9*
MAGNESIUM-1.6
[**2192-1-31**] 08:54PM WBC-18.0* RBC-4.27*# HGB-12.8*# HCT-36.7*
MCV-86 MCH-29.9 MCHC-34.8 RDW-12.8
[**2192-1-31**] 08:54PM PLT COUNT-200
[**2192-1-31**] 08:54PM PT-14.2* PTT-27.3 INR(PT)-1.3
[**2192-1-31**] 08:44PM CEREBROSPINAL FLUID (CSF) PROTEIN-1419*
GLUCOSE-225
[**2192-1-31**] 08:44PM CEREBROSPINAL FLUID (CSF) WBC-26 RBC-[**Numeric Identifier 5519**]*
POLYS-91 LYMPHS-4 MONOS-5
[**2192-1-31**] 07:05PM TYPE-ART TEMP-38.3 PO2-135* PCO2-40 PH-7.38
TOTAL CO2-25 BASE XS-0
[**2192-1-31**] 07:05PM K+-3.4*
[**2192-1-31**] 07:05PM freeCa-1.21
[**2192-1-31**] 05:27PM TYPE-ART TEMP-38.4 PO2-222* PCO2-46* PH-7.32*
TOTAL CO2-25 BASE XS--2 -ASSIST/CON INTUBATED-INTUBATED
[**2192-1-31**] 05:27PM O2 SAT-99
[**2192-1-31**] 01:40PM GLUCOSE-271* UREA N-16 CREAT-0.6 SODIUM-147*
POTASSIUM-2.4* CHLORIDE-117* TOTAL CO2-13* ANION GAP-19
[**2192-1-31**] 01:40PM CK(CPK)-260*
[**2192-1-31**] 01:40PM CK-MB-6 cTropnT-0.20*
[**2192-1-31**] 01:40PM ALBUMIN-2.7* CALCIUM-5.4* PHOSPHATE-3.4
MAGNESIUM-1.0*
[**2192-1-31**] 01:40PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2192-1-31**] 01:40PM WBC-19.1*# RBC-3.36* HGB-10.1* HCT-30.1*
MCV-90 MCH-30.2 MCHC-33.7 RDW-12.8
[**2192-1-31**] 01:40PM NEUTS-71.5* BANDS-0 LYMPHS-22.3 MONOS-5.5
EOS-0.3 BASOS-0.4
[**2192-1-31**] 01:40PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-2+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SCHISTOCY-OCCASIONAL BURR-2+ ACANTHOCY-1+
[**2192-1-31**] 01:40PM PLT SMR-NORMAL PLT COUNT-264
[**2192-1-31**] 01:40PM PLT SMR-NORMAL PLT COUNT-264
[**2192-1-31**] 01:40PM PT-16.8* PTT-38.7* INR(PT)-1.8
Brief Hospital Course:
The patient is a 54 year old male with presumed pneumococcal
meningitis s/p seizures now with delirium status post extubation
and transaminitis of unclear etiology.
1. Pneumococcal meningitis
- The patient completed a 14 day course of CTX on [**2192-2-13**]. He
was presumed to have pneumococcal meningitis although no
organism grew on CSF culture secondary to a high grade
pneumococcal bacteremia noticed at an outside hospital.
- The etiology of his pneumococcal meningitis is unclear. The CT
of his head had shown pansinusitis and further imaging showed no
temporal bone involvement. After his transfer to the floor, ENT
was consulted to comment on his pansinusitis and whether this
may have been the nidus for infection. However, they stated that
by the time he was transferred out of the MICU, he did not
appear to have clinical sinusitis on physical exam with clear
tympanic membranes and nares and there was nothing to drain or
to do differently in management. They were unable to comment on
whether his pansinusitis may have contributed to his presenting
symptoms as they only saw the patient after he had been treated
for his pneumococcal meningitis and his symptoms had resolved.
2. MRSA pneumonia
- The patient was maintained on Linezolid for a total of a 3
week course which he was to continue as an outpatient for 17
more days since discharge.
- His O2 sats were in the high 90s upon discharge on room air.
3. Delirium
- Neurology was consulted to see the patient. On exam, the
patient at first appeared to be weaker in his right lower
extremity in the MICU, however, a CT of the head showed no
intracranial abnormality except for pansinusitis. The patient
was intended to receive an MRI of the head, however, his
symptoms greatly improved before the study could be performed.
- It was felt that the patient's delirium was more consistent
with a toxic metabolic picture in the setting of pneumococcal
meningitis. His ammonia level was normal. He was initially
monitored with a 1:1 sitter but this was discontinued as he did
not exhibit any unusual, erratic behavior after being
transferred out of the MICU.
- On the day of discharge, the patient was able to get out of
bed, interact appropriately with his nurses and doctors. He was
alert and oriented x 3 ( at times, he would say that he was at
the [**Hospital **] hospital). He would have intermittent moments of
mumbling or strange affect but otherwise, his delirium was
slowly resolving.
- Neurology had recommended a slow taper of kaletra for his
febrile seizures. He remained seizure free after he was
transferred from the MICU on kaletra which was then discontinued
as it was felt that his seizures were secondary to his
meningitis and not from an intrinsic seizure disorder.
4. Transaminitis
- The origin of his transaminitis is unclear. However, it is
most likely drug-induced as it was new during his admission. The
most likely etiology of a drug-induced hepatitis in this patient
would be the dilantin load he originally received secondary to
his seizures. As a result of his elevated LFTs, his statin was
discontinued. His LFTs should be followed as an outpatient and
his statin restarted.
- An abdominal U/S showed fatty infiltration of liver with
diffuse changes and no other abnormalities..
- His ammonia level was within normal limits.
5. CAD
- The patient was continued on an aspirin, B-blocker, and ACE.
He was discontinued from his statin in the setting of elevated
LFTs. The patient was also continued on Plavix.
- Of note, the patient never underwent a cardiac catheterization
during this admission although he was transferred to [**Hospital1 18**] for
emergent catheterization as he had witnessed febrile seizures in
the cath lab.
6. HTN
- The patient was hypertensive on his maxed out regimen of an
ACE and B-blocker. As a result, norvasc 5 mg was added to his
antihypertensive regimen.
7. DMII- The patient was continued on a sliding scale, with
frequent fingersticks, and NPH was started on [**2192-2-13**] and
increased to 6 in am, 6 units in pm. He was discharged on
metformin 500 [**Hospital1 **] as well.
8. It was felt by the patient's wife and attending that the
patient would benefit most from being at home with his family in
his normal environment and receive home visits from a nurse.
Thus he was discharged with VNA.
9. After the patient's discharge, a preliminary result from one
blood culture showed coagulase negative staphylococcus. As a
result, his visiting nurse was called that day and asked to draw
3 sets of blood cultures on her upcoming visit and make sure
that the patient had been afebrile. The patient's blood culture
appears to have been contaminated with skin flora and did not
grow out any organisms in any other blood cultures taken
simultaneously. The results of the outpatient cultures were to
be sent to Dr. [**Last Name (STitle) **], who would see the patient the following
week.
Medications on Admission:
Seroquel 25 mg [**Name6 (MD) **]
[**Name8 (MD) **]
NP 4 qam, qpm
albuterol q4 prn
ipratropium prn
olanzapine 5 mg TID prn
Captopril 50 mg TID
Lopressor 75 mg TID
PPI
Isordil 10 mg TID
Glipizide 10 mg [**Hospital1 **]
Linezolid 600 mg IV Q12
Levetiracetam 1 gm
Bisacodyl 10 mg PR [**Hospital1 **]:PRN [**2-4**] @ 1216 View
Lactulose 30 ml PO Q8H:PRN constipation [**2-4**] @ 1216 View
Docusate Sodium (Liquid) 100 mg PO BID [**2-4**] @ 1216 View
Artificial Tear Ointment 1 Appl OU PRN
Ipratropium Bromide MDI 2 PUFF IH QID
Albuterol [**1-29**] PUFF IH Q4H
Aspirin 325 mg PO DAILY
Heparin 5000 UNIT SC TID
Clopidogrel Bisulfate 75 mg PO DAILY
Acetaminophen (Liquid) 650 mg PO Q6H:PRN
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Amlodipine Besylate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
8. Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 17 days.
Disp:*34 Tablet(s)* Refills:*0*
10. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. insulin
Please take 6 units of NPH insulin in the am and 6 units NPH
before bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Pneumococcal meningitis.
Delirium.
Transaminitis - likely drug-induced.
Coronary artery disease.
Urinary tract infection.
Discharge Condition:
Stable.
Discharge Instructions:
Please call your primary care physician or return to the ER if
you experience increased confusion, fevers, or seizures.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **], your cardiologist in 1 week, by
calling ([**Telephone/Fax (1) 5455**].
Please follow up with your primary care physician [**Last Name (NamePattern4) **] 2 weeks.
|
[
"5990",
"51881",
"5845",
"99592",
"25000"
] |
Admission Date: [**2191-5-23**] Discharge Date: [**2191-5-31**]
Service: CAR. [**Doctor First Name 147**].
HISTORY OF PRESENT ILLNESS: This 83-year-old male has a
known history of coronary artery disease with aortic
stenosis. He was referred for outpatient cardiac
catheterization to further evaluate the progression of his
aortic disease. He is status post percutaneous transluminal
coronary angioplasty and stenting of the right coronary
artery in [**2184**] and is status post repeat cardiac
catheterization in [**2186**] revealing the RCA to be patent and no
other significant disease noted. The patient has been
experiencing exertional angina for the past six months to a
year. He walks approximately one and a half miles per day.
He has some left arm numbness that occurs at the end of one
and a half miles and also chest tightness and dyspnea after
he walks up hills. His most recent echocardiogram done on
[**2191-4-1**], revealed moderate aortic stenosis with an
aortic valve area of 0.9 cm squared and a peak aortic
gradient of 64 mm/Hg with a mean aortic gradient of 42 mm/Hg
and an ejection fraction of 55%. There was [**11-18**]+ atrial
regurgitation and 1+ mitral regurgitation. He is now
admitted for cardiac catheterization.
PAST MEDICAL HISTORY: Significant for:
1. History of chronic back pain.
2. History of arthritis.
3. History of impaired memory.
4. Status post oral infection three weeks ago which is now
resolved.
5. History of BPH.
6. History of hypertension.
7. History of hypercholesterolemia.
8. History of PTCA and stenting of the right coronary artery
in [**2184**].
9. Status post repeat cardiac catheterization in [**2186**].
10. Status post multiple knee surgeries.
11. History of intestinal polyps removed which were
complicated by postoperative infection requiring temporary
colostomy.
12. Status post lung biopsy in [**2168**].
13. Status post transurethral resection of the prostate times
two.
14. Status post cholecystectomy.
ALLERGIES: He is allergic to penicillin.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg p.o. q. day.
2. Norvasc 5 mg p.o. q. day.
3. Lipitor 15 mg p.o. q. day.
4. Celebrex 200 mg p.o. q. day.
5. Terazosin 5 mg p.o. q. day.
6. Fosamax 70 mg p.o. q. week.
7. Aspirin 325 mg p.o. q. day.
SOCIAL HISTORY: He is married.
REVIEW OF SYSTEMS: Unremarkable.
PHYSICAL EXAMINATION: He is an elderly white male in no
apparent distress. Vital signs stable. Afebrile. HEENT
examination: Normocephalic, atraumatic. Extraocular
movements intact. Oropharynx benign. Neck is supple. Full
range of motion. No lymphadenopathy or thyromegaly.
Carotids 2+ and equal bilaterally without bruits. Lungs are
clear to auscultation and percussion. Cardiovascular
examination: 3/6 systolic murmur. Regular rate and rhythm.
Abdomen was obese, soft and non-tender with positive bowel
sounds. No masses or hepatosplenomegaly. Extremities were
without clubbing, cyanosis or edema. Pulses were 2+ and
equal bilaterally throughout. Neuro examination: Nonfocal.
HOSPITAL COURSE: He was admitted and underwent cardiac
catheterization on [**2191-5-23**], which revealed the left
ventricle had heavily calcified aortic valve and mitral
annular calcification. The ventriculography was not
performed because of an increased left ventricular end
diastolic pressure and history of renal failure. His left
main coronary had a 70-80% proximal stenosis. The left
anterior descending had mild luminal irregularities with
proximal serial 30% stenoses. The left circumflex had
diffuse mild luminal irregularities, moderately calcified
diffuse proximal 20-30% stenoses. RCA had a proximal
in-stent re-stenoses to 40% tapering down from ostium,
diffusely diseased mid RCA and an ostial 30-40% lesion. He
was referred to Cardiac Surgery. He had a carotid ultrasound
which showed no significant stenoses bilaterally. He had
Neuro consult identifying any progression of abnormalities
noted on prior films in the cervical region. He was cleared
for surgery by Neurology and on [**5-25**] he underwent an aortic
valve replacement with a #21 mm [**Company 1543**] porcine valve and a
coronary artery bypass graft times two with saphenous vein
graft to the left anterior descending and obtuse marginal.
The patient tolerated the procedure well and was extubated on
postoperative night. He was off all drips on postoperative
day one. He was transferred to the floor in stable
condition. He continued to progress well and on
postoperative day two in the late afternoon he had two long
conversion pauses after a run of paroxysmal atrial
fibrillation. His Lopressor was discontinued and he was
started on amiodarone 400 mg q. day. He was transferred back
to the CSRU. He continued to progress and did not have any
more pauses. On postoperative day four he was transferred
back to the floor in stable condition and discharged to rehab
on postoperative day five.
DISCHARGE LABS: Hematocrit 27.2, white count 8,600, platelet
count 174,000. Sodium 137, potassium 4, chloride 99, CO2 31,
BUN 17, creatinine 1.7, blood sugar 93.
DISCHARGE MEDICATIONS:
1. Lasix 40 mg p.o. q. day for seven days.
2. Colace 100 mg p.o. b.i.d.
3. Flomax 5 mg p.o. q. hs.
4. Lipitor 15 mg p.o. q. day.
5. Amiodarone 400 mg p.o. q. day for two weeks, then
decrease to 200 mg p.o. q. day.
6. Percocet one to two p.o. q. 4-6h. p.r.n. pain.
7. Celebrex 200 mg p.o. q. day.
8. Fosamax 70 mg p.o. q. week.
9. Ecotrin 325 mg p.o. q. day.
10. KCl 40 mEq p.o. q. day times seven days.
FOLLOW UP: He will be followed by Dr. [**First Name (STitle) 1806**] in one to two
weeks and by Dr. [**First Name (STitle) **] in two weeks and by Dr. [**Last Name (STitle) **] in 3 to
four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 13867**]
MEDQUIST36
D: [**2191-5-30**] 18:10
T: [**2191-5-30**] 17:55
JOB#: [**Job Number 92997**]
|
[
"4241",
"9971",
"42731",
"41401",
"4019",
"2720"
] |
Admission Date: [**2196-9-26**] Discharge Date: [**2196-10-12**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 724**] is an 82 year-old Asian
male with a history of dementia, who was transferred from the
MICU to the floor following a long stay for respiratory failure,
complicated by fevers and complicated by bilateral iatrogenic
pneumothoraces requiring chest tube placement. Briefly the
patient was admitted on [**2196-9-26**] following a respiratory and
cardiac arrest after choking on food. The patient was
resuscitated and intubated in the field by EMS. Estimated total
time of arrest (cardiac and respiratory) was 5 to 15 minutes
including 5 to 10 minutes of CPR. In the Emergency Department
the patient received a left pneumothorax following an attempted
left subclavian line placement. This left pneumothorax required a
chest tube. The Emergency Department course is also notable for
hypotension requiring Levophed, as well as witnessed aspiration
event. Upon arrival to the [**Hospital Unit Name 153**] complications of the left chest
tube resulted in a left tented pneumothorax as well as a right
sided pneumothorax presumed secondary to high PIPs in the 90s.
The cardiac surgery was consulted and bilateral chest tubes were
placed. The patient was initially begun on Levofloxacin/Flagyl
for presumed aspiration pneumonia with bilateral infiltrates on
chest x-ray. The patient intermittently spiked fevers in the
[**Hospital Unit Name 153**] for which Vancomycin was added on [**2196-9-30**]. In addition,
the patient had episodes of supraventricular tachycardia, which
was responsive to Adenosine and vagal maneuvers. A neurology
consult was obtained who felt that anoxic brain injury was highly
unlikely and his prognosis for recovery was poor. After an
extensive discussion with the patient's family the patient's code
status was changed to DNR/DNI. On [**2197-10-5**] the patient was
extubated and bilateral chest tubes were discontinued. Since
[**2197-10-5**] the patient remained hemodynamically stable and the
patient was transferred to the floor on [**2196-10-6**].
PAST MEDICAL HISTORY:
1. Dementia of Alzheimer's type.
2. Prior CEAs.
ALLERGIES: Bacitracin and Neosporin.
MEDICATIONS AT HOME:
1. Aricept 10 mg po q.d.
2. Zyprexa 25 mg po q.d.
3. Prevacid 30 mg po q.d.
4. Tube feeds.
ANTIBIOTICS WHILE INPATIENT:
1. Levofloxacin 500 mg q.d.
2. Vancomycin 500 mg q 24.
3. Flagyl 500 mg q 8 hours.
4. Subcutaneous heparin.
SOCIAL HISTORY: The patient is a resident of the [**Hospital3 45444**] facility). The patient's son [**Name (NI) **] is health
care proxy. The patient's daughter [**Name (NI) **] is power of attorney.
The patient's wife is living in she lives at home in [**Location (un) 86**]. The
patient has five children, four of whom who live locally and one
who is in route to the hospital.
PHYSICAL EXAMINATION ON TRANSFER: Temperature 97.3.
Temperature max 99.6. Heart rate 57. Blood pressure 95 to
130/35 to 60. Respiratory rate 12 to 14. O2 saturation
100%. In general, the patient is unresponsive to verbal
stimuli, but responsive to pain. Coarse upper airway sounds
are audible. Cardiovascular distal heart sounds without
murmurs. Lungs very coarse breath sounds, positive upper
airway noise, positive rhonchi. Abdomen soft, nontender,
nondistended. No masses, bowel sounds are positive.
Extremities bilateral upper extremities and bilateral lower
extremities with marked edema.
LABORATORY DATA ON [**2196-10-5**]: White blood cell count 10.4,
hematocrit 28.3, sodium 141, potassium 4, chloride 106,
bicarb 27, BUN 22, creatinine 0.5, albumin 2.3, calcium 7.6,
magnesium 1.9.
RADIOLOGY: Chest x-ray on [**10-6**] bilateral basilar lower lobe
opacities right greater then left increasing over the past
few days.
MICROBIOLOGY: [**10-1**] blood cultures times two, sputum is
negative. Urine is negative. [**9-29**] blood cultures times two
are negative. Urine is with positive coag negative staph.
Electrocardiogram on [**9-26**] normal sinus rhythm at 94 beats
per minute, right bundle branch block, low limb voltage.
IMPRESSION: The patient is an 82 year-old Asian male with
baseline dementia who is initially admitted after a prolonged
cardiac/respiratory arrest. He was admitted to the Medical
Intensive Care Unit with anoxic brain injury secondary to
prolonged cardiac and respiratory arrest. In addition his
hospital course was complicated by pneumothoraces as well as
continued aspiration. A neurology consult was obtained to
evaluate the patient and their overall consensus was that this
patient's prognosis was very poor. Upon transfer to the floor
the patient was currently aspirating with worsening bilateral
lower lobe infiltrates, and the risk of recurrent arrest or
decompensation was high.
HOSPITAL COURSE: 1. Pulmonary: The patient continued
aspirating. He remained on high oxygen flow by shovel mask. The
was continued with supplemental oxygen with suctioning prn.
2. Cardiovascular: The patient is hemodynamically stable,
blood pressure in the 90 to 120 range.
3. Infectious disease: Afebrile times 48 hours with negative
culture workup thus far. His fevers are likely secondary to
aspiration pneumonitis/pneumonia versus central in origin.
Because of worsening infiltrates the patient was continued on
aspiration coverage with Levofloxacin/Flagyl.
4. Renal: The patient's BUN to creatinine ratio was steadily
increasing. This increasing ratio is likely indicated of a
prerenal insufficiency. Intravenous fluids were given to the
patient to assist with the prerenal condition.
5. Neurology: As per the neurological evaluation significant
neurological recovery was very unlikely and the and patient's
prognosis was poor.
6. FEN: The patient's tube feeds were continued initially.
7. Prophylaxis: The patient was kept on a PPI and
subcutaneous heparin.
8. Code status: A family meeting was carried out with the
[**Hospital 228**] health care proxy, son [**Name (NI) **] and power of attorney
daughter [**Name (NI) **]. The [**Hospital 228**] medical condition was discussed
and at the patient's current state he was at extremely high risk
of decompensation and another cardiopulmonary arrest. The
patient on transfer to the floor was DNR/DNI. A family meeting
on [**2196-10-7**] with the son [**Name (NI) **] and daughter [**Name (NI) **] to represent the
family. The [**Hospital 228**] medical condition and treatment were
discussed in depth regarding DNR/DNI, intravenous fluids,
antibiotics, deep oropharyngeal suction, laboratory draws, chest
x-rays and blood cultures. [**Doctor Last Name **] stated that the family had
already made peace with their father's health condition and he
voiced the preference that the patient be kept comfortable. [**Doctor Last Name **]
also stated that he wished that his father would "go peacefully"
with no intervention. [**Doctor Last Name **] and [**Location (un) **] stated that they did
not want any intravenous fluids or any pressors. It was decided
by the family to discontinue all lines, intravenous fluids, with
prn morphine given for comfort. In addition, the family declined
deep oropharyngeal suctioning and laboratory draws. Regarding
feedings, daughter felt that the nasogastric tube feedings "would
not change anything" and they opted to have the nasogastric tube
feeds discontinued as well. The patient's family stressed that
the primary role is that the patient is to be kept comfortable
and peaceful. A plan was made that the patient would be kept on
supplemental oxygen for comfort, given prn morphine, oral
suctioning as needed for comfort, as well as Scopolamine patches
to decrease secretions.
From [**10-8**] through [**2196-10-12**] the patient was kept comfortable with
oxygen, morphine and prn Tylenol. Throughout his course the
patient remained unresponsive, though the patient did once open
his eyes to touch. The patient's course continued to decline
from [**10-7**] through [**10-12**] and he was without spontaneous movement.
On [**10-10**] the patient began having increased secretions, increased
gurgling and his respiratory status became more labored. In
addition, the patient began to have increased work of breathing.
Supplemental oxygen, Scopolamine patches to decrease secretions
and morphine GTT were continued for comfort. On [**2196-10-12**] at 12:17
p.m. the patient expired.
DISCHARGE DIAGNOSES:
1. Dementia secondary to Alzheimer's disease.
2. Aspiration of food causing cardiac arrest.
3. Anoxic brain damage secondary to prolonged
cardiopulmonary resuscitation.
4. Continued aspiration pneumonitis/pneumonia.
5. Iatrogenic pneumothorax status post subclavian line
attempt.
6. Left tension pneumothorax, secondary to displacement of
left sided chest tube, which also resulted in a small right
pneumothorax.
7. Status post placement of bilateral chest tubes and
removal of bilateral chest tubes.
8. Acute respiratory failure, requiring ventilator support
while in the Medical Intensive Care Unit.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAD
Dictated By:[**Numeric Identifier 45445**]
MEDQUIST36
D: [**2197-5-13**] 02:19
T: [**2197-5-16**] 12:43
JOB#: [**Job Number 45446**]
|
[
"51881",
"5070",
"2762"
] |
Admission Date: [**2128-12-5**] Discharge Date: [**2128-12-16**]
Date of Birth: [**2071-11-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2474**]
Chief Complaint:
Right hemiplegia
Headache with emesis
Major Surgical or Invasive Procedure:
[**2128-12-5**] Left craniotomy for microsurgical tumor resection and
hematoma evacuation.
Intubation/extubation
CT guided liver biopsy
Left PICC placement
History of Present Illness:
55 yo M with hx renal cell carcinoma s/p nephrectomy, HTN,
and HLD presented to [**Hospital1 18**] ER on [**12-4**] with R-sided hemipelgia.
On [**12-3**] patient noted some upper back discomfort and went to
bed but then woke up and vomitted. He then went on to shower and
was found down by his wife and 911 was called and brought to
[**Hospital1 18**]. He arrived at [**Hospital1 18**] with a GCS of 15
and a code stroke was called. His NIHSS was 14. A CT head
revealed a large intraparenchymal hemorrhage and a neurosurgical
consult was called. While in the CT scanner the patient
deteriorated rapidly and was subsequently intubated and brought
to the OR.
Past Medical History:
Renal cell carcinoma, s/p nephrectomy approximately 5 years
prior
MRSA skin abscesses
HTN
infrarenal abdominal aneurysm
diverticulosis
hypercholesterolemia
MVP with moderate/severe MR
Social History:
lives with wife, past history of alcohol abuse, current intake
unknown, has 3 children
Family History:
mother with pancreatic cancer
Physical Exam:
On Admission:
VS; BP 153/77 P 105 RR 20 100% on vent
Gen; intubated, sedated
Pulm; CTA b/l
CV; RRR, no murmurs
Abd; soft, NT, ND
Extr; no edema
Neuro; unable to perform neurological assessment as patient
received paralytic [**Doctor Last Name 360**] for urgent intubation and subsequent
craniotomy. As per neurology and ED teams, patient was alert
and
responsive at time of arrival. Exam was notable for left gaze
preference, RUQ visual field cut, plegic right arm and leg, and
mild-moderate aphasia.
Upon Discharge:
General: lying on back, 30 degree angle, A+Ox3
HEENT: head partially shaved/stitches from craniotomy visible,
no erythema or exudate. No scleral cterus. EOMI.
Cardiac: Regular rhythm, normal rate. Blowing systolic murmur,
III/VI, loudest in left axilla.
Lungs: mild bibasilar rhonchi, good air movement bilaterally
Abd: NABS, soft, NT, ND, no HSM
Extremities: right leg in contracture-prevention device. No
edema or calf pain bilaterally. Extremities warm and well
perfused.
Neuro: A&Ox3. Appropriate. Right hemiparesis. Light touch
sensation preserved throughout. 5/5 strength on left; 0/5 on
right.
Psych: Listens and responds to questions appropriately.
Pertinent Results:
Head CT [**12-5**]:
Note is made of a large intraparenchymal hemorrhage centered at
the
left frontal lobe, difficult to precisely marginate though
measuring
approximately 41 x 34 x 79 mm. Notably, this focus of hemorrhage
contains superolateral rim of frank parenchymal hemorrhage and
inferomedial to this is a 26 x 64 mm ovoid collection displaying
a blood-fluid level (2:23). The ventricles and sulci are normal
in size and in configuration. Extracranial soft tissue
structures are unremarkable. The included osseous structures
reveal no fracture or lesion. The visualized paranasal sinuses
are notable for mucus retention cysts at the maxillary sinuses
bilaterally, though most prominently on the left, as well as a
small amount of circumferential mucosal thickening at the
ethmoid air cells bilaterally.
IMPRESSION: Large focus of intraparenchymal hemorrhage on the
left as described above. Diagnostic considerations include
metastatic disease in this patient with known history of
previous renal cell carcinoma, primary mass, and alternatively
vascular malformations. These findings may be further
characterized with an MRI.
C-spine CT [**12-5**]:
IMPRESSION:
No fracture. Multilevel DJD with Moderate canal stenosis and
moderate- severe left neural foraminal narrowing. Mild
effacement of the ventral thecal sac at C5/6. If concern exists
for ligamentous and intrathecal abnormalities recommend
further characterization with MR. [**First Name (Titles) **] [**Last Name (Titles) 60441**].
MRI Brain w/ & w/o [**12-6**]:
Status post left frontoparietal craniectomy with post-surgical
edema and
hematoma at the resection site. No evidence of metastatic
disease.
No evidence of new hemorrhage or infarction.
Subdural thickening most consistent with post-surgical changes.
[**2128-12-12**] CXR:
Ill-defined opacities in the right upper and lower lobes
bilaterally have
improved consistent with improving pneumonia. There are no large
pleural
effusions. NG tube tip projects in the right upper quadrant as
before. Left PICC remains in place.
[**2128-12-9**] MRI C/T/L SPINE:
IMPRESSION:
1. 3-cm thoracic right paraspinal mass with a thick enhancing
rim and central fluid-intensity signal. There is no appreciable
bone marrow edema within the adjacent T12 vertebral body. In
this patient, status post right nephrectomy for renal cell
carcinoma, the findings are concerning for recurrent necrotic
tumor, perhaps in a retrocrural lymph node. Though abscess with
a thick rind of enhancement cannot be fully excluded, the lack
of reactive marrow change within the adjacent T12 vertebral
body, would be somewhat unusual.
Dedicated abdominal CT scan is recommended in further
evaluation.
2. Infrarenal aortic aneurysm, minimally changed from the prior
CT scan from [**2127**] with a maximal diameter measurement of
approximately 3.2 cm.
3. Edema versus artifactual signal overlying the left parotid
gland, which
should be correlated with clinical examination.
[**2128-12-10**] CT ABDOMEN/PELVIS:
IMPRESSION:
1. Status post right nephrectomy. There is a right
paravertebral/retrocrural soft tissue lesion, likely
representing a necrotic lymph node. There is an exophytic mass
arising from segment VI of the liver, with extension into the
adjacent retroperitoneum. Findings are highly concerning for
metastatic renal cell carcinoma.
2. Right lower lobe consolidation with thin peripheral clearing.
Findings
could represent aspiration or organizing pneumonia. A nodular
opacity at the left lung base has some surrounding ground-glass
opacity and is likely
infectious or inflammatory. This does not have the typical
appearance for
metastatic renal cell carcinoma.
3. Infrarenal abdominal aortic aneurysm and focal dissection of
the aorta
just above the bifurcation.
4. Moderate sigmoid diverticulosis, without evidence of acute
inflammation.
5. Small focal peripheral wedge-shaped hypodensity within the
spleen may
represent a small infarct.
6. New minimal pericardial fluid.
[**2128-12-11**] BLE ULTRASOUND:
IMPRESSION: No deep venous thrombosis within [**Month/Day/Year **] lower
extremity veins.
[**2128-12-14**] VIDEO SWALLOW:
IMPRESSION: Unremarkable swallow study.
[**2128-12-8**] TTE:
The left atrium is moderately dilated. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is moderate/severe mitral
valve prolapse. There is probable partial mitral leaflet flail
(posterior leaflet). No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Torn mitral chordae are present. An eccentric,
anteriorly directed jet of moderate to severe (3+) mitral
regurgitation is seen.
IMPRESSION: Mitral valve prolapse with moderate to severe MR. [**Name13 (STitle) **]
definite valvular vegetation seen. If indicated, a TEE would
better exclude a small valve vegetation.
[**2128-12-14**] TEE:
The left atrium is moderately dilated. No mass/thrombus is seen
in the left atrium or left atrial appendage. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the aortic arch. The aortic valve
leaflets (3) are mildly thickened. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. There
is moderate/severe mitral valve prolapse. There is focal
posterior flail mitral leaflet. No mass or vegetation is seen on
the mitral valve. Severe (4+) mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
CONCLUSION: Severe MVP with a focal flail posterior mitral
leaflet. Severe mitral regurgitation. No evidence of
endocarditis.
[**2128-12-5**] PATHOLOGY
DIAGNOSIS: Parietal "tumor":
Blood clot, see note.
Note: No viable or necrotic epithelial tumor is detected.
Confirmed by cytokeratin cocktail.
[**2128-12-13**] TOUCH PREP CYTOLOGY
Touch prep of core, Liver: POSITIVE FOR MALIGNANT CELLS.
[**2128-12-13**] LIVER BIOPSY:
Report not finalized.
Assigned Pathologist [**Last Name (LF) **],[**First Name3 (LF) **] H.
Please contact the pathology department, [**Name (NI) **] [**Numeric Identifier 1434**]
PATHOLOGY # [**-1/4333**]
LIVER BIOPSY (1 JAR)
[**2128-12-15**] 05:49AM BLOOD WBC-9.1 RBC-3.50* Hgb-10.8* Hct-31.6*
MCV-90 MCH-30.8 MCHC-34.1 RDW-13.7 Plt Ct-393
[**2128-12-5**] 03:35AM BLOOD WBC-10.4 RBC-4.16* Hgb-13.5* Hct-37.4*
MCV-90 MCH-32.5* MCHC-36.1* RDW-13.6 Plt Ct-210
[**2128-12-15**] 05:49AM BLOOD Plt Ct-393
[**2128-12-13**] 04:48AM BLOOD PT-11.7 PTT-23.6 INR(PT)-1.0
[**2128-12-5**] 03:35AM BLOOD Plt Ct-210
[**2128-12-5**] 03:35AM BLOOD PT-11.8 PTT-23.4 INR(PT)-1.0
[**2128-12-15**] 05:49AM BLOOD Glucose-121* UreaN-25* Creat-1.0 Na-139
K-4.1 Cl-103 HCO3-25 AnGap-15
[**2128-12-5**] 09:57AM BLOOD Glucose-207* UreaN-23* Creat-1.7* Na-134
K-4.6 Cl-102 HCO3-21* AnGap-16
[**2128-12-13**] 04:48AM BLOOD Albumin-3.1* Calcium-8.6 Phos-2.8 Mg-2.2
[**2128-12-5**] 09:57AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.7 Mg-1.4*
[**2128-12-14**] 05:22AM BLOOD Vanco-19.4
[**2128-12-5**] 09:57AM BLOOD Phenyto-12.9
[**2128-12-13**] 04:48AM BLOOD Phenyto-1.2*
Brief Hospital Course:
57M with PMH significant for renal cell carcinoma s/p
nephrectomy and MRSA skin abscesses who presented on [**12-4**] with
right hemipelgia.
1) Right hemiplegia: On [**12-5**], patient deteriorated and was
emergently intubated and brought to the OR for a left sided
craniotomy for evacuation. During surgery there was question of
an underlying lesion or cyst and the resected area was sent to
pathology for histology. The pathology returned as hemorrhage
and clot, there was no evidence of malignancy. Post-operatively
Mr. [**Known lastname **] was brought to the SICU. On [**12-6**] an MRI without
contrast was done which showed post-operative changes but no
lesion was seen. His neurologic symptoms progressively improved
during his hospitalization. At the time of discharge, he was
alert and oriented x 3, and was able to communicate with some
dysarthria, but mostly improved from admission. He continued to
have right sided weakness, but able to move slightly. He was
determined to be a candidate for rehab. Of note, initially, he
had difficulty swallowing and concern for aspiration pneumonia.
He was planned for PEG placement, but subsequent speech and
swallow consultation revealed that he had a good gag and
swallow, and after a video swallow, the patient was cleared for
solid foods with thin liquids, but medications to be crushed in
puree. He should have monitored eating at all time.
Patient will need to follow-up with Dr. [**Last Name (STitle) **] [**2129-1-11**] (appt in
the system) with a
Head CT. NSGY recommends no Aspirin, Coumadin, or Plavix until
follow-up appointment. He should continue Dilantin until seen by
Dr. [**Last Name (STitle) **]; Goal of [**11-30**]
(inpatient Dilantin levels have been corrected w/Albumin levels)
at current dose of 120 mg PO Q8H. Repeat level should be drawn
and dose should be adjusted accordingly on [**2128-12-17**].
Bacitracin should be applied to surgical incision on scalp TID
for 7 days per NSGY recommendations. Any questions or concerns
regarding his incision after discharge
can be addressed by calling [**Telephone/Fax (1) 3231**] and asking for the NP
for Dr. [**Last Name (STitle) **] to be paged
2) MRSA bacteremia: During the patient's SICU course, the
patient developed a fever to 102 on [**12-6**]. He was also noted to
have thick secretions at that time as well. His blood cultures
were positive for MRSA. The patient was started on vancomycin
and ID was consulted at that time. He had complained of back
pain, and an MRI C/T/L spine showed a paraspinal lesion that was
concerning for a necrotic lymph node or mets, and CT Abd/pelvis
showed a large liver mass. Initially, there was concern for
abscess or other infectious source there, but radiology did not
feel this was likely infectious. The liver lesion was biopsied,
and prelim pathology read was likely malignancy, not infectious
though final read is pending at the time of discharge. Patient
had a TTE which showed severe mitral regurgitation, but no
vegetations. He subsequently had a TEE which also showed no
vegetations, but there was posterior mitral leaflet flair with
severe MR. ID felt that this would warrant a full 6 week course
of antibiotic therapy as there may be some seeding or possible
endocarditis there. He will be maintained on vancomycin until
[**2129-1-18**]. He has a left sided PICC for access. ID will follow
as an outpatient.
3) Pneumonia: During the time the patient was in the SICU, there
was a CXR concerning for pneumonia. Most likely this represents
an aspiration pneumonia during the initial episode prior to
intubation. Other possibilites include a MRSA pneumonia as
well. The patient completed an 8 day course of ceftazidime
while he was in the hospital, but will need to complete a course
of vancomycin as above. Of note, at the time of discharge he
was satting well on room air.
**Followup CXR should be performed in [**7-19**] weeks to ensure
resolution.
4) Exophytic mass on liver: During the hospital course, imaging
revealed a liver mass concerning for malignancy. The patient
had the mass biopsied under CT guidance. At the time of
discharge, the final path report is pending. Preliminary read
is that mass is neoplastic; otherwise not yet characterized. Dr.
[**First Name (STitle) 1022**] (PCP) will follow up on results and inform the patient and
his family accordingly. Follow up will be made with appropriate
providers based on the results of the pathology.
**Follow-up of liver mass pathology will be needed as it was
pending at the time of discharge
5) Nutrition: Cleared by video swallow study read as
unremarkable. Speech/swallow recommends normal solids and thin
liquid diet.
6) Agitation: Patient has been intermittently agitated during
stay, pulling foleys, NG tubes. At discharge, he'd been fairly
calm, including nights. He was maintained on uetiapine Fumarate
12.5 mg PO DAILY in evening. Also, he will continue Lorazepam
0.5 mg IV Q4H:PRN agitation.
7) PPX: no anticoagulation given recent bleed, continue bowel
regimen
8) ACCESS: Left Picc
9) CODE: Full
Medications on Admission:
Aspirin 81 mg daily
Amlodipine 5 mg daily
Atenolol 100 mg daily
Lisinopril 40 mg daily
Ativan 0.5 mg q4h prn anxiety
Zocor 80 mg daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**First Name (STitle) **]: Ten (10) mL PO BID (2
times a day).
2. Simvastatin 80 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO once a day.
3. Lisinopril 40 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO once a day.
4. Senna 8.6 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**First Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Amlodipine 10 mg Tablet [**First Name (STitle) **]: One (1) Tablet PO once a day.
7. Phenytoin 125 mg/5 mL Suspension [**First Name (STitle) **]: One [**Age over 90 **]y
(120) mg PO Q8H (every 8 hours).
8. Atenolol 100 mg Tablet [**Age over 90 **]: One (1) Tablet PO once a day.
9. Quetiapine 25 mg Tablet [**Age over 90 **]: 0.5 Tablet PO DAILY (Daily):
please give dose at 1700 .
10. Furosemide 20 mg Tablet [**Age over 90 **]: One (1) Tablet PO once a day.
11. Vancomycin 500 mg Recon Soln [**Age over 90 **]: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 4 weeks: last day [**2129-1-18**].
12. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety/insomnia.
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Bacitracin 500 unit/g Ointment [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) for 7 days: apply to scalp incision.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Left Intraparenchymal Hemorrhage s/p craniotomy
Mitral valve regurgiation with flail mitral valve
MRSA Bacteremia
Aspiration Pneumonia
Exophytic Liver Mass
Discharge Condition:
stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] and found to have a bleed in your
head. You had emergent surgery of your head on the neurosurgery
service, and had improvement of your neurological symptoms
during your hospitalization. Below is regarding your
neurosurgery follow up.
Neurosurgery Discharge Instructions:
??????Exercise should be limited to walking; no lifting, straining,
or excessive bending. 10lb weight restriction x 4 weeks
??????If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, do not
restart until cleared by your neurosurgeon
??????If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
??????Please call the neurosurgeon's office if you experience: 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.
During your hospitalization, you were also found to have
bacteria in your blood. You had an extensive workup looking for
a source, but there was none evident at the time of discharge.
You also had a biopsy looking for infection, and this was
pending at the time of discharge. You will need to follow the
results of this with Dr. [**First Name (STitle) 1022**]. You will need to complete a 3
week course of vancomycin for the bacteria in your blood, and
complete an 8 day course of antibiotics for the pneumonia you
developed while you were in the hospital. You will be
discharged to a rehabilitation facility.
Please take all medications as prescribed.
The following medication changes were made during your
hospitalization:
1) Phenytoin 120 mg every 8 hours
2) Vancomycin 1250 mg IV Q12H for 6 week course (last day
[**2129-1-18**])
3) Furosemide 20 mg daily
4) Quetiapine 12.5 mg QPM
5) Bacitracin ointment to scalp TID
If you develop any of the following symptoms, please call your
PCP or go to the ED: fevers, chills, nausea, vomiting, weakness,
difficulty breathing, chest pain, or any other concerning
symptoms.
Followup Instructions:
Dr. [**Last Name (STitle) **] (Neurosurgery):
CT scan [**2129-1-11**] 2:30pm Clinical Center [**Location (un) **]
Office with Dr. [**Last Name (STitle) **] [**2129-1-11**] 3:00pm LMOB [**Location (un) **] Ste 3B
Please call [**Location (un) 3230**] at [**Telephone/Fax (1) 3231**] to make any changes or with
questions. NO ASPIRIN OR COUMADIN UNTIL SEEN WITH DR. [**Last Name (STitle) **]
Dr. [**Last Name (STitle) **], cardiology, [**12-31**] at 3:20pm
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2129-1-11**] 2:30
Please follow up with Dr. [**First Name (STitle) 1022**] [**Telephone/Fax (1) 250**] within 1 month of
discharge.
Please make an appointment with Dr. [**Last Name (STitle) 914**] (Cardiac Surgery)
after the pt. is discharged from rehab. [**Telephone/Fax (1) **]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**] MD, [**MD Number(3) 2478**]
|
[
"5070",
"4240",
"2720"
] |
Admission Date: [**2186-3-27**] Discharge Date: [**2186-4-13**]
Date of Birth: [**2137-5-24**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Prochlorperazine / Decongestant Sinus
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain due top scoliosis
Major Surgical or Invasive Procedure:
Removal previous [**Location (un) 931**] Rod Instrumentation
Total laminectomy of L5, L4, L3 and L2
Fusion T3-S1
Instrumentation L4-S1
History of Present Illness:
Ms. [**Known lastname **] returns for her posterior thoracolumbar fusion.
Past Medical History:
Gout
Social History:
Lives with husband.
Family History:
Non-contributory
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2186-4-12**] 09:47AM BLOOD WBC-7.5 RBC-4.11* Hgb-11.5* Hct-35.1*
MCV-85 MCH-28.0 MCHC-32.8 RDW-14.3 Plt Ct-653*
[**2186-4-9**] 02:14PM BLOOD WBC-6.1# RBC-3.92* Hgb-11.7* Hct-34.2*
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.7 Plt Ct-439#
[**2186-4-7**] 07:06AM BLOOD WBC-14.0* RBC-3.29* Hgb-9.6* Hct-27.5*
MCV-83 MCH-29.1 MCHC-34.9 RDW-15.2 Plt Ct-260
[**2186-4-6**] 02:07AM BLOOD WBC-10.4# RBC-3.11* Hgb-8.9* Hct-26.5*
MCV-85 MCH-28.7 MCHC-33.6 RDW-14.9 Plt Ct-419
[**2186-4-4**] 08:55AM BLOOD WBC-4.3 RBC-3.72* Hgb-10.5* Hct-31.7*
MCV-85 MCH-28.1 MCHC-33.0 RDW-14.9 Plt Ct-400#
[**2186-4-9**] 02:14PM BLOOD Glucose-105* UreaN-4* Creat-0.4 Na-140
K-3.4 Cl-101 HCO3-31 AnGap-11
[**2186-4-6**] 02:07AM BLOOD Glucose-146* UreaN-9 Creat-0.5 Na-138
K-4.4 Cl-103 HCO3-29 AnGap-10
[**2186-4-4**] 08:55AM BLOOD Glucose-102* UreaN-15 Creat-0.4 Na-139
K-3.7 Cl-102 HCO3-28 AnGap-13
[**2186-3-29**] 01:04AM BLOOD Glucose-121* UreaN-11 Creat-0.5 Na-139
K-3.8 Cl-106 HCO3-26 AnGap-11
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**3-27**] and taken to the Operating Room for a posterior
thoracolumbar fusion for scoliosis. Please refer to the dictated
operative note for further details. The patient was transferred
to the PACU in a stable condition. A lumbar drain was placed
intraoperatively due to a dural tear and was left in place for
one week. TEDs/pnemoboots were used for postoperative DVT
prophylaxis. Intravenous antibiotics were given per standard
protocol. Initial postop pain was controlled with a PCA.
Postoperative HCT was low and she was transfused PRBCs. She
remained flat for 48 hours and the head of her bed was slowly
elevated. She 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. She was fitted
with a TLSO to be worn when ambulating or sitting in a chair.
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:
See previous list.
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.
2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Estroven Maximum Strength 400 mcg Tablet Sig: One (1) Tablet
PO Daily ().
5. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
10. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
11. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
12. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q12H (every
12 hours) for 5 days.
13. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for spasm.
Discharge Disposition:
Extended Care
Facility:
apple rehab
Discharge Diagnosis:
Scoliosis
Post-op acute blood loss anemia
Dural tear
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With Fusion
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
for comfort 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: Activity as tolerated
Thoracic lumbar spine: when OOB
TLSO when OOB- Apply brace when sitting at bedside
Treatments Frequency:
Please change the dressing daily.
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 2 weeks
Completed by:[**2186-4-13**]
|
[
"2851"
] |
Admission Date: [**2141-7-13**] Discharge Date: [**2141-8-4**]
Date of Birth: [**2084-8-14**] Sex: F
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5667**]
Chief Complaint:
Poorly differentiated carcinoma right facial region, metastatic
to right neck.
Major Surgical or Invasive Procedure:
1. Facial nerve monitoring.
2. Right modified radical neck dissection.
3. Total parotidectomy with facial nerve dissection.
4. Resection of the zygomatic bone.
5. Right muscle sparing vertical rectus abdominis
myocutaneous perforator flap.
6. Reconstruction of total facial nerve resection.
7. Harvest of sural nerve graft 19 cm.
8. Microvascular microsurgical repair of facial nerve,
branches of the pes anserinus three major divisions of
the facial nerve.
9. Local tissue rearrangement 40 square cm of postauricular
skin and auricle to reconstruct postauricular and
preauricular defect.
10. Harvest of the skin graft.
11. 3 inches x 10 cm for closure of the anterior wall chest
defect as well as right preauricular area.
12. Right lateral tarsorrhaphy.
History of Present Illness:
56-year-old female with a history of having a right facial mass
that has been developing over the past five to six years. The
patient reports the lesion is not painful, but that it has been
growing more recently with changing characteristics in the last
month. She reports it does not bleed but occasionally oozes
liquid from the lesion. She also states that her forehead is
asymmetric with decreased ability to raise the forehead on the
right side as compared to the left side. She recalls about 10
years ago, that she noticed a patch of dry skin in the right
preauricular region that would come and go. About 1 year ago,
she noticed significant growth of the lesion. It started as
dime-sized and she was able to cover it with a regular-sized
bandaid. Then it grew until it reached the present size of 6 cm
in diameter, with cauliflower surface, slight smell, and
occasional bleeding. Additionally, she began noticing high
anterior right neck lymph node swellings a few months ago.
Unfortunately, she did not seek medical attention in [**State 108**] due
to "lack of health insurance" until [**2141-4-12**] when she met
dermatologist Dr. [**First Name8 (NamePattern2) 13740**] [**Last Name (NamePattern1) 4469**] who perfomed a shave biopsy of
the large mass, as well as shave biopsy of a much smaller
asymptomatic lesion on her anterior chest at the base of the V
of her neck.
Past Medical History:
squamous cell carcinoma of the right face
COPD
.
PSH:
hysterctomy
tubal ligation
[**Last Name (un) 3907**] augmentation
Social History:
She is originally from [**State 1727**], but has lived in [**State 108**] for the
past 16 years and has worked as a caregiver for the past 4-1/2
years. She returned to [**State 1727**] to live with her son and seek
treatment. Currently smokes. She has a 35-pack-year history.
Does not drink.
Family History:
Significant for breast cancer, diabetes, and depression.
Physical Exam:
Preprocedure/Admission PE as documented in Anesthesia Record
[**2141-7-13**]:
General: wd petite woman
Mental/psych; a/o
Airway: as documented in detail on anesthesie record
Dental; dentures (partial upper)
Head/neck range of motion: free range of motion
Heart: rrr
Lungs: clear to auscultation
Abdomen: soft nt
Extremties: no ankle edema
Other: no cerv lad
Pertinent Results:
[**2141-7-13**] 10:52AM freeCa-1.09*
[**2141-7-13**] 10:52AM HGB-12.8 calcHCT-38
[**2141-7-13**] 10:52AM GLUCOSE-132* LACTATE-1.6 NA+-140 K+-2.6*
CL--108
[**2141-7-13**] 09:41PM freeCa-1.04*
[**2141-7-13**] 09:41PM HGB-10.3* calcHCT-31
[**2141-7-13**] 09:41PM GLUCOSE-161* LACTATE-1.6 NA+-139 K+-3.7
CL--102
[**2141-7-16**] 02:59AM BLOOD WBC-12.4* RBC-2.87* Hgb-8.8* Hct-25.3*
MCV-88 MCH-30.8 MCHC-34.9 RDW-15.1 Plt Ct-150#
[**2141-7-24**] 08:10AM BLOOD WBC-19.6* RBC-2.24* Hgb-6.7* Hct-20.2*
MCV-90 MCH-29.8 MCHC-33.0 RDW-18.9* Plt Ct-832*#
[**2141-7-26**] 08:31AM BLOOD WBC-17.9* RBC-3.64* Hgb-10.9* Hct-32.2*
MCV-89 MCH-29.9 MCHC-33.8 RDW-18.8* Plt Ct-805*
.
MICROBIOLOGY
[**2141-7-24**] 1:32 pm URINE Source: CVS.
**FINAL REPORT [**2141-7-28**]**
URINE CULTURE (Final [**2141-7-28**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 1 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
.
[**2141-7-26**] 5:21 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2141-7-26**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-7-26**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
Pt was admitted to the Plastic Surgery Service on [**2141-7-14**]
following radical resection of R neck mass and subsequent free
TRAM flap w/ skin and nerve grafting.
.
POD#1 [**2141-7-14**]:
Patient was admitted directly to Trauma ICU (TICU) from the
operating room given lengthy surgery and precariousness of free
flap. Flap head good capillary refill throughout ([**12-28**] sec) with
small area at superior pole demonstrating sluggish refill and
slight duskiness. Patient with continuous Vioptix monitoring of
free flap. BP dipping to low 70s/40s with HR 100-120. Pt
received multiple fluid boluses (~3.5L NS) and 1 unit albumin
with some response but not sustained. Urine output remained
high. In the setting of low BP, tachycardia, and HCT 19.9 (from
25.9) pt received 2 units of PRBCs with resolution of symptoms
(one in am and one overnight). She remained intubated on
propofol.
.
POD#2 [**2141-7-15**]
Upper pole of free flap remained dusky with sluggish cap refill,
3-4 seconds. Pulses remained dopplerable in lower portion of
flap. Donor site for STSG and recipient site continued to look
healthy with good amount of oozing. Pt continued to require
frequent fluid boluses to maintain HR < 100. BP 80-90/40s.
Tolerating large amount of fluid with large urine output.
Patient maintained on strict 'no roll' precautions given
tenuousness of neck flap. Propofol was weaned and fentanyl
increased to help with possible pain induced tachycardia and
sedative induced hypotension.
.
POD#3 [**2141-7-16**]
Patient remained in TICU. She was rolled to change bedding and
inspected for pressure ulcers in am with plastics present and
providing axial support of the neck. Pt did not tolerate the
procedure well and sats dropped to high 80s with increased fluid
oozing from around flap site. Vioptix replaced with maximum % in
low 60s (94% sig quality)
.
POD#4 [**2141-7-17**]
Right thigh STSG donor site was open to air and drying out well.
Right lateral lower extremity sutures s/p sural nerve
harvesting remained dry and intact. Flap with + doppler signal
and vioptix stable. Patient remained intubated and on 'no roll
precautions. A multipodus boot was applied to right foot to
elevate heel off of bed and prevent foot drop. Abdominal steri
strips remained dry and intact. A left brachial PICC line was
placed to maintain long term access. A Dobhoff tube was placed
so that patient could be started on tube feeds.
.
POD#5 [**2141-7-18**]
Patient remained in TICU and was extubated and tolerated well.
.
POD#6 [**2141-7-19**]
Patient remained in TICU and her neck JP drain was removed for
low output. She was maintained on the heparin gtt for flap
protection. The bolster over the central chest STSG site was
removed, site appeared healthy and graft adherent and Xeroform
dressing placed. An anterior neck hematoma had accumulated and
was aspirated at bedside and iodoform gauze tape placed to wick
wound.
.
POD#7 [**2141-7-20**]
The anterior neck hematoma wick continued to drain moderate
amount of bloody fluid. The abdominal JP drain was pulled.
Chest PT and pulmonary toilet initiated. Patient was transfused
1 unit of PRBC's for HCT < 21.
.
POD#8 [**2141-7-21**]
Abd JP site with large amount of serosang drainage leak,
pressure dressing placed and oozing stopped. Patient
transferred to floor today. Erythromycin 0.5% Ophth Oint 0.5 in
RIGHT EYE QID initiated for eye protection due to inability to
completely close eye. Occupational and Physical therapy
initiated. Heparin gtt was discontinued. Heparin subcutaneous
injections TID initiated.
.
POD#9 [**2141-7-22**]
Posterior edge of flap with dehiscence of 2x4x1.5cm (indurated,
but no purulence), wet to dry dressings initiated. Anterior neck
with open wound (remained clean with some oozing, repacked
loosely) & STSG with Xeroform dressings QD. R thigh donor site
healing well. Right posterior lower leg with some eschar
formation (3x3cm), no fluctuance, no drainage)-topical applied.
Old abdominal drain site with decreased drainage. Patient OOB
to chair with assist. Ipratropium Bromide Neb 1 NEB IH Q6H and
Albuterol 0.083% Neb Soln 1 NEB IH Q6H initiated.
.
POD#10 [**2141-7-23**]
Post edge of flap unchanged, wet to dry continued. Anterior
neck wound more open laterally, packed with gauze. Foley was
discontinued and patient began using bedside commode with
assist. Nocturnal feeds at 100cc/hr 7p-7a (nutrition
following). Patient with some episodes of diarrhea.
.
POD#11 [**2141-7-24**]
Posterior flap area with open area...packed with W-D. Right
inferior neck skin graft area dead and left open to air, no
creams, ointments. Transverse open area (s/p hematoma I+D) base
of neck: Packed with loose sterile gauze and covered. Xeroform
QD to chest STSG site continued. RLE sutures intact. RLE
posterior pressure ulcer from multipodus boot (?)-->Ordered
softer posterior resting splint from orthotech. Calorie count
initiated...pt with POOR po intake. Nocturnal TFs goal 100cc/hr
x 12h continued. Lopressor 12.5 [**Hospital1 **] for tachycardia initiated.
IV fluids discontinued and free water via NGT (800cc QD)
initiated. Cefazolin IV discontinued and Flagyl initiated for
continued and increasing episodes of diarrhea. C.diff stool
testing ordered. Social Work consult requested for patient and
family coping. Vioptix monitoring continued and flap checks Q4h
continued. Patient agitated today...dilaudid discontinued and
trial of oxycodone initiated. Occupational therapy working with
patient on methods of taking PO nutrition. Patient transfused
with 2 units of PRBCs for HCT < 21.
.
POD#12 [**2141-7-25**]
Hemoglobin/hematocrit 10.3/31.2 s/p 2 units. Lopressor increased
to 25mg [**Hospital1 **] for better control of heart rate. RLE lateral
sutures by foot with para-incisional erythema and TTP. Some
sutures removed and hematoma drained at bedside. Flap vioptix
removed/discontinued. Psych consult-->for delirium, sundowning.
Psych recommendations: d/c hydroxyzine, re-orient at night,
initiate Haldol. Speech/swallow consult-->no mechanical reason
patient is not eating. Santyl [**Hospital1 **] to posterior leg wound eschar
area and boot from ortho tech-->Plantar fascia night splint with
[**Doctor First Name **] cloth lining for RLE.
.
POD#13 [**2141-7-26**]
Agitation last PM despite Haldol. Psych
recommendations-->Haldol 2.5mg QHS repeat dose x1 if still
agitated and difficulty sleeping. Increased lopressor to 37.5
[**Hospital1 **] for improved rate control. RLE erythema and swelling around
sutures improved. PO intake encouraged but continued poor
appetite.
.
POD#14 [**2141-7-27**]
Went to OR for debridement, STSG to scalp, gold weight Rt eye.
+ Pseudomonas UTI--->cipro 500 [**Hospital1 **] x 3 days. C.diff negative
but continued to treat with flagyl PO. Diarrhea x 2. Protein
shakes with trays: ordered Ensure plus shakes for lunch and
dinner. Nocturnal tube feeds continued. Wound VAC to right
face skin graft site.
.
POD#15/#1 [**2141-7-28**]
Patient ambulated 2 times today with PT around part of floor
with walker. PT recommended increased ROM exercises for R foot.
Increased PO intake today. Nocturnal tube feeds continued.
.
POD#16/#2 [**2141-7-29**]
Patient pulled out her Dobhoff overnight. Calorie counts
continued and increased PO intake encouraged with good effect.
Eschar debrided from R lateral ankle exposing a 1 cm deep
hematoma that was washed out. Wound then packed with wet/dry
dressing. VAC with clot at suction tip (lollipop). Excised and
replaced with good suction.
.
POD#17/#3 [**2141-7-30**]
Patient taking moderate amounts of POs. Calorie counts in
progress. Pt ambulating QID. VAC holding adequate suction.
.
POD#18/#4 [**2141-7-31**]
Patient continuing to increase PO intake, ambulating.
.
POD#19/#5 [**2141-8-1**]
AVSS, wound VAC in place and patent to right face STSG site.
Wet to wet dsg changes QID to neck wound. Bacitracin ointment
to chest STSG site. Right thigh STSG donor site open to air.
W-D dsg changes to 2 RLE wounds. Calorie ct continues with good
PO intake.
.
POD#20/#6 [**2141-8-2**]
VAC removed from R scalp. Underlying flap with healthy
granulation tissue but STSG appears non-adherent and
de-vitalized. Curisol gel and Adaptic applied over the R neck
and scalp wounds [**Hospital1 **], ensuring that both sites remain moist. PO
intake stable (calories ~1400-1700 kcal/day), pt taking high
calorie shakes as additional supplement. Flagyl discontinued,
no further episodes of diarrhea x 5 days.
.
POD#21/#7 [**2141-8-3**]
Pt wants to go home. Feels comfortable with daily
activities/wound dressing changes with her daughter-in-law.
Continues to eat regular meals with additional caloric
supplements (ensure+).
.
At the time of discharge on POD#22/#8 ([**2141-8-4**]), the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. Her right eye and face remain slack with
the right eye hanging open (gold weight in place). Ointment well
applied and covering the cornea. Her right scalp wound is well
healing with good granulation. The aquacel and underlying tissue
remain damp and there are no signs of further skin breakdown or
infection. Suprasternal split thickness skin graft site is well
healing and without signs of infection. Abdominal wounds are all
but healed completely with no signs of cellulitis. R thigh is
CDI with Xeroform dried to the most recent donor site (which
will remain on until it falls off on its own). The R ankle
wounds are clean and dry with wet/dry packing at the proximal
and distal most wounds. All wounds have had sutures removed.
Medications on Admission:
hydroxyzine, citalopram
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO
DAILY (Daily) for 10 days: Take aspirin until [**2141-8-13**] which
would finish one month of aspirin therapy.
Disp:*15 Tablet, Chewable(s)* Refills:*0*
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day): Max 8/day. Do not exceed 4gms/4000mg of tylenol
per day.
Disp:*180 Tablet(s)* Refills:*2*
3. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation four times a day: 2 INHALATIONS 4 times
per day; MAX 12 inhalations/day.
Disp:*1 HFA inhaler* Refills:*2*
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every six (6) hours: 2 ORAL INHALATIONS
every 4 to 6 hr or 1 ORAL INHALATION every 4 hr as needed.
Disp:*1 HFA inhaler* Refills:*2*
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day) as needed for corneal
protection.
Disp:*1 bottle/tube* Refills:*3*
8. Erythromycin 5 mg/gram (0.5 %) Ointment Sig: 0.5 inch ribbon
Ophthalmic Q4H (every 4 hours): Apply to right eye.
Disp:*1 tube* Refills:*3*
9. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for anxiety.
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 486**]
Discharge Diagnosis:
1. Poorly differentiated carcinoma right facial region.
2. Metastatic carcinoma right neck.
3. facial nerve paralysis, status post resection.
4. Large facial wound defect (defect measured at least 7 x 12 x
10
cm)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You may shower/bathe daily but do not let shower water onto your
facial/neck wounds. Shower from neck down only. You may remove
the wet to dry packing/dressings used on your right leg wounds,
shower, and then apply fresh dressings.
.
Activity:
1. You may resume your regular diet. Please try to have some
supplemental shakes/smoothies between meals to build up your
nutrition and proteins for good wound healing.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
4. Take prescription pain medications for pain not relieved by
tylenol.
5. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softerner if you wish.
6. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Wounds:
You will have a visiting nurse (VNA) help you with daily
dressing changes and wound care. However, you will need to have
your dressings changed at least one additional time during the
day without nursing help (ie by a family member or friend).
These dressings include:
1. Please apply prescribed eye drops and eye ointment to the
Right eye four times a day. The right eye should be taped shut
every night to prevent corneal abrasions.
2. Right scalp and Right neck wounds should be covered with
curisol gel two times a day. Ensure that the tissue is
relatively damp at all times. A dry gauze sponge can be taped
over the damp dressing with paper tape.
3. Suprasternal split-thickness skin graft site should be
covered with bacitracin ointment two times a day (cleaning off
by dabbing in between).
4. Right thigh wounds should be left to air to dry. Loose edges
of the Xeroform can be trimmed back if they are bothering the
pt.
5. Right ankle wound should be packed with wet-to-dry dressings
two times a day.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Separation of the incision.
4. Severe nausea and vomiting and lack of bowel movement or gas
for several days.
5. Fever greater than 101.5 oF
6. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Please follow up with your Plastic Surgeon, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]:
([**Telephone/Fax (1) 9144**]
Dr.[**Name (NI) 27488**] office is located on the [**Hospital Ward Name **], in the [**Hospital Unit Name **], on the [**Location (un) 442**], [**Hospital Unit Name 6333**].
.
Please follow up with Dr. [**Last Name (STitle) 1837**]: ([**Telephone/Fax (1) 6213**]
Office Location: [**Last Name (NamePattern1) **], [**Hospital Unit Name **] Suite 6E
|
[
"496"
] |
Unit No: [**Numeric Identifier 71058**]
Admission Date: [**2157-1-29**]
Discharge Date: [**2157-2-4**]
Date of Birth: [**2157-1-29**]
Sex: M
Service: NB
HISTORY: [**Known lastname **] is a former [**2104**] gram male born at 37-1/7
weeks gestation and admitted to the Newborn Intensive Care
Unit at [**Hospital1 69**] for a dusky
episode, low temperature, and hypoglycemia.
[**Known lastname **] was born at [**2104**] grams at 37-1/7 weeks to a 44-year-old
gravida I, para 0, now I female. Her prenatal screens reveal
she is B negative, antibody negative, RPR nonreactive,
hepatitis B surface antigen negative and group B strep
negative. There is a maternal history of mild hypertension
and depression being treated with Wellbutrin. This pregnancy
was complicated by intrauterine growth restriction. She was
induced for this reason and her membranes were ruptured 1-1/2
hours prior to delivery. There was no maternal fever or fetal
tachycardia noted. Cesarean section was performed secondary
to decelerations. The infant was born with a heart rate
greater than 100 but decreased tone and no respiratory effort
requiring bag and mask ventilation. His Apgars were 5 and 8.
The placenta was noted to be small and sent to pathology.
On admission to the Newborn Intensive Care Unit the infant
had a temperature of 97.7 and was saturating greater than 98%
in room air.
PHYSICAL EXAMINATION: His weight was [**2104**] grams which was
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] the 10th percentile, head circumference 31 cm, at
the 10th percentile, and length 44.5 cm, between the 10th and
25th percentile. His initial physical examination was notable
for a hypospadias.
PROBLEMS DURING HOSPITAL STAY:
1. Respiratory. Infant's initial dusky episode was likely
transitional. He remained in room air for his complete
hospital stay. He initially had a few brief episodes of
bradycardia without desaturations but none for 5 days post
discharge.
2. Cardiovascular. There were no cardiovascular issues.
3. Hypoglycemia. He initially had a Dextrostix level of 39,
fed and thereafter his Dextrostix have remained
euglycemic in the 70s to 80s range. He initially fed
slowly and remained without a feeding tube, able to take
a minimal volume. He was on Neosure 24 calories per ounce
formula and mother's milk when available. At the time of
discharge he was feeding well by bottle and breast. His
weight the day prior to discharge was [**2139**] grams.
4. Infectious disease. There were no infectious disease
issues. It was felt that this infant's small for
gestational age and hypoglycemia were secondary to
uteroplacental insufficiency and maternal hypertension.
CMV urine culture was negative.
5. Genitourinary. The patient on admission was noted to have
hypospadias. This was discussed with the mother and
explained why he would not be circumcised. Follow up as
an outpatient for eventual surgical repair will be done
by the private pediatrician.
6. GI: The infant never developed any significant
jaundice. Mother B neg/Baby B+/DAT neg.
7. Immunizations: Hepatitis B vaccine given [**2157-2-3**].
8. Hearing screen passed on [**2157-2-4**].
Upon discharge the patient will be followed up at [**Hospital1 35174**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Visiting nurse will come to the home the day post discharge.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], [**MD Number(1) 55783**]
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2157-2-1**] 11:18:27
T: [**2157-2-1**] 11:47:04
Job#: [**Job Number 71059**]
cc:[**Last Name (NamePattern4) 71060**]
|
[
"V053",
"V290"
] |
Admission Date: [**2128-4-27**] Discharge Date: [**2128-5-4**]
Date of Birth: [**2076-12-31**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 13129**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
TEE with cardioversion [**2128-4-30**]
History of Present Illness:
51 year old male with history of morbid obesity, hemoptysis,
depression, OSA, lymphedema, psoriasis who presents with
worsening shortness of breath from home. He states that two
weeks ago, he noticed onset of dyspnea initially on exertion and
eventually also with sitting. He felt some nasal congestion so
self-medicated with Mucinex. One week ago, he noticed paroxysmal
nocturnal dyspnea even though he uses CPAP, up to every 1.5
hours. The patient also endorses nausea, no vomiting with
abdominal pain (deep, achy, in the middle of his stomach, not
postprandial), increased abdominal girth and ?night sweats X5
days. The patient also reports decreased urine output at home,
with urination twice in the last two days. Denied chest pain,
pleuritic chest pain. Denies cough, sputum, fevers at home
although ?night sweats recently. No hemoptysis.
.
In the ED, initial vs were: T97.0 P130 BP122/palp R40 O2 sat 97%
on NRB. Appeared to be working hard to breath. Patient was given
aspirin 325mg, Levofloxacin 750mg IV, Ceftriaxone 1 gram IV.
Reportedly en route with EMS, patient was reported to be in
atrial fibrillation with RVR (HR130s). Continues to be
tachycardic in the 100s but tolerating bipap (O2 sat 100%). BNP
elevated in [**2117**] but no priors to received Lasix 40mg IV
(naive), no nitroglycerin. 18 gauge PIV placed, attempting
second PIV. On transfer, afebrile, BP124/74, RR24, HR110, 100%
on Bipap. Foley placed with 400cc urine output.
.
On arrival to the ICU, patient states he feels "much better"
than when he came in. Mentating, able to hold conversation,
tolerating Bipap.
Past Medical History:
[**2123**]-s/p hemoptysis-IP LLL
depression: reports recent worsening with intermittent passive
SI and some preliminary plan formation; denies HI; denies any
AH/VH in the past but does report some paranoid delusions
- obstructive sleep apnea: on CPAP at home
- morbid obesity: has worsened over past year
- lymphedema
- psoriasis
Social History:
Has not left his house in >1 year due to depression and now
worsening obesity; lives with his sister. Formerly smoked 1 ppd
up until 5 yrs ago. Was a binge drinker in his 20s, but no
longer drinks. Distant marijuana and intranasal cocaine use.
Denies IVDU.
Family History:
Father with 2 [**Name2 (NI) **] in his 50s but still living in his 70s
currently. Mother with schizophrenia.
Physical Exam:
On admission:
Vitals: T: 97.2 BP: 135/90 P: 112 R: 20 O2: 100% on Bipap
General: Alert, oriented, no acute distress, tolerating BiPAP
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated and no hepatojugular reflux
although difficult to assess given neck circumference, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Irregular rhythm, tachycardic, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: Soft, non-tender, non-distended, obese, bowel sounds
present, no rebound tenderness or guarding, no organomegaly, no
shifting dullness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
edema with brawny/dusky chronic venous stasis changes on
bilateral anterior shins
Skin: Scattered psoriatic plaques on bilateral arms, middle of
abdomen with mild erythema, shiny [**Doctor Last Name **], no purulence
On discharge:
Vitals: Tc 97.6 Tmin 94.4 BP 113/68 (97-127/50-86) HR 58 (58-86)
RR 20 O2 sat 96% CPAP Weight 227kg
I/O: 0/500 over 8H; 1432/3025 over 24H
General: Alert, oriented x3, NAD
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP assessment limited by neck circumference
Lungs: Clear to auscultation, mild crackles at left base, no
wheezes
CV: Heart sounds difficult to assess given body habitus
Abdomen: Soft, non-tender, non-distended, obese, bowel sounds
present, no rebound tenderness or guarding, no organomegaly, no
shifting dullness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+
edema with brawny/dusky chronic venous stasis changes on
bilateral anterior shins
Skin: Scattered psoriatic plaques on bilateral arms, middle of
abdomen with mild erythema, shiny [**Doctor Last Name **], no purulence
Pertinent Results:
On admission:
[**2128-4-27**] 06:30PM BLOOD WBC-9.7 RBC-4.96 Hgb-15.7 Hct-45.9 MCV-93
MCH-31.7 MCHC-34.3 RDW-15.4 Plt Ct-230
[**2128-4-27**] 06:30PM BLOOD Neuts-70.3* Lymphs-23.1 Monos-3.6 Eos-1.7
Baso-1.3
[**2128-4-27**] 06:30PM BLOOD PT-17.8* PTT-27.1 INR(PT)-1.6*
[**2128-4-27**] 06:30PM BLOOD Glucose-165* UreaN-18 Creat-1.2 Na-136
K-4.8 Cl-106 HCO3-16* AnGap-19
[**2128-4-27**] 06:30PM BLOOD ALT-63* AST-81* AlkPhos-79 TotBili-1.1
[**2128-4-27**] 06:30PM BLOOD Lipase-23
[**2128-4-27**] 06:30PM BLOOD proBNP-2407*
[**2128-4-27**] 06:30PM BLOOD cTropnT-0.01
[**2128-4-27**] 06:30PM BLOOD Albumin-4.1 Calcium-9.5 Phos-4.2 Mg-1.9
[**2128-4-28**] 05:27AM BLOOD %HbA1c-6.4* eAG-137*
[**2128-4-30**] 02:58AM BLOOD Triglyc-71 HDL-25 CHOL/HD-5.8 LDLcalc-106
[**2128-4-27**] 10:02PM BLOOD TSH-2.1
[**2128-4-27**] 06:30PM BLOOD Lactate-3.8*
[**2128-4-27**] 08:40PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.025
[**2128-4-27**] 08:40PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG
[**2128-4-27**] 08:40PM URINE RBC-28* WBC-29* Bacteri-NONE Yeast-NONE
Epi-1
[**2128-4-27**] 08:40PM URINE CastHy-296*
[**2128-4-27**] 08:40PM URINE CaOxalX-MOD
[**2128-4-27**] 08:40PM URINE Mucous-FEW
[**2128-5-2**] 05:31PM URINE Hours-RANDOM UreaN-1198 Creat-159 Na-15
K-55 Cl-13
[**2128-5-2**] 05:31PM URINE Osmolal-653
On discharge:
[**2128-5-4**] 06:35AM BLOOD WBC-8.1 RBC-4.41* Hgb-13.7* Hct-41.2
MCV-94 MCH-31.2 MCHC-33.3 RDW-15.8* Plt Ct-141*
[**2128-5-4**] 06:35AM BLOOD PT-30.3* PTT-36.3* INR(PT)-3.0*
[**2128-5-4**] 06:35AM BLOOD Glucose-91 UreaN-26* Creat-1.0 Na-137
K-3.8 Cl-101 HCO3-24 AnGap-16
[**2128-5-4**] 06:35AM BLOOD ALT-359* AST-256* AlkPhos-81 TotBili-0.9
[**2128-4-28**] 05:27AM BLOOD CK-MB-4 cTropnT-<0.01
[**2128-5-4**] 06:35AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.8
[**2128-5-2**] 12:58PM BLOOD TSH-4.2
[**2128-5-2**] 12:58PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2128-5-2**] 03:47PM BLOOD Smooth-POSITIVE *
[**2128-5-2**] 03:14PM BLOOD AMA-NEGATIVE Smooth-POSITIVE *
[**2128-5-2**] 03:47PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2128-5-2**] 03:14PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2128-5-2**] 12:58PM BLOOD IgG-[**2027**]*
[**2128-4-29**] 02:27AM BLOOD Lactate-1.8
Micro:
Blood Culture, Routine (Final [**2128-5-3**]): NO GROWTH.
Legionella Urinary Antigen (Final [**2128-4-28**]): NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
URINE CULTURE (Final [**2128-4-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
ECG [**2128-4-27**]:
Atrial fibrillation with rapid ventricular response. Generalized
low voltages. Delayed R wave progression with late precordial
QRS transition is non-specific but cannot exclude possible prior
anterior wall myocardial infarction. Clinical correlation is
suggested. Since the previous tracing of [**2126-5-15**] atrial
fibrillation has replaced sinus rhythm and generalized low
voltages are now present.
Portable CXR [**2128-4-27**]:
IMPRESSION:
Limited exam. Low lung volumes. Pulmonary edema with partially
imaged bibasilar airspace opacities, which could represent
atelectasis or infection. Widening of the mediastinum may be
secondary to technique and poor inspiratory effort. Recommend
repeat PA and lateral chest radiographs when patient is able for
further assessment.
TTE [**2128-4-28**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
Overall left ventricular systolic function is severely depressed
(LVEF= 20-25 %). The right ventricular cavity is dilated with
depressed free wall contractility. The ascending aorta is mildly
dilated. The aortic valve is not well seen. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. [**Month/Day/Year **] [2+] tricuspid
regurgitation is seen. There is [**Month/Day/Year 1192**] pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Very poor image qualityl, even with the addition of
myocardial contrast. Dilated left ventricle with severe global
hypokinesis. Dilated and hypokinetic right ventricle. Mild
mitral and [**Month/Day/Year 1192**] tricuspid regurgitation. At least [**Month/Day/Year 1192**]
pulmonary artery systolic hypertension.
TEE [**2128-4-30**]:
Mild spontaneous echo contrast is seen in the body of the left
atrium. No mass/thrombus is seen in the left atrium or left
atrial appendage. The left atrial appendage emptying velocity is
borderline depressed (=0.2m/s). No spontaneous echo contrast or
thrombus is seen in the body of the right atrium or the right
atrial appendage. Normal interatrial septum with no patent
foramen ovale or atrial septal defect seen by 2D or color
Doppler. Overall left ventricular systolic function is
moderately depressed (LVEF= 35-40 %). with [**Month/Day/Year 1192**] global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild to [**Month/Day/Year 1192**] ([**1-11**]+) mitral
regurgitation is seen. Tricuspid valve is normal. There is mild
to [**Month/Day (2) 1192**] tricuspid regurgitation. Pulmonic valve is not well
seen. There is no atheroma in the descending thoracic aorta down
to 35cm from incisors. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: No thrombus in the LA/LAA or RA/RAA. Mild
spontaneous echo contrast in the body of the LA. [**Month/Day (2) **]
globally depressed LV systolic function. Mild to [**Month/Day (2) 1192**] mitral
and tricuspid regurgitation.
Portable CXR [**2128-5-2**]:
One view. Comparison with the previous study done [**2128-4-30**]. The
right chest
is not entirely included. There appears to be slight interval
improvement in pulmonary vascular congestion. Mediastinal
structures are unchanged.
IMPRESSION: Limited study demonstrating interval improvement in
vascular
congestion.
RUQ ultrasound with doppler [**2128-5-2**]:
FINDINGS: The examination is limited due to body habitus. The
liver appears echogenic. No intrahepatic bile duct dilation or
focal lesions are detected. The CBD is not visualized. The
right, left and main portal veins demonstrate proper hepatopetal
flow. The main, left and right hepatic veins demonstrate proper
hepatofugal flow. No definite thrombus is identified.
IMPRESSION: Limited study due to body habitus. Echogenic liver
denotes fatty infiltration, but more advanced disease such as
cirrhosis and fibrosis cannot be excluded. No definite portal or
hepatic venous thrombus.
Brief Hospital Course:
HOSPITAL COURSE:
Pt is a 51 year old male with history of depression, morbid
obesity and OSA who presented to the MICU with worsening dyspnea
X 14 days. Dyspnea likely [**2-11**] volume overload in the setting of
heart failure and new onset atrial fibrillation. Pt was
diuresed, and dyspnea improved.
.
# Dyspnea: Patient was volume overloaded by exam and imaging
with new Afib with RVR and Echo confirmed EF 20-25%. Likely
dyspnea was secondary to CHF exacerbation in setting of new
Afib. CXR on arrival showed pulmonary edema but could not rule
out infection. Pt also complained of night sweats and was
started empirically on levofloxacin and ceftriaxone for possible
PNA. Antibiotics were discontinued 24 hours later given lack of
fever and leukocytosis and benign chest x-ray findings. Patient
was admitted to MICU initially where he was diuresed,
transitioned from Diltiazem to metoprolol, and continued on
Aspirin. Patient was anticoagulated with heparin gtt. A TEE did
not show evidence of Clot and he was cardioverted and loaded
with amiodarone. His CPAP was titrated to 17. He was diuresed
with IV lasix which was transitioned to po lasix prior to
discharge and met goals of being net negative 1L daily. Most
recent chest x-ray prior to discharge showed improvement in
pulmonary edema. Pt was satting mid 90s on room air during the
day and mid 90s on CPAP at night.
.
# Dilated cardiomyopathy: TTE revealed dilated cardiomyopathy
with EF 20-25% and mild MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] TR. He as diuresed per
above with iv lasix which was later transitioned to po lasix.
Ins/outs were closely monitored and pt was meeting goal of net
negative 1L daily. Lasix was briefly held one day as his Cr
rose to 1.4 but restarted when Cr downtrended to baseline. He
was discharged on 40mg oral lasix; Cr was 1.0 at time of
discharge. Aspirin was reduced to 81mg daily and he was started
on a small dose of lisinopril 2.5mg daily and beta blocker
(metoprolol 50mg TID).
.
# Lactate: On admission, lactate was elevated at 3.8, concerning
for early sepsis/cellular breakdown vs. ongoing hypoxia. Lactate
improved to 1.8 with diuresis and rate control.
.
# Atrial fibrillation with RVR: Pt presented to ED with HR 130s
and was found to have new atrial fibrillation with RVR.
Multiple triggers included possible CHF, obesity, hypoxia,
general catecholinergic process of being ill. The possibility
of pulmonary embolism was considered. However, CTA could not
completed [**2-11**] body habitus. Rates were controlled initially
with diltiazem and later with metoprolol. Digoxin was briefly
added as uptitration of beta blockers were limited by low blood
pressures. Blood pressures ranged systolic 90s to 120s
throughout hospital stay. He was placed on a heparin gtt with
coumadin given his afib in the setting of poor EF. He underwent
TEE with cardioversion on [**2128-4-30**]. After the procedure he was
amiodarone loaded and started on amiodarone gtt with plans to
start po amiodarone 400mg daily. Digoxin was discontinued. On
[**2128-5-2**], LFTs rose ten-fold and amiodarone was discontinued.
Rates were controlled in 50s-70s throughout hospital admission.
Pt was in sinus rhythm prior to discharge. His coumadin was
held briefly when INR rose to 4.1 and heparin gtt was
discontinued when he remained supratherapeutic the following
day. INR was 3.0 on day of discharge and he was discharged on
3mg po warfarin with instructions for close monitoring of INR at
LTAC.
.
# Transaminitis: LFTs on admission were elevated in the 70s.
This was attributed to likely fatty liver. On [**2128-5-2**], LFTs
rose dramatically, ALT 465, AST 732. Amiodarone was
discontinued as this medication can cause transaminitis. RUQ
ultrasound showed likely fatty liver but was otherwise
unremarkable. Hepatitis serologies were negative. Anti-smooth
muscle antibody was mildly positive but other markers of
autoimmune hepatitis were negative. Hepatology consult was
initiated and felt that transaminitis was most likely due to
poor perfusion given pt's low blood pressures (systolic 90s to
120s at baseline) as well as severe CHF with EF 25%. LFTs
downtrended to ALT 359, AST 256 by time of discharge. Bilirubin
was normal; INR increased to 4.1 (while pt was on coumadin) and
downtrended to 3.0 by time of discharge. Of note, his effexor
dose of 225mg daily was reduced to 150mg daily due to elevated
LFTs.
.
# Abdominal pain: Pt complained of increasing abdominal girth
and discomfort on admission. On exam, he had no tenderness to
palpation. He endorsed constipation, which likely was causing
the discomfort. He was able to have BMs and abdominal pain
resolved.
.
# Obstructive Sleep Apnea: On CPAP machine at home. While in
MICU, respiratory therapy titrated settings to 17cm/h20 with 3L
O2. He had some mild blood tinged nasal discharge, likely from
nasal prongs of CPAP causing dryness. He was given nasal saline
spray.
.
# Hemoptysis: Pt with history of hemoptysis in [**2123**] and [**2126**]
secondary to AVM that was intervened upon. He had mildly blood
tinged sputum while in the ICU as he was on heparin gtt and
coumadin for his afib. Again, possiblity of PE was entertained;
however, pt's body habitus could not accomodate CTA. Blood
tinged sputum resolved without intervention.
.
# Psoriasis: Stable, improved since [**2126**] with a cream that he
could not recall. He was given clobetasol and lactic acid
creams.
.
# Depression: Pt reported depression was stable with no SI/HI
recently. He reported that he had not left his home for several
months and that he feared going out in public. He was seen by
psychiatry while he was in the hospital; no additional
medications were recommended as pt reported depression was
stable. He will benefit from outpatient psych. He was also
seen by social work for further support. His effexor dose was
decreased to 150mg daily given his transaminitis.
.
# Weight loss/Hyperglycemia: Pt with morbid obesity; Weight
>550lbs, BMI >70. A1c was elevated to 6.4; pt may benefit from
metformin as outpatient. Pt will need outpatient follow-up to
monitor for onset of diabetes as well as for possible
hyperlipidemia. LDL was 106. Statin was not initiated during
hospital stay as pt had rising LFTs. Nutrition consult was
obtained for weight loss strategies while he was in the
hospital. He will benefit from outpatient weight loss clinic.
Medications on Admission:
Aspirin 325mg daily
Effexor ER 225mg daily
Multivitamin daily
Omega 3-Fish Oil 1000-5 daily
Vitamin D 400 units daily
Nonsteroidal "Cream" for psoriasis and lower extremity venous
stasis changes
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-11**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for irritation.
6. clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
7. ammonium lactate 12 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
8. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
10. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. venlafaxine 150 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for [**Hospital 70232**] Medical Care
Discharge Diagnosis:
Primary:
Dilated Cardiomyopathy
Atrial fibrillation, s/p cardioversion
Secondary:
Morbid obesity
Depression
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 in the hospital. You were
admitted with shortness of breath and found to have heart
failure and an irregular heart rhythm. Fluid was removed with
medications and your breathing improved. For your heart rhythm,
you underwent a cardioversion and your heart rate was controlled
with a medication. You were also started on a blood thinner
because irregular heart rhythms can cause strokes. Your
hemoglobin A1c is at 6.4, which is a marker for diabetes, shows
a pre-diabetic state. You will likely benefit from starting on
Metformin once your liver function stabilize.
.
Of note, you had elevation in your liver enzymes while you were
in the hospital. This is likely due to your heart failure that
results in poor blood flow to the liver. Medications that may
be toxic to the liver were discontinued.
The following medications were changed:
1) START Lasix 40mg by mouth daily
2) START coumadin 3mg daily (you will need close monitoring of
the level of the blood thinner; you will need to be restarted on
an IV heparin drip if levels drop below therapeutic range)
3) START lisinopril 2.5mg daily
4) Aspirin was REDUCED to 81mg daily
5) START metoprolol 50mg three times a day which may be able to
change to the extended release once you are discharge home
6) Venlafaxine was REDUCED to 150mg daily because your liver
enzymes were elevated
7) START Clobetasol and lactic acid creams for your psoriasis
Followup Instructions:
You have the following appointment scheduled for you. Please
schedule an appointment with your current primary care doctor as
soon as you leave the rehabilitation facility. He/she will then
help you transfer your care to a [**Hospital1 18**] provider if this is what
you would like. Please have your primary care doctor refer you
to psychiatry as well as gastroenterology clinic to monitor your
liver tests. We have also recommended that you have a
consultation with the obesity clinic at [**Hospital1 2177**]. The phone number
for the [**Hospital1 2177**] obesity clinic referral is [**Telephone/Fax (1) **].
Department: CARDIAC SERVICES
When: FRIDAY [**2128-5-21**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2128-5-4**]
|
[
"51881",
"4280",
"42731",
"32723",
"311"
] |
Admission Date: [**2118-3-28**] Discharge Date: [**2118-3-31**]
Date of Birth: [**2053-11-10**] Sex: F
Service: MEDICINE
Allergies:
Zosyn / ceftriaxone
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
slurred speech, left sided weakness
Major Surgical or Invasive Procedure:
endotracheal intubation and removal
History of Present Illness:
64F with hx Multiple Sclerosis with chronic foley catheter, PVD,
diplegia of lower extremities, presenting with abrupt change in
mental status noted by staff at nursing home around 9am,
including increased slurred speech, L sided weakness today as
well as episode of emesis en route by EMS. Patient had received
AM meds at nursing home, at which time she was noted to be at
baseline blood pressure and mental status. Soon afterwards, she
complained to another staff member that she was hot and wanted a
drink; when nurse returned with a drink, she was more lethargic
with elevated BP 180/90. In the ambulance, patient was noted to
not be withdrawing to pain on the left side.
Of note, per nursing home staff, patient's foley [**Last Name (un) **] has been
changed about 3 times since [**2118-3-24**] because it has either fallen
our or was noted to have increased urine sediment.
In the ED, initial vs were: 101.9 92 152/72 16 100% 4L NC. Both
eyes were deviated downwards, and patient was not following any
commands. She was agitated and had another episode of emesis in
the ED in setting of altered mental status. [**Name8 (MD) **] RN note, she
was noted to be 83% on ?room air, presenting with some
difficulty breathing. Patient was intubated for airway
protection with etomidate and succynlcholine, pretreated with
lidocaine 100mg x1 IV. ETT was initially placed in Right
Mainstem Bronchus, pulled back about 4-5cm with bilateral breath
sounds noted on exam. She dropped BPs initially on propofol, so
she was switched to midazolam and fentanyl for sedation.
Patient was previously DNR/DNI, but husband revoked this and
made her Full Code in the ED. Code Stroke was called in the ED
at 12:45pm. CTA and CT-perfusion unremarkable. On Neurology
team exam post intubation, patient was moving all extremities.
She was noted to have significant UTI and was given a dose of IV
ciprofloxacin 500mg x1. Given fever and hx of UTIs, Neurology
team suspects that symptoms were secondary to UTI rather than a
central neurologic process. Vitals in ED prior to ICU transfer
were as follows: 65 127/62 100% on AC FiO2 100% RR 15 PEEP
5.
On arrival to the MICU, patient was intubated and sedated,
appearing comfortable, unable to provide further history.
Past Medical History:
Multiple Sclerosis -- about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
- wheelchair at baseline, lives in nursing home
- has no use of her lower extremities, sometimes spastic
movements
UTI
Chronic Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-26**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C Diff
Hx of Sacral [**Name (NI) **]
LE spasticity
Hx of jaw pain -- ?TMJ, improved on Tegretol
Social History:
Lives in nursing home for last 3.5 [**Name (NI) 1686**]. Husband is HCP, lives
with one of their daughters. [**Name (NI) **] daughter married and lives
in the area. Wheelchair at baseline, dependent for transfers
and some of ADLs. Has no use of lower extremities at baseline.
Tobacco: started at age 20, quit about 15yrs ago
ETOH: social, occasional, per husband
[**Name (NI) 3264**]: none
Family History:
No family members with Multiple Sclerosis.
Physical Exam:
Admission
Vitals: T: 100.4 BP: 127/56 P: 77 R: 18 O2: 100% on FiO2 100% AC
General: intubated and sedated, no acute distress
HEENT: Sclera anicteric, pupils 1.5mm equal, sluggish, dry mm,
cannot visualize oropharynx with ETT in place
Neck: supple, JVP not elevated
Lungs: Clear to auscultation laterally, no wheezes, rales, but
soft upper airway sounds audible diffusely
CV: Regular rate and rhythm
Abdomen: mildly distended, no grimace to palpation, bowel
sounds present, no rebound tenderness or guarding
GU: foley catheter in place
Ext: warm, well perfused, pulses, no peripheral edema
Pertinent Results:
[**2118-3-28**] 09:42PM TYPE-ART PO2-148* PCO2-45 PH-7.35 TOTAL
CO2-26 BASE XS-0
[**2118-3-28**] 04:12PM LACTATE-4.1*
[**2118-3-28**] 09:42PM LACTATE-0.6
[**2118-3-28**] 04:04PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
[**2118-3-28**] 04:04PM URINE RBC->182* WBC-83* BACTERIA-NONE
YEAST-NONE EPI-<1
[**2118-3-28**] 02:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
[**2118-3-28**] 02:00PM URINE RBC-92* WBC-60* BACTERIA-MANY YEAST-NONE
EPI-0
[**2118-3-28**] 12:50PM GLUCOSE-129* UREA N-16 CREAT-0.7 SODIUM-140
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
[**2118-3-28**] 12:50PM CK(CPK)-56
[**2118-3-28**] 12:50PM CK-MB-1 cTropnT-<0.01
[**2118-3-28**] 12:50PM WBC-10.2 RBC-4.21 HGB-14.1 HCT-38.6 MCV-92
MCH-33.4* MCHC-36.4* RDW-14.2
[**2118-3-30**] 06:25AM BLOOD WBC-4.9 RBC-3.66* Hgb-11.7* Hct-35.3*
MCV-96 MCH-31.9 MCHC-33.1 RDW-14.1 Plt Ct-172
[**2118-3-30**] 06:25AM BLOOD Glucose-77 UreaN-9 Creat-0.6 Na-141 K-3.6
Cl-107 HCO3-25 AnGap-13
[**2118-3-30**] 06:25AM BLOOD ALT-19 AST-18 AlkPhos-104 TotBili-0.3
[**2118-3-31**] 07:40AM BLOOD Phos-1.6*
[**2118-3-28**] 09:42PM BLOOD Lactate-0.6
[**2118-3-28**] 4:04 pm URINE Site: CATHETER
**FINAL REPORT [**2118-3-29**]**
URINE CULTURE (Final [**2118-3-29**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
[**2118-3-28**] 4:17 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final [**2118-3-29**]):
Reported to and read back by DR. [**Last Name (STitle) **]. HEDGE ON [**2118-3-29**] AT
0635.
GRAM NEGATIVE ROD(S).
[**2118-3-29**] 10:45 am BLOOD CULTURE x 2 Source: Venipuncture.
Blood Culture, Routine (Pending):
[**2118-3-30**]: ct abdomen/pelvis with contrast
IMPRESSION:
1. No evidence of intra-abdominal source for the patient's
bacteremia.
2. Essentially normal abdomen and pelvic CT.
Brief Hospital Course:
64F with hx of Multiple Sclerosis, chronic indwelling foley,
presenting with altered mental status, including slurred speech
and temporary left-sided weakness, found to have UTI, hypoxia,
intubated after emesis x2 in setting of altered mental status.
Altered Mental Status, urinary tract infection based on + u/a
but culture with mixed colonization, e coli bacteremia:
Patient was noted to have altered mental status in addition to
new Left-sided arm weakness and worsening of baseline slurred
speech on presentation to EMS and in ED. On Neurology
examination post-intubation, patient was moving both upper
extremities spontaneously, and CT Head and Neck Perfusion showed
no acute process. Neurology team felt that symptoms likely
represented delirium in setting of UTI and not likely central
process. No known stroke history. Patient does have hx of
multiple sclerosis, so UTI likely exacerbated multiple sclerosis
symptoms. Patient had negative cardiac enzymes and UTI was
treated. She was extubated on [**3-29**] without complication. Her
mental status after extubation was at baseline. Neurologic
symptoms improved with treatment of infection.
E coli bacteremia: Blood cultures grew E coli so Meropenem was
added to Cipro morning of [**3-29**]. Ciprofloxacin had been started
in the ED. Surveillance blood cultures were sent. Surveillance
cultures negative, E coli grew from +BCx and was ESBL. She will
require an additional 11 DAYS OF MEROPENEM FOR A TOTAL 14 DAY
COURSE, LAST DAY OF ANTIBIOTICS SHOULD BE [**2118-4-11**]. CT of the
abdomen / pelvis done to search for other cause of bacteremia
given that the u/a had mixed flora, this was negative for any
acute intraabdominal findings. In addition LFTs were normal
making a biliary source unlikely. Foley was replaced in ED as
the most likely source. Lactate elevated to 4.1 in ED which
decreased to 0.6.
Hypoxia
Patient intubated in ED to protect airway due to emesis in
setting of altered mental status. She was reportedly not having
any respiratory symptoms in the ED, though nursing report shows
O2sat of 83% prior to intubation. Patient was extubated on [**3-29**]
without complication.
Code: Full Code (confirmed with family in ED and on arrival to
MICU)
Patient was DNR/DNI previously, but husband revoked it in the
[**Name (NI) **], [**First Name3 (LF) **] she is now Full Code. PCP was emailed with this new
status.
Communication: Husband HCP = [**Name (NI) **] [**Name (NI) **]
Medications on Admission:
Simvastatin 20mg at bedtime
Tegretol XR 100mg - 3 tabs [**Hospital1 **] ;
Carbamazepine 1000mg daily at 12 noon
cyclobenzaprine 10mg [**Hospital1 **]
baclofen 5mg [**Hospital1 **]
Copaxone 20mg/ml 20mg daily
OsCal 500 1250mg daily
alendronate 70mg weekly
citalopram 40mg daily
Aricept 10mg at bedtime
trazodone 25mg QHS
cranberry supplements 2 tabs [**Hospital1 **]
Norvasc 5mg daily
aspirin 81mg daily
albuterol nebs daily in AM and prn
ipratroprium nebs daily in AM and prn
acetaminophen 650mg Q6H prn
vitamin E 400u daily
senna 8.6mg x2tabs at bedtime
multivitamin daily
potassium chloride 20meq daily
fleet enema MWF evenings
docusate 100mg [**Hospital1 **]
oyster [**Doctor First Name **] 500mg daily
Flovent HFA 110mg 2x daily
.
Allergies: Zosyn/Ceftriaxone --> bad rash while on both of
these medications, unclear which is the offender
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
2. carbamazepine 100 mg Tablet Extended Release 12 hr Sig: Three
(3) Tablet Extended Release 12 hr PO BID (2 times a day).
3. carbamazepine 200 mg Tablet Sig: Five (5) Tablet PO once a
day: at noon.
4. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. baclofen 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).
6. Copaxone 20 mg Kit Sig: Twenty (20) mg Subcutaneous once a
day.
7. Os-Cal 500 + D Oral
8. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime.
12. cranberry Oral
13. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation once a day: qam and
prn.
16. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation once a day: qam and prn.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
18. vitamin E Oral
19. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
20. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
21. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
q mon, wed, fri.
22. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
23. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
24. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 11 days.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House Rehab & Nursing Center
Discharge Diagnosis:
Primary Diagnosis:
E coli bacteremia
Urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the hospital with a severe blood stream
infection which was caused by a severe urinary tract infection.
You will need antibiotics IV for the next 11 days for a total 2
week course. No other medication adjustments have been made.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of your discharge
from the hospital: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 608**]
|
[
"5990",
"496",
"2720"
] |
Admission Date: [**2133-12-11**] Discharge Date: [**2133-12-15**]
Date of Birth: [**2059-2-23**] Sex: M
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 74-year-old male from
[**State 531**] referred to Dr. [**First Name (STitle) 2031**] for cardiac consultation.
The patient denied any history of myocardial infarction or
prior cardiac catheterizations. He stated that for several
years he has had on and off mild chest discomfort or aching
in his chest that seemed to occur with exertion. The patient
had ETT done in [**State 531**] which revealed 1.0-1.5 mm ST segment
depression in leads V5 and V6. Cardiac catheterization
revealed significant coronary artery disease.
PAST MEDICAL HISTORY: Mitral valve prolapse. Depression.
Hiatal hernia. History of bronchitis.
PAST SURGICAL HISTORY: Cholecystectomy. Hernia repair.
Tonsillectomy.
MEDICATIONS: Aspirin 81 mg q.d., Tylenol 50 mg q.d.,
................. 1000 mg q.d., Lescol 40 mg q.d., Norvasc 5
mg q.d., Amitriptyline 10 mg q.h.s.
PHYSICAL EXAMINATION: Vital signs: The patient was
afebrile. Vitals signs stable. Lungs: Clear to
auscultation bilaterally. Heart: Regular, rate and rhythm.
Abdomen: Benign scar. Soft, nontender, nondistended.
Extremities: No edema. No varicosities.
LABORATORY DATA: On admission sodium was 141, potassium 4.1,
chloride 100, bicarb 31, BUN 12, creatinine 0.8, glucose 120;
white count 8.1, hematocrit 42.8.
HOSPITAL COURSE: The patient went to the Operating Room on
[**2133-12-11**], for coronary artery bypass grafting times
four. The LIMA went to the left anterior descending, and the
saphenous vein graft went to OM1, diagonal 1, posterior
descending artery. The patient was transferred to the
Intensive Care Unit and rapidly extubated. He was atrial
paced with bradycardia. His Neo-Synephrine drip was
appropriately weaned on postoperative day #1. On
postoperative day #2, he was tolerating p.o. intake well, and
he was transferred to the floor. Bypass times from his
surgery was 77 min, XT was 67 min.
On postoperative day #2, his mediastinal and pleural tubes
were removed. A .................. chest x-ray revealed no
pneumothorax. On postoperative day #3, his atrial and
ventricular wires were removed, and the patient was in normal
sinus rhythm. His Foley catheter was also removed. On
postoperative day #4, the patient achieved level IV activity.
His central venous line was also discontinued.
On exam his sternum was stable and revealed no drainage, and
his saphenous vein graft sites were clean, dry, and intact.
DISCHARGE LABORATORY DATA: White count 10.3, hematocrit
26.4, platelet count 270; sodium 135, potassium 4.9, chloride
99, bicarb 30, BUN 13, creatinine 0.6, glucose 128.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Lopressor 25 mg b.i.d., Lasix 20 mg
b.i.d. x 7 days, KCl 20 mg x 7 days, Colace 100 mg b.i.d.,
Ecotrin Aspirin 325 mg q.d., Lipitor 20 mg q.d., Tylenol #3
[**12-9**] tab p.o. q.4-6 hours p.r.n.
DISCHARGE STATUS: Home.
FOLLOW-UP: The patient will follow-up with his primary care
physician and cardiologist in three weeks. He will be
followed by Dr. [**Last Name (STitle) **] in four weeks.
DISCHARGE INSTRUCTIONS: No driving for one month. No
lifting of greater than 10 lbs for approximately six weeks.
DISCHARGE DIAGNOSIS: Status post coronary artery bypass
grafting times four.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 1308**]
MEDQUIST36
D: [**2133-12-15**] 13:13
T: [**2133-12-15**] 13:12
JOB#: [**Job Number 14627**]
|
[
"41401",
"42789",
"4019",
"2720"
] |
Admission Date: [**2188-1-18**] Discharge Date: [**2188-2-5**]
Date of Birth: [**2129-11-4**] Sex: M
Service: HEPATOBILIARY SURGERY SERVICE
ADMISSION DIAGNOSIS: Bile duct stricture.
HISTORY OF PRESENT ILLNESS: Patient is a 58-year-old male
past medical history for Hodgkin lymphoma treated in the late
[**2151**] that is in remission. Status post radiation therapy,
complicated by significant brachial plexus injury rendering
his right upper extremity, which is illicitly nonfunctional.
The patient complained of abdominal discomfort that was
consistent with biliary colic in [**2187-10-2**], underwent
an ultrasound, which demonstrated an intra and extrahepatic
biliary ductal diltation prompting an ERCP. ERCP was
performed in [**2187-12-2**] that demonstrated findings
consistent with a Klatskin type tumor and/or stricture
located at the junction of the right and left hepatic ducts.
CT of the abdomen was performed demonstrating a mass located
in the hilum abutting the cystic and the common and hepatic
duct with intrahepatic ductal diltation. Findings were
consistent with cholangiocarcinoma. Also noted was abdominal
lymphadenopathy with no evidence of hepatic disease, no
intrahepatic metastases. Patient underwent brushings at the
time of the ERCP and there was no evidence of malignancy
observed.
Complains of significant pruritus and back pain. Weight loss
of 16 pounds over several weeks. Complains of dark urine. No
chest pain. No shortness of breath. No nausea, vomiting,
fever, chills.
PAST MEDICAL HISTORY: Significant for hypertension,
hyperthyroidism, Hodgkin lymphoma status post radiation
treatments, history of questionable pancreatitis and duodenal
ulcer.
PAST SURGICAL HISTORY: Splenectomy and appendectomy.
MEDICATIONS: On admission HCTZ and Synthroid 150 every day.
ALLERGIES: Bacitracin and penicillin.
PHYSICAL EXAMINATION: Temperature is 98.4. Blood pressure
178/54. Pulse 84. Respirations 16. Height 5'[**91**]". Weight 142.
HEENT pupils equal, round and react to light. EOMs are full.
Tongue midline. No exudates. Lungs clear to auscultation
bilaterally. Abdomen positive bowel sounds, soft, nontender,
no hepatomegaly. Incisions are well healed. No hernias
appreciated. Extremities no CCE.
HOSPITAL COURSE: The patient was admitted on [**2188-1-18**] and patient was operated by Drs. [**First Name (STitle) **] and [**Name5 (PTitle) **] for a
cholecystectomy, common bile duct excision, septoplasty, Roux-
en-Y hepaticojejunostomy, liver biopsy. Please see operative
note from [**2188-1-18**] for more details of the surgery.
Postoperatively, patient went to PACU and then eventually to
the CICU. Patient was intubated on Propofol. Patient received
fluid boluses for low blood pressure. Patient had 2 JP drains
in place. Patient was placed on meropenem, vancomycin and
fluconazole postoperatively. MRS [**Last Name (STitle) 15570**] was performed with a
rectal swab demonstrating staph aureus coag positive. On
[**2188-1-22**], patient had a bronchioloalveolar lavage.
It was noted on chest x-ray that patient had a right main
stem bronchus with narrowing correlated to secretions that
was demonstrated on recent CAT scan on [**1-16**]. On
[**2188-1-22**], the patient had bronchoalveolar lavage
demonstrating staph aureus coag positive. ID was consulted.
Urine culture, blood cultures were obtained on [**2188-1-22**]. Urine culture demonstrate no growth. Blood cultures
demonstrated no growth. On [**2188-1-24**] the patient had
a post pyloric feeding tube placed for nutrition. Patient
continued being ventilated. Levophed was being weaned off.
Nutritional services were consulted for tube feed
recommendations. Patient continued on Vancomycin and
meropenem. Patient was written for Lasix for diuresis.
Patient was eventually extubated. Physical therapy was
consulted. Patient still had JP drain in place and biliary
tube 1 and biliary tube 2.
The patient was continued on antibiotics for MSSA pneumonia
and polymicrobial cholangitis. On [**2188-1-28**], the
patient had a cholangiogram that demonstrated no evidence of
obstruction, extravasation or anastomotic stricture. Labs on
[**2188-1-29**] were 21.3, hematocrit 29.7, platelets 593,
sodium 138, 4.0, 97, 37, 20, 0.5, glucose 111, ALT is 28, AST
46, alkaline phosphatase 66, total bili is 0.3. [**2188-1-24**] bile fluid was sent for gram stain and culture
demonstrating staph aureus coag positive [**Female First Name (un) **] albicans. JP
drain was removed. Diet was advanced. Calorie counts were
obtained. The patient was transferred to the floor on [**2188-1-30**]. Physical therapy continued working with patient.
Patient received Boost t.i.d. On the floor patient received
aggressive chest PT, pulmonary toilet, calorie counts,
bedside swallow to evaluate if he had any problems
swallowing. His abdomen with 3 cm lateral wall defect,
getting wet to dry dressings. Speech had seen him on [**2188-2-1**] demonstrating that he has significant dysphagia at the
bedside. Speech pathologist suggested him to be NPO pending a
video swallow. Barium swallow was notable for a weak tongue,
dysarthria, right Horner and severe dysphagia. Etiology is
unclear, but is likely multifactorial and felt that he should
be NPO and continue tube feeds. It was strongly suggested by
the speech pathologist that neurology see the patient for
dysphagia and other findings including Horner syndrome. They
felt that patient should be NPO and time course of recovery
of swallow is unclear.
Physical therapy continued to work with patient. Calorie
counts from the [**2188-2-5**] demonstrated 370 calories and 9
grams of protein, but food was supplemented with tube feeds.
All drains have been removed. Continues to be afebrile. Vital
signs stable and the patient has been walking around with
physical therapy, done remarkably well. On [**2188-2-5**]
postop day 18, no significant overnight events. Afebrile.
Vital signs stable. Good Is and Os. Abdomen with bowel sounds
soft, nontender, nondistended. Repeat barium swallow is being
performed today. He is being screened by rehab and hopefully
will have a bed very soon. He will be going home on the
following medications, albuterol inhalers 6 puffs every 4
hours p.r.n., Clobetasol propionate 0.05% cream one
application b.i.d. to effected areas. Heparin subQ 5000
b.i.d., insulin sliding scale, levothyroxine 150 mg every
day, Protonix 40 mg every 24. Patient should call [**Telephone/Fax (1) 30335**] if any fevers, chills, nausea, vomiting, inability to
take medications, any abdominal pain, jaundice, incision
redness/bleeding or purulent discharge, patient to unable eat
or drink or any increased swelling in legs, please call
immediately. Patient is to follow up with Dr. [**Last Name (STitle) **], please
call [**Telephone/Fax (1) 673**] for an appointment.
FINAL DIAGNOSIS: A 58-year-old male status post Roux-en-Y
hepaticojejunostomy for benign stricture on [**2188-1-28**].
SECONDARY DIAGNOSES: Dysphagia.
Path results came back on [**2188-1-18**] from the surgery
demonstrating the lymph node shows no malignancies. The
common bile duct distal margin shows acute and chronic
inflammation and fibrosis. Common bile cyst duct and common
bile duct demonstrate acute and chronic inflammation and
fibrosis. Gallbladder with chronic cholecystitis, 2 lymph
nodes that were not malignant. The septum of bifurcation
demonstrated fibrous and granulation tissue with chronic
inflammation and fibrosis and liver needle core biopsy
demonstrated mild portal inflammation with focal bile duct
proliferation, 2 minimal macrovesicular steatosis without
intracellular hyalin or neutrophils. Also trigone stain
increased portal fibrosis, no bridging and iron stain no
stainable iron.
Patient will go to rehab on tube feeds at this point. He will
be going to rehab on Impact with fiber at 3/4 strength, goal
rate is 110 milliliters per hour. Please check residuals
every 4 hours and hold for residuals of greater than 100
milliliters. Also flush with 30 cc of water ever 4 hours.
Patient should receive physical therapy, occupational therapy
in the rehab setting. Also make sure he has pulmonary toilet.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **]
Dictated By:[**Last Name (NamePattern1) 4835**]
MEDQUIST36
D: [**2188-2-5**] 10:26:22
T: [**2188-2-5**] 11:22:28
Job#: [**Job Number 101653**]
|
[
"496",
"51881",
"5119",
"5180",
"486",
"5070"
] |
Admission Date: [**2136-9-28**] Discharge Date: [**2136-10-8**]
Date of Birth: [**2069-3-21**] Sex: M
Service: CSU
CHIEF COMPLAINT: A 67-year-old patient of Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 51437**] referred for outpatient cardiac cath due to recent
exertional symptoms and an abnormal EKG.
HISTORY OF PRESENT ILLNESS: A 67-year-old man who has 6-week
history of exertional chest pain. He and his wife teach line
dancing on a daily basis, and he noticed a new sharp
bilateral shoulder discomfort that radiates down the left
arm. The pain is associated with shortness of breath and the
sensation that his heart is pounding. The symptoms resolve
with rest. He has no nocturnal symptoms or rest symptoms.
He was recently seen by Dr. [**Last Name (STitle) 51437**], where he was told that
his EKG was abnormal. He has not had any recent stress test
or echo.
PAST MEDICAL HISTORY: Hyperlipidemia.
AAA which measures 4.4 cm by CT in [**2136-4-26**].
Arthritis of the left knee.
Nocturnal leg cramps.
Prostate CA, status post right radical prostatectomy done in
[**2135-7-26**].
Tonsillectomy.
Remote rectal fistula repair.
MEDICATIONS PRIOR TO ADMISSION:
1. Glucosamine 1 tablet q.i.d.
2. Salmon oil 2 tablets b.i.d.
3. Aspirin 325 q.d.
4. Cromolyn 1 q.i.d.
5. Ginkgo biloba 2 q.d.
6. [**Male First Name (un) 4542**] jelly 1 q.d.
ALLERGIES: Include penicillin which causes throat and leg
swelling; statin drugs which cause muscle aches; Klonopin
which causes headache; chocolate cake which causes gout; and
red yeast rice which causes muscle aches.
LAB DATA AT ADMISSION: White count 7.7, hematocrit 41.8,
platelets 290, INR 1.0. Sodium 141, potassium 4.8, chloride
104, CO2 28, BUN 16, creatinine 0.9.
SOCIAL HISTORY: Retired maintenance worker and dance
teacher. Tobacco - four packs per day x 20 years, quit 20
years ago. Alcohol - six drinks a day for 20 years, quit 10
years ago. Denies any recreational drug history.
FAMILY HISTORY: Parents died of natural causes. No history
of CAD or stroke in the family.
PHYSICAL EXAM: Blood pressure 127/70, heart rate 67,
respiratory rate 12, O2 sat 97 percent on room air. GENERAL:
Pleasant male, lying in bed with no acute distress, alert and
oriented x 3. HEENT: Pupils equally round and reactive to
light. Extraocular movements intact. Anicteric. Mucous
membranes moist. Neck supple with no JVD, no
lymphadenopathy. Positive right carotid bruit.
Cardiovascular: Regular rate and rhythm, S1, S2, with no
murmurs. Chest clear to auscultation. Abdomen soft,
nontender, nondistended with positive bowel sounds.
Extremities: Warm, and well-perfused with no clubbing,
cyanosis or edema.
LABS: EKG shows a sinus rhythm at 67 with normal axis,
normal intervals, and [**Street Address(2) 4793**] elevations in V1 and 2, and T
wave inversions in V2 through 6, as well as lead I and AVL.
Cardiac catheterization was done on [**9-28**] that showed
an EF of 55 percent, left main 30-40 percent disease, LAD 90
percent, left circumflex 30 percent, and RCA with a total
occlusion. UA was negative.
HOSPITAL COURSE: Following cardiac cath, the patient was
seen by cardiothoracic surgery and accepted for coronary
artery bypass grafting. On [**10-2**], the patient was
brought to the operating room (please see the OR report for
full details). In summary, the patient had a CABG x 3 with a
LIMA to the LAD, saphenous vein graft to the RCA, saphenous
vein graft to OM. His bypass time was 73 minutes with a
crossclamp time of 61 minutes. He tolerated the operation
well and was transferred from the operating room to the
Cardiothoracic Intensive Care Unit. At the time of transfer,
the patient was A-paced at 80 beats per minute, with a mean
arterial pressure of 76, and a CVP of 8. He had propofol at
20 mcg/kg/min.
The patient did well in the immediate postoperative period.
His anesthesia was reversed. He was weaned from the
ventilator and successfully extubated. He remained
hemodynamically stable throughout the operative day.
On postoperative day 1, the patient continued to be
hemodynamically stable, however, requiring only low dose Neo-
Synephrine infusion to maintain an adequate blood pressure.
Additionally, the patient had a moderate amount of chest tube
drainage and required several units of packed red blood
cells.
On postoperative day 2, the patient continued to be
hemodynamically stable. He was weaned from his Neo-
Synephrine drip. His chest tube drainage had subsided
substantially. He was begun on beta blockade, as well as
diuretics. Additionally, the patient was noted to have short
runs of atrial fibrillation for which he was started on
amiodarone. Additionally, the patient was transferred from
the Cardiothoracic Intensive Care Unit to Far-2 for
continuing postoperative care and cardiac rehabilitation.
On postoperative day 3, the patient continued to have short
runs of atrial fibrillation. He was bolused with IV
amiodarone and continued on oral doses as well. His chest
tubes were removed, as were his Foley catheter and his
central venous access and his temporary pacing wires. With
the assistance of the nursing staff and physical therapy,
over the next several days the patient's activity level was
increased, and on postoperative day 6, it was decided that
the patient was stable and ready to be discharged to home.
PHYSICAL EXAM ON DISCHARGE: Vital signs: Temperature 98.2,
heart rate 77/sinus rhythm, blood pressure 104/60,
respiratory rate 18, O2 sat 93 percent on room air.
Neurologically, alert and oriented x 3. Moves all
extremities. Following commands. Respiratory clear to
auscultation bilaterally. Cardiac: regular rate and rhythm,
S1, S2, with no murmurs. Sternum is stable. Incision with
staples, open to air, clean and dry. Abdomen soft,
nontender, nondistended. Extremities: Warm and well-
perfused with no edema. Right saphenous vein graft harvest
site with Steri-Strips, open to air, clean and dry.
CONDITION AT DISCHARGE: Good. He is to be discharged home
with visiting nurses.
DISCHARGE DIAGNOSES: Coronary artery disease status post
coronary artery bypass grafting x 3 with a left internal
mammary artery to the left anterior descending, saphenous
vein graft to the right coronary artery, and saphenous vein
graft to obtuse marginal.
Hyperlipidemia.
Abdominal aortic aneurysm measuring 4x4 cm by CAT scan.
Arthritis.
Prostate cancer status post prostatectomy.
FOLLOW UP: The patient is to follow-up in the [**Hospital 409**] Clinic
in 2 weeks, follow-up with Dr. [**Last Name (STitle) 30224**] [**Name (STitle) **] in [**3-29**] weeks,
follow-up with Dr. [**Last Name (STitle) 51437**] in [**3-29**] weeks, and follow-up with
Dr. [**Last Name (STitle) **] in 4 weeks.
DISCHARGE MEDICATIONS:
1. Niferex 150 mg q.d. x 1 month.
2. Ascorbic acid 500 mg b.i.d. x 1 month.
3. Amiodarone 400 mg q.d. x 1 week and then 200 mg q.d. x 1
month.
4. Lasix 20 mg q.d. x 2 weeks.
5. Metoprolol 25 mg b.i.d.
6. Colace 100 mg b.i.d.
7. Aspirin 325 q.d.
8. Plavix 75 q.d. x 3 months.
9.
Hydromorphone 2 mg q. [**3-29**] p.r.n.
10.Vioxx 25 mg q.d. p.r.n.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2136-10-8**] 12:06:42
T: [**2136-10-8**] 15:33:02
Job#: [**Job Number 56923**]
|
[
"41401",
"42731",
"4019",
"2720",
"V1582"
] |
Admission Date: [**2109-8-28**] Discharge Date: [**2109-9-18**]
(anticipated)
Date of Birth: [**2058-4-29**] Sex: F
Service: CCU
HOSPITAL COURSE PRIOR TO TRANSFER TO CARDIAC CARE UNIT: Upon
presentation to the cardiac care unit team, Ms. [**Known lastname **] was a
51-year-old woman who had been admitted to the vascular
surgery service on [**2109-8-28**] for a left heel ulcer. She
underwent a femoral to posterior tibial bypass on [**2109-9-2**].
Her postoperative course was complicated by pulmonary edema
and decreased urine output. Her CK and troponin levels were
elevated with a troponin of greater than 40. Her peak first
CK was measured at 305. The patient received a cardiac
catheterization on [**2109-9-4**] and had a left anterior
descending artery stent placed. Her other coronary arteries
were normal during the cardiac catheterization.
Since that time, the patient had remained intubated with a
Swan catheter in the surgical intensive care unit. An
echocardiogram on [**2109-9-5**] showed an ejection fraction of 35%
with apical, septal and anterior hypokinesis. The patient
has required inotropic support, dopamine and Levophed. She
also had decreased urine output and elevated creatinine. She
was transferred to the cardiac care unit for further
evaluation and treatment.
PAST MEDICAL HISTORY: The past medical history was
significant for diabetes mellitus type 1,
hypercholesterolemia, hypothyroidism, coronary artery
disease, pernicious anemia, status post appendectomy and
status post cesarean section.
MEDICATIONS: Her outpatient medications had been Avapro,
vitamin B-12, Cardizem, calcium with vitamin D, colchicine,
Diamox, folate, potassium chloride, Lasix, Lipitor,
Neurontin, nitroglycerin patch, Plavix, Prevacid, Epogen,
cisapride, magnesium, Synthroid and Xanax. She was also on
aspirin, Zantac, subcutaneous heparin, levofloxacin, heparin
drip, Levophed and dopamine drips and Dilaudid upon
presentation to the cardiac care unit.
SOCIAL HISTORY: The social history was negative for tobacco
use, alcohol use or recreational drug use.
PHYSICAL EXAMINATION: Vital signs showed a temperature of
37.7??????C, a blood pressure of 115/40, a pulse of 82,
respirations of 13 and an oxygen saturation of 99% on assist
control ventilation with a rate of 11, tidal volume of 700,
FiO2 of 60% and PEEP of 10. In general, the patient was
intubated and sedated. The pupils were equal, round and
reactive to light and accommodation. There were scattered
rhonchi on chest examination. The heart was a regular rate
and rhythm with a II/VI systolic ejection murmur at the left
upper sternal border. The abdomen was obese, nontender and
nondistended with normal active bowel sounds. The
extremities had 1+ edema. On neurological examination, the
patient responded to painful stimuli and remained sedated.
LABORATORY: Upon admission to the cardiac care unit, the
patient had a white blood cell count of 19,000, a hematocrit
of 30, an INR of 1.4, BUN and creatinine of 48 and 2.8, CK of
66 and troponin of greater than 50. Her arterial blood gases
upon admission to the cardiac care unit revealed a pH of
7.26, a pCO2 of 39 and a pO2 of 97 and a bicarbonate of 18.
HOSPITAL COURSE:
CARDIOPULMONARY: The patient was found to be in severe
pulmonary edema. She received multiple doses of intravenous
Lasix and diuresed approximately three liters per day over
the course of a week. She was finally extubated after three
failed trials of pressor support on [**2109-9-14**]. She was
stable for transfer to the floor on [**2109-9-15**], but no
medications were available. Therefore, she went to the floor
on [**2109-9-16**]. While in the hospital, her chest x-ray cleared
significantly. She initially presented with severe bilateral
pulmonary edema. Her chest x-ray upon transfer to the floor
revealed mild bilateral alveolar opacities.
As far as her pump was concerned, she received Lopressor,
Aldactone and Univasc for treatment of her congestive heart
failure with an ejection fraction of approximately 35%.
Regarding her coronary arteries, she had the stent placed and
received aspirin and Plavix. Niacin was started for a low
HDL. She had no issues with her rhythm. The pulmonary edema
resolved. However, the patient still had atelectasis, which
improved with ambulation and incentive spirometry.
ENDOCRINE: The patient had issues with an elevated blood
glucose; however, she was switched to her regular regimen
from home. This regimen included lente and Ultralente with
Humalog coverage and her blood glucose remained in the low
100s after this change was made on [**2109-9-16**].
PSYCHIATRY: The patient had a psychiatric consultation and
TSH and RPR were normal. B-12 and folate were still pending.
However, her mood improved significantly after she was
transferred to the floor and extubated.
DISCHARGE STATUS: The patient is currently stable.
DISPOSITION: The patient will be transferred most likely to
[**Hospital6 1293**] in [**Location (un) 1294**] or perhaps to
another rehabilitation facility, possibly on oxygen and on
the following medications: atenolol, Zantac, Lasix 80 mg
p.o. q.d., Aldactone 25 mg p.o. q.d., Norvasc 10 mg p.o.
q.d., Ambien, Univasc 30 mg p.o. q.d., aspirin, Plavix,
Neurontin, Synthroid, vitamin B-12, Nystatin swish and
swallow, Prozac, her usual regimen of lente and Ultralente
with lispro Humalog coverage and niacin 50 mg p.o. t.i.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2109-9-18**] 07:23
T: [**2109-9-18**] 08:39
JOB#: [**Job Number 35045**]
cc:[**Location (un) 35046**]
|
[
"4280",
"5849",
"0389"
] |
Admission Date: [**2143-1-2**] Discharge Date: [**2143-1-19**]
Date of Birth: [**2077-3-8**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 66-year-old woman with
a complicated medical history who was admitted to Cardiology
Service in the Coronary Care Unit with shortness of breath,
chest pain, congestive heart failure and chronic obstructive
pulmonary disease. She ruled in for a non-ST elevation
myocardial infarction with elevated cardiac enzymes and ST
depressions. She was treated medically on the Cardiology
Service with an ejection fraction of 15-20%. She had no
prior known history of coronary artery disease. She was
taken to the Cardiac Catheterization Laboratory on the 15th,
the day of admission, which showed an 80% proximal left main
lesion and a total occlusion of the right coronary artery
with wedge pressure of 35 and PA pressure of 30. Patient was
unable to lie flat and access was gained through basilic
artery and basilic vein.
PAST MEDICAL HISTORY:
1. Chronic renal insufficiency.
2. Bronchitis and chronic obstructive pulmonary disease.
3. Prior heavy alcohol abuse.
Patient was started on nitroglycerin drip in the
Catheterization Laboratory. Echocardiogram showed an
ejection fraction of 20% with inferior hypokinesis and
lateral hypokinesis and dyskinesis. Chest x-ray showed
congestive heart failure and a left-sided effusion. Patient
had an inferior aortic balloon pump placed in the Cardiac
Catheterization Laboratory. The patient was on intravenous
steroids at that time and was referred to Cardiac Surgery
after cardiac catheterization. The patient also had no prior
surgical history and no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Solu-Medrol.
2. Lasix.
3. Aspirin.
SOCIAL HISTORY: The patient did admit at that time to one
and a half packs of tobacco per day and 12 to 15 beers per
week.
PREOPERATIVE LABORATORIES: Sodium 137, potassium 3.9,
chloride 100, carbon dioxide 23, BUN 35, creatinine 1.8,
blood sugar 183. White count 18.6, hematocrit 34.5. PT
14.8, PTT 36.7 and INR of 1.5.
PHYSICAL EXAMINATION: The patient was sedated in the
Intensive Care Unit with intra-aortic balloon pump and blood
pressure of 128/68 and sinus rhythm in the 80's. PA
pressures were 42/20 at the time with an index of 4.7. The
patient was satting 94% on two liters. Her lungs were clear.
Abdomen was soft and non-tender. Her right lower extremity
was cool with no palpable or dopplerable DP or PT's. Her
left lower extremity had dopplerable PT and DP pulses.
The patient was referred to Dr. [**Last Name (STitle) 1537**] for evaluation of
coronary artery bypass graft after her non-Q wave myocardial
infarction and remained in the Coronary Care Unit. The
patient remained under the care of Dr. [**First Name (STitle) **] _____ of
Cardiology. She remained sedated in the unit. Creatinine
came down slightly to 1.7. The patient had a Swan-Ganz
placed preoperatively on the Medical Service for better
hemodynamic monitoring. Preoperative diagnoses included
cardiogenic shock and acute tubular necrosis. On the [**1-4**], the patient underwent coronary artery bypass
grafting times four by Dr. [**Last Name (STitle) 1537**] with a LIMA to the LAD, vein
graft to the PDA, vein graft to the OM1 and a vein graft to
the diagonal. The patient was transferred to the
Cardiothoracic ICU on a milrinone drip at 0.5 mcg/kg/min, a
Levophed drip at 0.07 mcg/kg/min and propofol at 20
mcg/kg/min with an intra-aortic balloon pump in place. On
postoperative day one patient remained on insulin, Levophed,
milrinone and propofol drips. She was in the 100's in sinus
rhythm with a blood pressure of 100/46. The balloon remained
at 1:1. The patient remained intubated and sedated with weak
peripheral pulses. White count was 9, hematocrit 26, BUN 40,
creatinine 1.9 with a potassium of 4.4. The plan was to try
and wean the IVP first and hopefully discontinue it and then
wean the milrinone down. The patient was transfused one unit
packed red blood cells for an hematocrit of 26. Platelet
count was 55,000. HIT panel was sent off. Levophed was
increased slightly to raise her pressure above 100 systolic
and the patient remained in critical condition in the
Intensive Care Unit. On postoperative day two the patient
was started on amiodarone at 1.0 and remained on Milrinone,
Levophed, propofol. She was also given an alcohol drip in
addition to insulin. The patient at 100 A-paced with a blood
pressure 116/60. She remained ventilated. She had coarse
bilateral breath sounds. Her abdomen was soft, non-tender,
non-distended. She did have monophasic right DP and PT
pulses. Also on postoperative day two the balloon had been
pulled out. The chest tubes remained in. The patient's
Lasix diuresis was increased to help keep her urine output
about 100 cc an hour. Her index was 2.5 so Milrinone wean
was begun. She was up 16.5 kg. The patient was also seen by
Physical Therapy for follow up. Also on postoperative day
two later in the day the patient received three cardioversion
shocks which failed. The amiodarone was re-bolused. The
patient also had poor paO2's and sputum was sent. Empiric
ceftriaxone was started for very thick sputum and a chest
x-ray was obtained. By postoperative day three, the patient
continued diuresis. Remained on amiodarone, Levophed at 0.1,
Milrinone at 0.25 as well as propofol and insulin and alcohol
drip at 0.5. The patient was also started on Plavix and
continued with intravenous Lasix. The patient remained on
ceftriaxone. Potassium was 3.6, BUN 45, creatinine 3.0 with
a white count of 10.4 and hematocrit of 29.2. The patient
was dosing vancomycin by level and it was 29.6 on that
morning. Patient remained intubated with propofol continued
on the ventilator and sedated. Sternum was stable. The
lungs were clear bilaterally with S1, S2. No murmur. The
patient remained in stable but critical condition.
Electrophysiology Fellow came by to see the patient for
consult for continuing atrial fibrillation and hepatic
dysfunction on amiodarone. They recommended decreasing the
dose but continuing the amiodarone and trying to
anticoagulate the patient if the HIT antibody was negative or
possibly using Angiomax if the patient was HIT positive and
only considering coumadization if those steps had to be
taken. In addition, liver function tests had to be followed
carefully. The patient was also seen by the Clinical
Nutrition team and the Renal Fellow on [**1-7**] for
evaluation due to continued renal failure for known baseline
creatinine of 1.5 which had risen to 3.0 on the 20th. They
suggested that with ATN secondary to her low blood pressure
and a decreased ejection fraction with some element of sepsis
that the patient had decreased systemic vascular resistance
that morning with a blood pressure of 83-136/40-60's, in that
setting there also could possibly be a pneumonia or biliary
source for the sepsis and the workup was begun to try and
determine any potential source. The patient continued on
ceftriaxone and it was recommended that Carafate be
discontinued. They said they would continue to follow. The
patient might require hemodialysis or CVDHD for volume
overloading issues. The patient was also seen by the
Hematology Fellow and they were asked to consult for the
possibility of hemolysis with a rising total bilirubin, liver
function tests and LDH. The total bilirubin on the day of
examination was 7.6 up from 5.4 the day before. The patient
had a liver ultrasound done that day. Please refer to the
final report. The patient did remain sedated and intubated.
Obviously did not respond to any verbal stimuli. In atrial
fibrillation with a pressure of 136/61 and a heart rate of
117. The patient was satting 94%. Hematology made the
recommendations. Patient was also seen by the Neurology
attending. On the day of her examination, [**1-7**], the
patient also was noted to have a sluggish left pupil and an
upgoing right toe on neuro examination by house staff. She
noted the patient's altered mental status which could be due
possibly to multiple metabolic issues such as elevated CPK's,
creatinine and being febrile versus stroke. Recommendations
were made to the Cardiothoracic team. A transesophageal
echocardiogram was performed. There was right ventricular
hypokinesis. The echocardiogram showed an ejection fraction
of approximately 20% with severe regional left ventricular
systolic dysfunction and overall systolic dysfunction was
severely depressed. There was also noted to be mobile
atheroma of the ascending aorta and in the arch and also
atheroma in the descending thoracic aorta. Please refer to
the final report. The patient had moderate mitral
regurgitation at the time and trace atrial insufficiency.
The patient again was followed by the Renal Fellow who
suggested adding in Diuril in addition to the Lasix with a
plan to try and start CVDHD shortly. The patient on the 21st
had a blood pressure of 90-130 over 50-60. She remained on
amiodarone, heparin, insulin, Levophed, Milrinone, propofol
as well as 10% alcohol drip and ceftriaxone for antibiotic
coverage. On postoperative day four the patient had received
Cardiology, Electrophysiology, Renal and Neurology consults
as well as Hematology. A head CT was negative. A right
upper quadrant ultrasound was done. A heparin drip was
started. Bicarb was given. Plavix was discontinued per
recommendations. Sputum from the 19th showed gram positive
cocci in pairs. On that morning potassium was 3.6 with a BUN
of 51 and creatinine of 2.9 down from 3 with a blood sugar of
87. The chest x-ray showed a question of ARDS versus
congestive heart failure. The patient continued on
antibiotics and continued on all the aforementioned drips
with a lactate of 1.6 on that morning. Dopplerable pulses
were heard in both extremities. There was 2+ edema. The
patient continued to be up 13 kilograms in weight. Levophed
was at 0.25 that morning and Milrinone at 0.25. Patient
remained in atrial fibrillation with a pressure of 109/50.
The patient was seen again by Nutrition and followed up by
Hematology and Renal. Hematology thought that she had a
hypoproliferative anemia, question secondary to alcohol abuse
or chronic renal insufficiency. They recommended only giving
supportive care with blood products. On the evening of the
21st the patient started CVDHD via left femoral venous
temporary catheter. The patient was also seen by the
cardiologist for follow up. The patient also was followed by
Hematology and seen daily by Electrophysiology Services and
the Renal staff. On postoperative day five the patient had a
ventricular tachycardia arrest overnight and was shocked into
sinus rhythm. CVDHD had been started. Diuril was added to
try and keep her urine output up. Hydrocortisone was also
added. The patient desatted with a tachypnea and exertion.
The patient was A-paced at 90 with a pressure of 125/58, PA
pressures of 38/21 with an index of 2.2. The patient
remained intubated and sedated. Lungs were clear
bilaterally. Sternum was stable. Abdominal examination was
benign. The plan was to try and start weaning the Levophed.
The patient had been placed on a lidocaine drip after the
ventricular tachycardia arrest and that was discontinued.
The patient continued on antibiotics and remained in critical
condition. On the 23rd the patient had recurrent and ongoing
and nonsustained ventricular tachycardia. Lidocaine was
resumed. It was thought that this was perhaps secondary to
ongoing ischemia possibly exacerbated by the pressors and
Milrinone that were required to support the patient. They
recommended considering cardiac catheterization if the
patient could tolerate it and to try and wean the Milrinone
if the index was above 2. On that morning it was 2.5.
Amiodarone and lidocaine were continued. On postoperative
day six, diuretics and TPN had been discontinued and the
lidocaine drip was restarted as previously noted. The
patient remained on heparin drip and amiodarone as well as
Levophed at 0.07 and Milrinone at 0.25. The patient remained
intubated and sedated with the examination unchanged with the
plan to try and wean the ventilator as tolerated and wean the
lidocaine as well as the Levophed which the patient was
requiring at that point. The plan was to try and take the
patient back to the Catheterization Laboratory. The patient
was also seen by Neurology, Dr. [**Last Name (STitle) **], again on [**1-10**],
who noted that the toxic metabolic issues were ongoing and
with continued altered mental status, she recommended holding
the propofol or tapering it whenever the patient could
tolerate it and a stroke protocol MRI to be done when the
patient could also tolerate it as well as adding in thiamine,
folate and multivitamins to the patient's regimen for the
history of alcohol abuse. The patient did not withdraw to
noxious stimuli on that morning on neurologic examination.
Catheterization showed a patent vein graft to the PDA, patent
vein graft to the OM1 but the upper pole on the OM1 was
totally occluded and totally occluded vein graft to the
diagonal. The LIMA appeared patent at the take-off but no
distal flow to the PTCA at the upper pole of the OM and
tri-PTCA in the native left vein (please refer to the cardiac
catheterization report). The CVDHD was re-initiated as the
patient remained on multiple pressors and inotropics. She
continued amiodarone at one and lidocaine for an additional
24 hours. Also on the 24th thoracentesis was attempted to
tap pleural effusion and CVDHD was continued for the fourth
day. TPN was being managed by input from the Clinical
Nutrition team. The left effusion was tapped. The patient
received one unit of packed red blood cells on the 24th and
remained on amiodarone, heparin, insulin, Levophed,
lidocaine, Milrinone and ReoPro. The patient was intubated
and sedated at the time but the plan was to hold the sedation
and see what kind of response the patient got. The patient
was A-paced at 80 with a pressure of 104/48 and index of 2.6.
She remained on assist control ventilation with a white count
of 25 and an hematocrit of 30.4. She was on vancomycin day
seven and ceftriaxone day six with a BUN of 56 and a
creatinine of 2.0. CK was 950. She remained critically ill
with a couple of episodes of bradycardia interspersed in her
atrial fibrillation. Overnight she had non-sustained
ventricular tachycardia again in the setting of atrial
fibrillation. Lidocaine was restarted. With the patient
lidocaine at one, amiodarone at 0.5 and was being A-paced at
90, VOR did not work. Hemodynamically, she was doing worse
with an increasing pressor requirement and a septic picture.
Infectious Disease consulted on [**1-12**]. The ultrasound
on [**1-7**] showed a fatty liver, gallbladder sludge and
small left kidney with no pleural fluid results at that time
from the tap that had take place two days prior. They
recommended changing her antibiotic therapy and continuing
vancomycin, eliminating ceftriaxone and switching to
PIP/TAZO. Blood cultures, urine cultures, sputum cultures,
urinalysis and routine fever workup were initiated again as
well as checking stools for Clostridium difficile. Repeat
blood cultures were sent. Antibiotics were switched to
vancomycin and Zosyn with plans to re-dose vancomycin for a
level of a less than 15. No stool but patient would have
some sent for Clostridium difficile culture. At 11:00 p.m.
that evening patient reverted to atrial fibrillation and was
cardioverted to sinus rhythm with 200 joules times one shock.
Chest incision continued to be intact without drainage. The
patient moved into atrial fibrillation again and atrial
flutter and continued to be A-paced. They recommended
checking the lidocaine level again. On postoperative day
nine the patient had Diamox added in for an ABG of
7.51/40/109/33. The patient had been cardioverted again back
to atrial fibrillation. Additional cultures were sent.
Ceftriaxone had been discontinued. The patient remained on
Levophed drip at 0.07, amiodarone 0.5, Milrinone at 0.1,
vasopressin at 0.04, lidocaine at 0.5. TPN and insulin also
continued. The patient had been restarted on Plavix.
Lidocaine was turned to off later that day. The patient had
a pressure of 110/54 with a heart rate of 97 in atrial
fibrillation, an index of 2.9 with very limited urine output
and no response to any noxious stimuli. The patient was
followed daily by Renal and the Infectious Disease Fellow at
that point. Amphojel and Diamox were discontinued on day
ten. Milrinone was decreased to 0.05 but the patient
required Levophed at 0.06 and remained on Vasopressin at 0.04
with a pressure of 124/57, A-paced at 90. Sputum on [**1-13**] showed Gram negative rods. Creatinine slowly came down
with a BUN of 46 and a creatinine of 1.4. On [**1-14**]
the patient remained intubated and sedated. Propofol
continued. The patient continued with ventilatory support as
well as pressor support. The patient continued CVDHD. Had
an episode of bigeminy. Recommended weaning the pressors as
the patient had a pressure of 128/59 and a MAP in the 80's
and hopefully decreasing the lidocaine when the pressors had
been decreased first. It was recommended by Cardiology that
the patient probably needed an endocardial screw-in system in
the next few days but it was not urgent. General Surgery was
consulted for acidosis with a pH of 7.20. Over the prior 24
hours on [**1-14**] the patient was weaned off of Levophed,
Pitressin and propofol but had an increasing progressive
acidosis with a base excess of -8, a lactate of 5 and a pH of
7.2. There were no other changes in index, output blood
pressure or SVR. They were asked to consult for helping to
rule out an abdominal source of acidosis with a known chronic
postoperative elevated bilirubin. Concern was for ischemic
bowel secondary to an embolic event, perhaps, or her low
output from her myocardial infarction. She had a totally
soft abdomen. They recommended following her serially with
blood gases and lactate, checking a KUB and bilateral upper
quadrant ultrasound again to rule out any acute cholecystitis
noting her prior gallbladder sludge and CT of her abdomen if
her lactate continues to rise and her acidosis persists. In
addition, they recommended amylase and lipase be sent.
Consult was discussed with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] who noted he
doubted intra-abdominal source but would continue to follow
the patient. Acidosis improved the following day on [**1-16**] slightly with a blood gas that showed a 7.49 pH. The
patient was also transfused one unit of packed red blood
cells, continued on Milrinone, amiodarone and Vasopressin at
that point and insulin and lidocaine. The patient also was
on day four of Zosyn. The patient did have an eight beat run
of nonsustained ventricular tachycardia times two as well as
recurrent atrial flutter and low blood pressure overnight.
On that morning pressure was 105/54 with an index of 2.6.
White blood count was 22 and they recommended weaning the
Milrinone first. Dr. [**Last Name (STitle) 468**] evaluated the patient again on
the evening of the [**1-14**] who repeated her abdominal
examination and continued to follow the patient although no
recommendation was made for any particular intervention at
that time. Renal continued to manage the patient's metabolic
issues with the team. The patient was unresponsive off
propofol since 1:00 p.m. that day. They tried to wean the
ventilator without success. Ultrasound of the abdomen was
negative for cholecystitis. PE was reportedly negative for
clot and vegetation. The KUB was of poor quality with a
question of ascites versus density. Lactate dropped from 5
to 1.7. The patient had been weaned off Levophed at that
point but not Vasopressin. The patient also had two purple
toes and continuing edema. Bilirubin and pancreatic enzymes
continued to be elevated with occasional lactic acidosis. It
might have been bowel ischemia. Please note their comments
on examination. The patient was seen again by Case
Management for continuing follow up. On postoperative day 11
propofol was discontinued as previously noted with a pressure
of 95/49, hematocrit of 28.6. The patient continued on
vancomycin and Zosyn. There was essentially no change in the
examination. The patient continued to be off all sedation
but unresponsive with sluggish pupils and no spontaneous
movements. The patient had additional runs of a nonsustained
ventricular tachycardia versus atrial fibrillation, again on
the evening of the 28th. Continuing supportive care was
given. General Surgery saw the patient again on the 29th.
It was discussed with Dr. [**Last Name (STitle) 468**] with no interventions
recommended at that point. On the 29th the patient was noted
by the Infectious Disease Fellow to have not had any other
hypotensive or other destabilizing events overnight even
though the patient had been rolled and the patient still had
no wakening off propofol. Some worries about an abdominal
focus persisted in the face of her continuing coma and known
multiple distribution ischemia. They recommended having a CT
of the head again to rule out stroke and a CT of her abdomen
to see if there was evidence of bowel ischemia or any
continuing pneumonia or recurrent effusion. CVDHD day nine
also was continued. Hopefully the plan would be to get the
screw-in lead system if the patient was able to continue to
recover although at the time of evaluation again on the 29th
by Electrophysiology the patient continued in critical
condition and was unresponsive. On postoperative day 13 the
patient was off Milrinone and lidocaine. Pitressin had been
decreased to 0.01. FiO2 had been decreased. The patient
continued tube feeds. Sputum came back again positive for
Gram positive cocci. The patient was A-paced with a pressure
of 121/53, hematocrit of 29.9, BUN 48, creatinine 1.3 with a
potassium of 4.5. Lactic acid was 1.5. The patient had
coarse breath sounds bilaterally. The abdomen was soft. The
extremity toes and fingers were dusky. Sedation continued to
be held. The patient was switched back to IMV and the
patient remained in critical condition. The patient
continued to remain unresponsive to painful stimuli with dim
corneal reflexes. On postoperative day 14 Pitressin was
discontinued. The patient was in sinus rhythm in the 80's
with a pressure of 122/54. White count continued to drop to
11.4. The patient remained on amiodarone drip, receiving
Plavix and remained on SIMV with a gas of 7.42/34/132/23 and
-1. Creatinine stabilized at 1.3. The patient did not
respond. Lungs were clear bilaterally. Sternum was stable.
Abdomen was soft. Amiodarone continued. Vent weaned.
Continued slowly. Tube feeds continued as well as
antibiotics. The patient was examined again by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] of Neurology on [**1-18**] who noted that she had no
response and remained intubated, no response to verbal
stimuli, minimal resistance to eye opening. Her pupils were
nonreactive. She had a corneal reflex on the right. There
was no movement on all four extremities to any noxious
stimuli. A CT of the brain showed multiple posterior
circulation strokes, left occipital, left thalamic, mid
brain, right pons, bilateral cerebellar and left occipital
with petechial bleeding. Prognosis as she noted was
exceptionally poor for full recovery from a neurologic
standpoint. She noted that if the family wished to pursue
full care they would recommend mannitol and possibly
considering Neurosurgery input. If full care was continued,
she also recommended repeat CT in 24 hours and to please hold
the patient's heparin. CVDHD was stopped on [**1-19**].
Neuro status continued to be poor with a dismal prognosis.
Renal signed off at that time as they were unable to continue
CVDHD. Patient had a pressure of 97/40 and remained in very
grave condition given her multiple extensive infarcts to her
brain. Her pupils were fixed. On postoperative day 14 drug
therapy continued but the patient remained unresponsive. A
family meeting was held on the 13th. The patient was
examined again on the morning of [**1-19**] by the
Neurology attending, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who again noted that
the prognosis was grave neurologically and at 8:00 p.m. on
the evening of [**1-19**] the patient was found
unresponsive without any respirations, pulse or blood
pressure. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] pronounced the patient expired at
[**2139**] on [**2143-1-19**].
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times four.
2. Chronic obstructive pulmonary disease.
3. Cardiogenic shock.
4. Myocardial infarction.
5. Chronic renal insufficiency complicated by acute tubular
necrosis.
6. Bronchitis.
7. Multiple cerebrovascular accidents.
The patient expired in the Cardiothoracic Intensive Care Unit
on [**2143-1-19**].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 46342**]
MEDQUIST36
D: [**2143-4-23**] 12:39
T: [**2143-4-26**] 12:56
JOB#: [**Job Number 46343**]
|
[
"41071",
"4280",
"9971",
"42731",
"5845"
] |
Admission Date: [**2177-6-23**] Discharge Date: [**2177-7-3**]
Service: MEDICINE
Allergies:
Valium / Elavil / Niaspan / Zithromax / Levaquin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
fever, cough
Major Surgical or Invasive Procedure:
1. Central line placement - R IJ
History of Present Illness:
89 yo male with a history of CLL s/p multiple treatments, most
recently pentastatin (last dose [**2177-3-17**]) complicated by F+N so
stopped and reassessed [**2177-5-16**](no further treatment at that time
and acyclovir/aerosolized pentamidine started for ppx) chronic
hypogammaglobulinemia(treated intermittently w/ IVIG, last
[**2177-3-19**]) who was admitted [**2177-6-23**] for febrile neutropenia.
Relevant admission history included productive cough at home,
two recent falls without apparent loss of consciousness,
progressive weight loss, recurrent aspirations, strep viridans
bacteremia (as below) and ongoing diarrhea.
.
Of note, recent admission [**Date range (1) 104260**], diagnosed with strep
viridans bacteremia treated with broad spectrum abx and GCSF for
neutropenia. TEE was negative for vegetations. Prior to d/c,
antibiotics changed to clindamycin according to sensitivities,
and he was discharged to rehab to complete a 14 day course. He
was a known aspiration risk at that time (failed video swallow)
but refused PEG. He was continued on thickened liquids with
aspiration precautions. Patient signed himself out of rehab. It
is unclear whether he completed a complete course of
antibiotics.
.
Patient was seen by PCP [**Last Name (NamePattern4) **] [**6-23**] for chills, cough, s/p mult falls
(no LOC) and was referred to ED. In the ER, he was found to have
a T 100.3, HR 109, and O2 sat of 91% RA 94% on o2. CXR showed a
?RLL pna and he was started on levaquin 750mg.
.
On the floor, antibiotics were broadened to cefipime and SBP's
were running 110's. In the am of [**6-24**], the patient had a syncopal
episode while in the bathroom and BP was found to be in the
70's. Aggressive IVF's were started and BP returned to 100's.
Then, that afternoon, BP back to 80's despite IVF's. ECG
unremarkable. Repeat CXR demonstrated no infiltrates. ABG
7.34/34/60 on 2 liters oxygen. Patient was admitted to the ICU.
.
In the ICU, SBP dropped to 70s and temp spiked to 104.6.
Antibiotics were broadened to cefipime/vancomycin/flagyl. A
central line was placed and patient required dopamine x 36 hours
which was eventually weaned off [**6-25**]. No culture data could be
obtained to guide treatment. C diff negative x 3 ([**6-24**], [**6-26**],
[**6-28**]). Blood cxs [**6-24**] and [**6-26**] pending. Urine xc [**6-24**] and [**6-26**]
negative. Sputum from [**6-25**] grew OP flora. However, source
presumed to be aspiration pna. Heme/Onc consulted and
recommended giving IVIG at 400 mg/kg and GCSF at 300 mg sc QD.
Received treatment [**6-26**](per Heme/Onc should receive Q4-5 wks). A
Doboff was placed for tube feeds. Also transfused 1 unit PRBCs
on [**6-27**] for Hct 21 (-> 25). Also complained of RUE swelling/pain.
RUE u/s and XR both unremarkable. Vancomycin d/c'ed [**6-27**].
Intermittently required IV lasix 20 mg for volume overload with
good response. At the time of transfer, BPs had stabilized off
pressors, fever curse declining on broad spectrum antibiotics
(but off vanco), and ANC improving on GCSF.
.
Currently, patient feels breathing is improved. Denies any
chest pain, SOB, fevers, chills, abdominal pain. Resting
comfortably.
Past Medical History:
# CLL-
- s/p induction with chlorambucil at 6 mg/day x 3 weeks in
[**8-22**].
- s/p cycle of maintainence chlorambucil 24 mg /day x 5 days in
[**10-22**] (--> low counts).
- s/p 4 cycles maintainence chlorambucil at 24 mg/daily, for
five days/month starting in [**2173-12-6**].
- s/p 2 cycles of maintainence chlorambucil at 12 mg/day for 5
days every months in [**1-24**] and [**2-24**].
- intermittently on pentostatin, re-started on [**2177-2-7**]
following approx 2 month hiatus.
# CAD
- s/p cath in [**3-23**] with PTCA and PCI of LAD and D2.
# Hyperlipidemia
# Anemia
# BPH
# Osteoarthritis
# Diverticulosis
# Dementia
# h/o chronic low back pain
# Prostate ca
- s/p TURP
# recurrent aspiration pneumonitis
# s/p appy
# s/p tonsillectomy
# s/p b/l inguinal hernia repair
# Anxiety
# h/o malaria
Social History:
Lives alone in [**Location (un) 3146**]. Widowed with four children.
Family History:
non contributory
Physical Exam:
T: 98.2 BP: 112/58 HR: 84 RR: 24 O2 97% 3LNC
Gen: chronically ill appearing gentleman, laying flat in bed,
NAD
HEENT: No conjunctival pallor. Dry MMs. OP clear. Doboff in
place
NECK: Supple. Bilateral cervical adenopathy. No JVD. R IJ in
place. CDI
CV: RRR. nl S1, S2. [**1-25**] holosys murmur at apex
LUNGS: bibasilar crackles, L>R
ABD: NABS. Soft, NT, ND. No HSM
EXT: WWP. 1+ RUE swelling. Trace LE edema. No splinter
hemorrhages, Osler nodes, [**Last Name (un) 1003**] lesions
SKIN: multiple ecchymoses on forearms
NEURO: Alert. Oriented x3. CN 2-12 grossly intact. Preserved
sensation throughout. Moving all extremities.
Pertinent Results:
[**6-28**] R humerus XR:
No fracture detected involving the right humerus. Although
subtle marrow involvement might not be detected
radiographically, no obvious evidence for marrow involvement or
osteolysis is detected.
.
[**6-27**] UE u/s: No evidence of right upper extremity DVT.
.
[**6-24**] CXR: Allowing for technical differences, there has been no
significant change since the previous study of [**2177-6-23**].
Heart size is normal with tortuosity of the thoracic aorta and
coronary artery stent in situ. No definite pulmonary
consolidation or pleural effusions. Slight prominence of the
right hilum, likely vascular related to the relatively high
position of the right hemidiaphragm.
IMPRESSION: No evidence for pneumonia.
.
[**6-23**] CXR: The cardiomediastinal silhouette is unchanged. The
lungs are clear. No pleural effusions or pneumothoraces are
identified. The hilar structures are normal. The aorta is
unfolded.
IMPRESSION: No acute cardiopulmonary process identified.
.
[**2177-6-23**] 08:50PM BLOOD WBC-15.3* RBC-2.95* Hgb-10.0* Hct-30.9*
MCV-105*# MCH-33.9* MCHC-32.4 RDW-15.9* Plt Ct-282#
[**2177-6-24**] 01:23PM BLOOD WBC-8.9 RBC-2.56* Hgb-9.2* Hct-26.3*
MCV-103* MCH-35.8* MCHC-34.8 RDW-15.6* Plt Ct-223
[**2177-6-25**] 05:20AM BLOOD WBC-12.4* RBC-2.65* Hgb-9.1* Hct-27.9*
MCV-105* MCH-34.4* MCHC-32.7 RDW-15.7* Plt Ct-207
[**2177-6-26**] 04:57AM BLOOD WBC-6.2 RBC-2.26* Hgb-7.8* Hct-23.3*
MCV-107* MCH-34.4* MCHC-32.1 RDW-15.4 Plt Ct-174
[**2177-6-28**] 04:08AM BLOOD WBC-8.9 RBC-2.35* Hgb-8.0* Hct-23.8*
MCV-101* MCH-34.0* MCHC-33.6 RDW-16.8* Plt Ct-134*
[**2177-6-30**] 05:35AM BLOOD WBC-13.4* RBC-2.49* Hgb-8.4* Hct-25.1*
MCV-101* MCH-33.7* MCHC-33.3 RDW-17.0* Plt Ct-111*
[**2177-7-1**] 05:29AM BLOOD WBC-17.4* RBC-2.40* Hgb-8.4* Hct-25.1*
MCV-105* MCH-34.9* MCHC-33.4 RDW-16.5* Plt Ct-95*
[**2177-7-2**] 05:45AM BLOOD WBC-21.6* RBC-2.35* Hgb-8.0* Hct-24.7*
MCV-105* MCH-34.1* MCHC-32.5 RDW-16.5* Plt Ct-93*
[**2177-6-23**] 08:50PM BLOOD Neuts-3* Bands-3 Lymphs-88* Monos-1*
Eos-1 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2177-6-25**] 05:20AM BLOOD Neuts-9* Bands-4 Lymphs-79* Monos-3 Eos-0
Baso-0 Atyps-3* Metas-2* Myelos-0
[**2177-6-27**] 03:00AM BLOOD Neuts-5* Bands-0 Lymphs-92* Monos-1*
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2177-6-24**] 07:50AM BLOOD PT-13.0 PTT-25.4 INR(PT)-1.1
[**2177-6-24**] 07:50AM BLOOD Gran Ct-1020*
[**2177-6-27**] 03:00AM BLOOD Gran Ct-520*
[**2177-6-28**] 04:08AM BLOOD Gran Ct-780*
[**2177-6-30**] 05:35AM BLOOD Gran Ct-970*
[**2177-6-23**] 08:50PM BLOOD Glucose-164* UreaN-18 Creat-1.0 Na-137
K-4.3 Cl-102 HCO3-26 AnGap-13
[**2177-6-24**] 01:23PM BLOOD Glucose-110* UreaN-22* Creat-1.0 Na-142
K-4.6 Cl-108 HCO3-24 AnGap-15
[**2177-6-27**] 03:00AM BLOOD Glucose-94 UreaN-24* Creat-1.0 Na-139
K-3.4 Cl-112* HCO3-21* AnGap-9
[**2177-6-29**] 05:23AM BLOOD Glucose-119* UreaN-20 Creat-0.9 Na-144
K-3.3 Cl-112* HCO3-26 AnGap-9
[**2177-7-1**] 05:29AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-146*
K-4.2 Cl-112* HCO3-29 AnGap-9
[**2177-6-24**] 01:23PM BLOOD ALT-8 AST-12 CK(CPK)-39 AlkPhos-66
TotBili-1.9*
[**2177-6-24**] 01:23PM BLOOD CK-MB-3 cTropnT-<0.01
[**2177-6-24**] 07:50AM BLOOD calTIBC-282 Ferritn-562* TRF-217
[**2177-6-27**] 03:00AM BLOOD Hapto-174
[**2177-6-27**] 03:00AM BLOOD Cortsol-14.6
[**2177-6-24**] 12:37PM BLOOD Type-ART pO2-62* pCO2-34* pH-7.43
calTCO2-23 Base XS-0
[**2177-6-23**] 08:56PM BLOOD Lactate-2.0
[**2177-6-24**] 12:37PM BLOOD Lactate-3.5*
[**2177-6-24**] 08:44PM BLOOD Lactate-1.5
Brief Hospital Course:
89 yoM w/ a h/o CLL s/p multiple treatments, h/o
hypogammaglobulinemia (intermittently treated with IVIG), CAD
who p/w febrile neutropenia attributed to presumed aspiration
pna, admitted to the MICU for hypotension, now on broad spectrum
antibiotics without clear source of infection.
.
# febrile neutropenia: neutropenic and febrile on admission.
Possible sources include aspiration pneumonia, bacteremia
(unknown if completed course for strep viridans), C diff (given
diarrhea post clindamycin), skin(given small decub), SBE, UTI,
CNS infection. Pulmonary source seems most likely given cough
although no culture data guiding treatment currently. C diff
negative x 3. Decub only small so unlikely source. Urine
negative. SBE unlikely w/ negative blood cultures and no
stigmata of endocarditis. Vanco d/c'ed [**6-27**]. No evidence to
support CNS infection. Neutropenia resolved with Filgastrim
treatment and Filgastrim d/c'ed. Patient received a dose of IVIG
per Heme/Onc recs. Afebrile on broad spectrum antibiotics.
Patient completed a 10 day course of cefepime/flagyl and was
changed to cefpodoxime and flagyl oral at the time of discharge
to complete 4 more days. As described elsewhere, it was decided
by the patient and family that he would go to rehab with an
eventual goal of going home with hospice once services were in
place. He was continued on Acyclovir until discharge and was
then discontinued to minimize po medications.
.
# hypotension: presumed secondary to sepsis in the setting of
aspiration pna. Briefly required pressors in MICU but
stabilized on broad spectrum antibiotics and was weaned off. AM
cortisol normal. BPs otherwise remained normal for the
remainder of admission.
.
# CLL: s/p multiple treatment regimens. Near neutropenic at
baseline and was neutropenic on admission. Patient had a h/o
hypogammaglobulinemia, intermittently treated with IVIG. As
above, he was treated with IVIG and Filgastrim. Per Heme Onc
there were no other treatments available for his CLL.
.
# h/o aspiration: failed speech and swallow last admission but
refused PEG placement. He had a Doboff placed in the ICU and
received tube feeds. However, after discussions with the family
it was clear that the patient wanted to leave the hospital with
a focus more on comfort measures. He continued to refuse a PEG
tube. It was decided that patient would be discharged to rehab
with a goal of going home with hospice. Therefore, the Doboff
was removed for patient comfort and a a soft solid, thickened
liquid diet was started to allow feeding for comfort and patient
happiness.
.
# RUE swelling: unclear cause. Per family, fell and hit that
arm. Possibly secondary to trauma with fall. U/S and XR
unrevealing. Improved during course of admission.
.
# agitation: agitation in ICU requiring restraints. Per family,
patient has a history of sundowning. Seroquel started.
Alprazolam weaned down. However, once goals of care were focused
more on comfort, family requested increasing patient's Xanax
which was done. He was continued on Seroquel and Zyprexa to
help aid with continued evening agitation throughout admission.
.
# CAD: No active issues. Continued on his aspirin and beta
blocker throughout and remained asymptomatic.
.
# anemia: baseline Hct high 20s to low 30s. Transfused 1 unit
PRBCs for Hct 21 with appropriate resonse while in the ICU. His
hematocrit then remained stable.
.
# thrombocytopenia: patient initially had significant drop in
his platelets soon after admission. However, did not become
thrombocytopenic until more than a week after admission.
However, given concern for potential HIT, all heparin products
were stopped and a HIT antibody was sent but was pending at the
time of discharge. His platelets were 97 at discharge which is
stable.
.
# FEN: tubefeeds via Doboff then discontinued and restarted on
soft solid, thickened liquids for comfort.
.
# PPx: heparin sc until platelets dropped. Heparin d/c'ed and
pneumoboots placed.
.
# CODE: DNR/DNI, do not transfer to ICU, No central lines, no
pressors following meeting with healthcare proxy on [**2177-6-30**].
PLAN FOR COMFORT MEASURES WITHOUT REHOSPITALIZATION.
Medications on Admission:
Aspirin 81 mg Daily
Acyclovir 400 mg Q8H
Finasteride 5 mg DAILY
Folic Acid 1 mg DAILY
Benzonatate 100 mg TID prn
Alprazolam 0.25 mg TID as needed for anxiety.
Albuterol Sulfate 0.083 % Q 8H
Ipratropium Bromide 0.02 % Solution Sig: One Q8H
Clindamycin HCl 150 mg Q6H for 7 days.
Fluconazole 100 mg Q24H for 14 days.
Aranesp
Discharge Medications:
1. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
2. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO three times
a day.
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
7. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
9. Cefpodoxime 100 mg/5 mL Suspension for Reconstitution Sig:
Two Hundred (200) mg PO twice a day for 4 days.
10. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Primary:
1. aspiration pneumonia
2. neutropenia
Secondary:
1. CLL
2. CAD
3. Anemia
4. Dementia
5. anxiety
Discharge Condition:
Stable O2 sats on room air. Vitals stable. Aspirating on
minimal soft solids and thickened liquids. Agitated at times at
night improved with Zyprexa.
Discharge Instructions:
Please continue to take all medications as prescribed. Please
note that your Acyclovir, folic acid, fluconazole, and aranesp
have been discontinued. You have been started on Quetiapine and
you have been given Olanzapine to be used as needed for
agitation. You should also continue taking oral antibiotics for
the next 4 days.
Please continue to work with rehabilitation until you are ready
to return home.
Followup Instructions:
Please follow up with your Primary Physicians as needed.
Completed by:[**2177-7-3**]
|
[
"5070",
"4240",
"0389",
"99592",
"51881",
"78552",
"2760",
"41401",
"2724",
"V4582"
] |
Admission Date: [**2107-3-16**] Discharge Date: [**2107-4-5**]
Date of Birth: [**2049-11-29**] Sex: F
Service: SURGERY
Allergies:
Aspirin / Sulfa (Sulfonamides) / Trazodone
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abd pain
Major Surgical or Invasive Procedure:
SBR X 2
Ex lap
Closure of abd with absorbable mesh
VAC dressing placement
History of Present Illness:
56F with multiple abd operations and large ventral hernias who
presented with abd pain and nausea for 2 days. Pain was diffuse
and crampy. Last BM 1 day previous and no flatus since that
time. Vomitting started the day of admission. No
F/C/Diarrhea/Constipation
Past Medical History:
Asthma
GERD
MI
Morbid obesity
s/p umbilical hernia repair
s/p multiple ventral hernia repairs
SBO
Social History:
NC
Family History:
NC
Physical Exam:
AVSS
NAD, morbidly obese
CTA(b)
RRR
Soft, obese, tender RLQ with muliple hernias
No rebound or guarding.
Draining track at umbilicus
No edema
Pertinent Results:
[**2107-3-16**] 05:00AM WBC-11.8* RBC-5.00 HGB-14.1 HCT-41.6 MCV-83
MCH-28.1 MCHC-33.8 RDW-13.6
[**2107-3-16**] 05:00AM PLT SMR-NORMAL PLT COUNT-356
[**2107-3-16**] 05:00AM LIPASE-22
[**2107-3-16**] 05:00AM ALT(SGPT)-22 AST(SGOT)-18 ALK PHOS-71 TOT
BILI-0.3
[**2107-3-16**] 05:00AM GLUCOSE-205* UREA N-17 CREAT-0.6 SODIUM-139
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-30* ANION GAP-14
[**2107-3-16**] 08:42PM URINE RBC-0 WBC-[**3-12**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2107-3-16**] 08:42PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2107-3-16**] 08:42PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.034
Brief Hospital Course:
Pt was admitted to the hostipal and monitored overnight. On HD
#2 she began having temps to 104.0. That night she became
hypotensive and somulent and was transferred to the ICU. She was
intubated and fluid resusitated. She was taken to the OR
emergently for exploration. She was found to have a closed loop
obstruction of her SB. 100 cm of SB were resected and she was
left open and transferred to the ICU. Post op she had severe
sepsis and was started on broad spectrum abx and Xigris. She
slowly improved and was weaned from her pressors. She stablized
and was taken back to the operating room for a washout and
closure. Intraoperatively, a focal area of necrosis of the SB
was identified and it was resected. She was closed with Dexon
absorbable mesh and a VAC was placed. Plastic surgery was
consulted intra-op and followed the her throughout her stay. She
was transferred back to the ICU and she slowly improved. She was
attempted to be weaned from the vent but was unable. Therefore
it was decided to proceed with a perc trach. After the trach was
placed she was able to wean from the ventilator and was
tolerating trach mask prior to discharge. A post-pyloric feeding
tube was placed intra-op and she was started on TF. She had high
stool output which was checked multiple times for C diff. All
were negative. Her TF were changed and her output decreased. She
had a PICC line placed for a 2 wk abx course of Vanco/Levo. She
had a MRSA/Ecoli bacteremia likely from her necrotic bowel. She
was afebrile for over 1 wk after starting the abx. PT/OT were
consulted and worked with her throughout her hospital stay.
Speech and Swallow evaluated her and she was able to pass her
beside evaluation. She will need a Video swallow when more
stable prior to starting to take PO.
Medications on Admission:
Theodur 300 QD
Claritin 10 QD
Nexium 40 QD
Prozac 40 QD
Klonipin 0.5 prn
Albuterol
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Disp:*60 * Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*60 * Refills:*0*
3. Fluoxetine HCl 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
4. Clonidine HCl 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
Disp:*60 Patch Weekly(s)* Refills:*2*
5. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
Disp:*60 * Refills:*2*
6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 * Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*400 ML(s)* Refills:*0*
8. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*60 Tablet(s)* Refills:*0*
9. Vancomycin HCl 1,000 mg Recon Soln Sig: 1.5 g Intravenous
twice a day for 5 days.
Disp:*5 * Refills:*0*
10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Small Bowel Obstruction s/p ex lap small bowel resection X 2.
Abd washout and closure using dexon mesh.
MRSA pneumonia
MRSA and E coli bacteremia
Discharge Condition:
Stable
Discharge Instructions:
Trach Mask as tolerated.
VAC dressing on abd. Change dressing every 3 days.
PICC line in R antecub.
Chest PT
OOB to chair as tolerated.
Followup Instructions:
F/U with Dr. [**Last Name (STitle) **] in [**1-9**] wks for wound evaluation and down
sizing trach.
F/U Speech and Swallow for video swallow evaluation.
F/U Dr. [**First Name (STitle) 3228**] in 2 wks for wound evaluation and plan skin
grafting
Completed by:[**0-0-0**]
|
[
"99592",
"53081",
"49390"
] |
Admission Date: [**2131-9-9**] Discharge Date: [**2131-9-18**]
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubation
Right Subclavian Central Line
Swan Ganz catheter
History of Present Illness:
HPI: 89 yo with severe 3VD, declines CABG who has had multiple
admits to OSH for CHF exacerbation transferred from [**Location (un) **] ED
for cardiogenic shock, intubated and on pressors. Initially
presented there with SaO2 70%, cyanotic, rales, BP 70/P. On 100%
NRBFM 97%, followed by BiPAP -> intubated, dopamine, IV lasix
and transferred to [**Hospital1 18**].
In ambulance route, given 2L IVF for hypotension. Switched from
dopamine to levophed in ED. VT in ED which resolved without
intevention.
Past Medical History:
1. CAD, cath [**2128**] with 99% LAD, TO RCA, 90% LCx. Refused CABG
2. CHF with EF 15-25%
3. DM
4. HTN
5. Hyperlipidemia
Family History:
non-contributory
Physical Exam:
T 100.2 HR 74 BP 115/56
Gen: intubated, frothy pink ETT sputum
Neck: jugular vein distension
Resp: intubated, + diffuse crackles
Cardio: RRR S1/S2 +S3 difficult to hear heart sounds through
load rales, vented BS
Abd: NABS, NTND
Ext: mild cyanosis
Neuro: follows commands
Pertinent Results:
[**2131-9-9**] 09:25PM PTT-150 IS HIG
[**2131-9-9**] 08:05PM POTASSIUM-4.1
[**2131-9-9**] 08:05PM CK(CPK)-1243*
[**2131-9-9**] 08:05PM CK-MB-95* MB INDX-7.6*
[**2131-9-9**] 08:05PM MAGNESIUM-2.5
[**2131-9-9**] 05:33PM HCT-27.6*
[**2131-9-9**] 05:33PM PT-18.3* PTT-150 IS HIG INR(PT)-2.2
[**2131-9-9**] 05:33PM PT-18.3* PTT->150* INR(PT)-2.2
[**2131-9-9**] 05:30PM TYPE-ART TIDAL VOL-600 O2-40 PO2-135*
PCO2-34* PH-7.34* TOTAL CO2-19* BASE XS--6 INTUBATED-INTUBATED
[**2131-9-9**] 05:30PM HGB-10.6* calcHCT-32 O2 SAT-73
[**2131-9-9**] 05:30PM O2 SAT-98
[**2131-9-9**] 02:41PM TYPE-ART TEMP-36 TIDAL VOL-600 PEEP-5 O2-40
PO2-96 PCO2-33* PH-7.32* TOTAL CO2-18* BASE XS--8
INTUBATED-INTUBATED
[**2131-9-9**] 02:41PM O2 SAT-98
[**2131-9-9**] 12:26PM O2 SAT-65
[**2131-9-9**] 12:21PM TYPE-ART O2-0 PO2-74* PCO2-38 PH-7.25* TOTAL
CO2-17* BASE XS--9 INTUBATED-INTUBATED VENT-CONTROLLED
[**2131-9-9**] 12:21PM LACTATE-2.3*
[**2131-9-9**] 11:57AM GLUCOSE-157* UREA N-56* CREAT-1.7* SODIUM-137
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-16* ANION GAP-17
[**2131-9-9**] 11:57AM ALT(SGPT)-61* AST(SGOT)-209* LD(LDH)-704*
CK(CPK)-1413* ALK PHOS-100 TOT BILI-0.3
[**2131-9-9**] 11:57AM CK-MB-99* MB INDX-7.0*
[**2131-9-9**] 11:57AM WBC-4.8 RBC-3.22* HGB-9.6* HCT-27.2* MCV-85
MCH-29.9 MCHC-35.4* RDW-17.5*
[**2131-9-9**] 11:57AM ALBUMIN-3.1*
[**2131-9-9**] 11:57AM PLT COUNT-190
[**2131-9-9**] 09:54AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2131-9-9**] 09:54AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2131-9-9**] 09:54AM URINE RBC-0 WBC-0 BACTERIA-OCC YEAST-NONE
EPI-<1
[**2131-9-9**] 09:54AM URINE HYALINE-4*
[**2131-9-9**] 09:20AM O2 SAT-70
[**2131-9-9**] 09:17AM TYPE-ART PO2-240* PCO2-32* PH-7.25* TOTAL
CO2-15* BASE XS--11 INTUBATED-INTUBATED
[**2131-9-9**] 09:17AM HGB-11.5* calcHCT-35 O2 SAT-98
[**2131-9-9**] 07:09AM TYPE-ART PO2-136* PCO2-33* PH-7.25* TOTAL
CO2-15* BASE XS--11 INTUBATED-INTUBATED
[**2131-9-9**] 07:09AM HGB-10.1* calcHCT-30 O2 SAT-98
[**2131-9-9**] 07:08AM TYPE-MIX
[**2131-9-9**] 07:08AM O2 SAT-56
[**2131-9-9**] 05:20AM GLUCOSE-290* UREA N-58* CREAT-1.8* SODIUM-133
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-12* ANION GAP-19
[**2131-9-9**] 05:20AM CK(CPK)-744*
[**2131-9-9**] 05:20AM CK-MB-46* MB INDX-6.2*
[**2131-9-9**] 05:20AM cTropnT-6.01*
[**2131-9-9**] 05:20AM CALCIUM-6.5* PHOSPHATE-4.8* MAGNESIUM-1.8
[**2131-9-9**] 05:20AM WBC-8.3 RBC-3.47* HGB-10.2* HCT-30.9* MCV-89
MCH-29.3 MCHC-33.0 RDW-17.3*
[**2131-9-9**] 05:20AM NEUTS-78* BANDS-13* LYMPHS-7* MONOS-1* EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0
[**2131-9-9**] 05:20AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2131-9-9**] 05:20AM PLT SMR-NORMAL PLT COUNT-255#
[**2131-9-9**] 05:20AM PT-16.1* PTT-37.9* INR(PT)-1.7
[**2131-9-9**] 04:35AM TYPE-ART PO2-117* PCO2-37 PH-7.22* TOTAL
CO2-16* BASE XS--11 INTUBATED-INTUBATED
[**2131-9-9**] 04:35AM LACTATE-3.1*
Brief Hospital Course:
1) CHF - Pt was initially started on dobutamine and levophed,
and pt was diuresed with lasix. Pt was eventually switched from
dobutamine to milrinone. Initially tried to wean pt off pressor
but continued to become hypotensive. Pt had swan cath placed to
monitor volume status and cardiogenic shock. Once pt was
determined to be DNI/DNR with comfort support, pressors were
stopped as well as lasix. Pt BP and HR remained stable once pt
was off pressor support. Restarted pt on Imdur.
2) Ischemia - Pt refused CABG or cath procedures. Initial EKG
showed STE in AVR and inf lat STD. Follow up EKG showed
improvement of ST depressions. Pt was intially kept on heparin
drip, ASA, plavix. Medications stopped after discussion with
pt/family and wishes changed to comfort support.
3) Respiratory Failure - secondary to cardiogenic shock. Pt was
intially intubated, did well, then exubated and switched to
Bipap. Pt did well on Bipap and was switched to oxygen via
nasal cannula. Once pt wished for only comfort support.
Morphine drip started and titrated to comfort support. Pt
respiratory status stable once on oxygen via nasal cannula.
Restarted pt on lasix. Pt switched to oral morphine and ativan
for comfort support.
4) ID - Pt had one blood culture bottle come back positive for
gram + cocci. Most likely contamination, Pt given vancomycin 1g
and repeat bld cultures and urine cx sent. Repeat bld cultures
showed no growth to date, and urine cultures negative. Pt WBC
remianed WNL and pt remained aferbrile.
Medications on Admission:
Lasix 40mg [**Hospital1 **]
ASA 325
Hydroxyurea 500 qd
bisoprolol 2.5 [**Hospital1 **]
plavix 75 qd
enalopril 10 [**Hospital1 **]
spironolactone 25 qd
Discharge Disposition:
Extended Care
Facility:
Tower [**Doctor Last Name **] Center
Discharge Diagnosis:
CHF exacerbation
Discharge Condition:
Fair
|
[
"4280",
"51881",
"41401",
"25000",
"4019",
"2724",
"2859"
] |
Admission Date: [**2116-4-21**] Discharge Date: [**2116-5-6**]
Date of Birth: [**2051-9-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
STEMI, s/p PCI with RCA perforation at OSH
Major Surgical or Invasive Procedure:
IABP and Swan ganz catheter placement [**4-22**]
RVAD placement [**4-22**]
History of Present Illness:
64 M with htn and hyperlipidemia admitted to OSH for elective R
knee replacement. Post-operatively, he developed symtpoms of
indigestion and chest pain with STE's in the inferior leads. He
was sent to [**Location (un) 80662**] for catheterization.
Apparently, two days prior to his surgery he reported
intermittent chest pain to his wife that he minimized.
Pre-operatively, there were no EKG changes compared to prior
tracings.
.
At OSH cath, he was found to have a right dominant system and
had subtotally occluded RCA. There was 60% mid LAD and 80-90% D1
disease; no disease in Lcx. Thrombectomy of the RCA lesion was
performed. The procedure was complicated by a perforation and
dissection of his RCA. A 9x20 balloon was deployed at the
perforation and he was started on Neo and Dopamine for
hypotension. He also had a bradycardic arrest and needed
temporary pacing. He was then transferred to [**Hospital1 18**].
.
At catherization here, he was semi-electively intubated. His
pressures dropped and a balloon pump was placed with Neo and
Dopamine running. Two coated stents were placed at RCA along
with one BMS distally. He is then transferred to the CCU.
.
ROS: From his wife, he had been feeling well prior to surgery:
denies SOB, stable 2 pillow orthopnea, stable mild ankle edema,
no PND, no claudications, no stroke, no bleeding disorder, no GI
bleeding, no palpitations, no syncope.
Past Medical History:
HTN
Hyperchol
s/p R TKR
R knee and L knee meniscetomy
Appendectomy
? impaired glucose tolerance
Social History:
Occasional pipe smoker; mild tobacco use in the past. Currently
lives with wife, semi retired plumber.
Family History:
No known FH of early CAD per family
Physical Exam:
GEN: Intubated and sedated
HEENT: Right pupil 6mm reacting to 5mm, left 5mm to 4mm.
NECK: Obese, cannot assess JVP.
CV: Distant heart sounds. S1, S2, RRR, intraaortic balloon pump,
no murmurs, gallops or rubs.
PULM: CTAB anteriorly
ABD: Soft, NT, ND, +BS. obese.
EXT: Trace peripheral edema, balloon pump r groin, DP/PT
dopplerable BL
Pertinent Results:
Admission labs [**2116-4-21**]
WBC-13.5* RBC-3.71* Hgb-11.2* Hct-33.8* MCV-91 MCH-30.1
MCHC-33.1 RDW-13.7 Plt Ct-222
Neuts-92.3* Lymphs-4.7* Monos-2.8 Eos-0.1 Baso-0.1
PT-15.1* PTT-30.1 INR(PT)-1.3*
Glucose-315* UreaN-19 Creat-1.0 Na-137 K-5.9* Cl-107 HCO3-18*
AnGap-18
ALT-70* AST-256* LD(LDH)-820* AlkPhos-34* TotBili-1.0
%HbA1c-6.0*
Triglyc-117 HDL-31 CHOL/HD-4.9 LDLcalc-99
ART Rates-/20 pO2-39* pCO2-48* pH-7.22* calTCO2-21 Base XS--8
Intubat-NOT INTUBA Comment-NON-REBREA
Conclusions
Study performed in the CVICU, under sedation, with care team
present to dynamically assess RVAD weaning. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. The right atrium is dilated. The
interatrial septum is dynamic and bows into the left atrium but
no atrial septal defect is seen by 2D or color Doppler. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is dilated.
There is severe hypokinesis of the basal and mid right
ventricular free wall with sparing of the right ventricular
apex. Comparted to the study from [**2116-4-22**], the basal and mid
walls appear improved. With weaning of RVAD support, little if
any change in right ventricular size and/or function is
appreciated. No changes are appreciated in the left ventricle
either. There are simple atheroma in the aortic arch. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Very trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a small pericardial effusion.
There is a left pleural effusion. Dr. [**Last Name (STitle) **] was notified in
person of the results in the ICU at the time of the study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2116-5-1**] 15:24
[**2116-5-6**] 04:42AM BLOOD WBC-18.0* RBC-3.33* Hgb-11.0* Hct-30.9*
MCV-93 MCH-33.0* MCHC-35.6* RDW-22.1* Plt Ct-146*#
[**2116-5-6**] 04:42AM BLOOD PT-19.0* PTT-76.3* INR(PT)-1.8*
[**2116-5-6**] 04:41PM BLOOD Glucose-137* UreaN-41* Creat-1.6* Na-131*
K-4.6 Cl-97 HCO3-18* AnGap-21*
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 80663**]Portable TEE
(Complete) Done [**2116-5-6**] at 4:53:29 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2051-9-9**]
Age (years): 64 M Hgt (in): 71
BP (mm Hg): 100/62 Wgt (lb): 270
HR (bpm): 90 BSA (m2): 2.40 m2
Indication: Congestive heart failure.
ICD-9 Codes: 428.0, 427.31, 424.0
Test Information
Date/Time: [**2116-5-6**] at 16:53 Interpret MD: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) **], MD
Test Type: Portable TEE (Complete) Son[**Name (NI) 930**]:
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W004-1:50 Machine: Vivid i-4
Sedation: Versed: 4 mg
Fentanyl: 150 mcg
(See comments below for other sedation.)
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 40% to 50% >= 55%
Findings
Patient was intubated, sedated (on Midazolam and Fentanyl
drips), and paralyzed (with Cisatracurium Besylate) for the
procedure.
This study was compared to the prior study of [**2116-4-28**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Markedly dilated RA. No ASD by
2D or color Doppler.
LEFT VENTRICLE: Moderate symmetric LVH. Low normal LVEF.
RIGHT VENTRICLE: Small RV cavity. Severe global RV free wall
hypokinesis.
AORTA: Mildly dilated ascending aorta. Simple atheroma in
descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR.
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 monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. The patient was sedated
for the TEE. Medications and dosages are listed above (see Test
Information section). Image quality was suboptimald - poor
esophageal contact. The patient appears to be in sinus rhythm.
Compared with the findings of the prior study, the findings are
similar. Echocardiographic results were reviewed by telephone
with the MD caring for the patient.
Conclusions
The left atrium is moderately dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler but marked bowing of the intra-atrial septum leftward
was noted, indicative of elevated right-sided pressure. Overall
left ventricular systolic function is normal (LVEF 50-55%) with
inferior wall hypokinesis. The right ventricular cavity appears
somewhat small with severe global free wall hypokinesis. A
catheter was noted at the RV outflow tract. The ascending aorta
is mildly dilated.There are simple atheroma in the thoracic
aorta. The aortic valve leaflets (3) are mildly thickened. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is a trivial/physiologic pericardial effusion.
Large pleural effusion was incidentally noted.
Compared with the prior study (images reviewed) of [**2116-4-28**]:The
Rv appeared smaller.
IMPRESSION: Low-normal LVEF with inferior hypokinesis. Severely
dilated RA, The RV was smaller than seen on previous studies and
remains severely depressed. Large pleural effusion.
Dr. [**Last Name (STitle) **] was notified by telephone after the procedure.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2116-5-6**] 18:03
Brief Hospital Course:
CCU Course: Patient was initially transferred from cath lab to
CCU intubated with IABP and Swan ganz catheter in place. He was
initially on dopamine and neosynephrine to maintain MAPs in 50s
but subsequently had increased pressor requirement, maxed out on
dobutamine, dopamine, neosynephrine and levophed. Initial CVP
was high around 20 so he did not receive fluids but subsequently
received 3L NS boluses due to low CVPs around [**1-10**]. He
developed afib and cardioversion was attempted x 3 with 200J,
300J, then 350 J. He converted to junctioanl rhythm then sinus,
but BPs remained low with MAPs in 40s-50s.
C-[**Doctor First Name **] was consulted and he was taken emergently to the OR for
RVAD placement. Transferred to the CVICU in critical condition
on levophed, epinephrine, and propofol drips. IABP removed on
POD #2. Over the course of the week, drips were titrated while
RV and LV function were monitored closely. CVVH was instituted
for volume management with acute renal failure. Liver failure
also noted post- RV failure. Necrotic areas noted on left hand
and left foot.Continued to require epinephrine and levophed
support. Head/ abd CT scan negative on [**5-5**]. Vasopressin required
for escalating pressor support. Continued to have intermittent A
Fib. Emergent bedside bronchoscopy done on [**5-6**] for thickened
bloody secretions. His marked acidosis continued with
hypotension despite maximal pressor support. Family decided to
withdraw support and comfort measures only were instituted. Pt.
expired at 19:55 with family at bedside.
Medications on Admission:
dobutamine drip
dopamine drip
levophed drip
Discharge Disposition:
Expired
Discharge Diagnosis:
myocardial infarction s/p intra-aortic balloon pump
right heart failure s/p right ventricular assist device
cardiogenic shock
hypertension
hyperlipidemia
coronary artery disease s/p PCI of RCA
right total knee replacement
liver failure
renal failure
Discharge Condition:
death
Completed by:[**2116-5-20**]
|
[
"51881",
"9971",
"5849",
"41401",
"42731",
"2875"
] |
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